Proper Documentation and Limits of Liability of Insurance

Assignment:
For this assignment, read the case study and answer the questions. Total of about 1500 words
(A) Read the case studies and answer the following questions:
The elderly patient resided in a nursing home for almost a year before she died at the hospital. She had been hospitalized for six days, with admitting diagnoses of gram-negative septicemia, gram negative sepsis, and acute myeloid leukemia. Also, discovered on admission to the hospital was a necrotic Stage III pressure ulcer on her coccyx, which was nowhere documented in the clinical records from the nursing home. A review of the nursing progress notes was silent regarding any specialized mattress or other comfort devices used for this patient. The family sued on behalf of the patient, alleging that the patient’s demise from leukemia was linked to the negligence of the care that the patient had received in the nursing facility. The defense lawyer for the facility denied any negligence in the cause of the patient’s death
Questions to answer for A
1. Did the lack of documentation affect the ultimate outcome of this case?
2. Was there negligence on the part of the nursing staff in the care of this patient?
3. Was negligence in the care of this patient the ultimate cause of her demise?
4. What standards for documentation did the patient’s nurse breach?
5. How would you decide this case?
(B) Read the Declaration policy and answer the following questions:
DECLARATIONS Policyholder’s Name: ___Judy Doe __________________________________________ Covered Professional Occupation: Registered Nurse; Staff position Acute care institution or community health/home health Coverage Period: May 1, 2018 through April 30, 2019 Duties in Event of a Claim: If there is a claim, you must do the following: 1. notify us and our program administrator, in writing, as soon as possible; 2. specify the names and addresses of the injured party(s) and any witnesses, information on the time and place of the event; 3. verbally discuss the nature of the event with our claims representative; 4. immediately forward all documents that you receive in connection with the claim to us: 5. fully cooperate with us, or our designee, in the consummation of settlements, the defense of suits or other proceedings, enforcing any right of contribution or indemnity against another who may be liable to you because of injury or damage. You shall attend hearings and trials, assist in securing and giving evidence, and obtaining the attendance of witnesses; 6. refuse, except at your own cost, to voluntarily make any payment, assume any obligation, or incur any expense. Limits of the policy: $1,000.000 per claim/$3,000,000 aggregate In consideration of payment of the premium, in reliance upon the statements in the declarations and subject to all of the terms of this policy, agrees with the named insured as follows: COVERAGE AGREEMENTS The company will pay on behalf of the insured all sums that the insured shall become legally obligated to pay as damages because of: COVERAGE—INDIVIDUAL PROFESSIONAL LIABILITY Injury arising out of the rendering of or failure to render, during the policy period, professional services by the individual insured, or by any person for whose acts or omissions such insured is legally responsible, except as a member of a partnership, performed in the practice of the individual insured’s profession described in the declarations including service by the individual insured as a member of a formal accreditation or similar professional board or committee of a hospital or professional society. EXCLUSION This insurance does not apply to: 1. Liability of the insured as a proprietor, superintendent, or executive officer of any hospital, sanitarium, clinic with bed and board facilities, laboratory or business enterprise other than as stated in the above declarations; 2. Liability of the insured as a nurse-anesthetist or as a nurse midwife. LIMITS OF LIABILITY Individual Professional Liability The limit of liability stated in the declarations as applicable to each claim is the limit of the company’s liability for all damages because of each claim or suit covered hereby. All claims arising from the same rendering of or failure to render the same professional services shall be considered a single claim for the purposes of this insurance. The limit of liability stated in the declarations as aggregate is, subject to the above provision respecting each claim, the total limit of the company’s liability under this coverage for all damages. Such limits of liability shall apply separately to each insured.
SUPPLEMENTARY PAYMENTS The company will pay, in addition to the applicable limit of liability:
1. All expenses incurred by the company, all costs taxed against the insured in any suit defended by the company, and all interest on the entire amount of the judgment therein that accrues after entry of the judgment and before the company has paid or tendered or deposited in court that part of the judgment that does not exceed the limit of the company’s liability thereon.
2. Such premiums on appeal bonds required in any such suit, premiums on bonds to release attachments in any such suit for an amount not in excess of the applicable limit of liability of this policy, and the cost of bail bonds required of the insured because of accident or traffic law violations arising out of the use of any vehicle to which this policy applies, not to exceed $250 per bail bond, but the company shall have no obligation to apply for or furnish such bonds.
3. Reasonable expenses incurred by the insured at the company’s request in assisting the company in the investigation or defense of any claim or suit, including actual loss of earnings not to exceed $25 per day.
DEFINITIONS “Insured” means any person or organization qualifying as the policy holder in the person’s insured
provision of this policy. The insurance afforded applies separately to each insured against whom claim is made or suit is brought, except with respect to the limits of the company’s liability.
“Damages” means all damages, including damages for death, that are payable because of injury to which the insurance applies. “Named insured” means the person or organization named in the declarations of this policy.
CONDITIONS Insured’s duties in the event of occurrence, claim, or suit:
1. Upon the insured’s becoming aware of any alleged injury to which this insurance applies, written notice containing particulars sufficient to identify the insured and also reasonably obtainable information with respect to the time, place, and circumstances thereof, and the names and addresses of the injured and of available witnesses, shall be given by or for the insured to the company or any of its authorized agents as soon as practicable.
2. If claim is made or suit is brought against the insured, the insured shall immediately forward to the company every demand, notice, summons, or other process received by him or his representative.
3. The insured shall cooperate with the company and, upon the company’s request, assist in making settlements, in the conduct of suits and in enforcing any right of contribution or indemnity against any person or organization who may be liable to the insured because of injury or damage with respect to which insurance is afforded under this policy; and the insured shall attend hearings and trials and assist in securing and giving evidence and obtaining the attendance of witnesses. The insured shall not, except at his own cost, voluntarily make any payment, assume any obligation, or incur any expense.
SUBROGATION
In the event of any payment under this policy, the company shall be subrogated to all of the insured’s rights of recovery therefore against any person or organization, and the insured shall execute and deliver instruments and papers and do whatever else is necessary to secure such rights. The insured shall do nothing after loss to prejudice such rights.
ASSIGNMENT The interest hereunder of any insured is not assignable. CHANGES
1. Notice to any agent or knowledge possessed by any agent or by any other person shall not effect a waiver or change in any part of this policy or stop the company from asserting any right under the terms of this policy; nor shall the terms of this policy be waived or changed, except by endorsement issued to form a part of this policy, signed by a duly authorized representative of this company.
2. The dollar amount of the average awards in their geographic area
3. The unit or type of nursing care they normally provide (critical care versus general medical-surgical nursing)
4. The propensity for lawsuits against nurses in that geo-graphic area
The hospital attorney can provide nurses with information regarding trends in malpractice in their locality. Then nurses should find a policy that provides the necessary coverage. They can extend coverage as their job status changes or as they expand practice roles.
Questions to answer B
Using the sample professional liability insurance policy above, locate the various provisions:
• Limits of liability
• Declarations
• Deductibles
• Exclusions
• Reservation of rights
• Covered injuries
• Defense costs
• Coverage conditions and supplementary payments
• Did you have difficulty finding some of the sections? Would this be a policy that you would consider purchasing for your own liability coverage? Why or why not?
(C) Read the case studies and answer the following questions:
During an unexpected heat wave, the administrator of a nursing home decided against turning on the air conditioner, which resulted in the death of four of the residents of the home. One of the deceased residents’ daughters brought a lawsuit against the home for a wrongful death suit. She was awarded a judgment of $275,000. She then filed a second lawsuit against the nursing home’s insurance company to collect payment on the judgment. The insurance company refused to pay, stating that the judgment underlying the lawsuit was professional liability and the insurance company did not cover the nursing home for professional judgment. The nursing home then filed a lawsuit against the insurance company for payment of this judgment.
Questions to answer C
1. What provisions of an insurance policy would you consult to determine if an insurance company should pay such a claim and what would the limits of the liability be?
2. Is the nursing home insurance company correct in saying that this is a professional judgment issue?
3. Which insurance company (that of the nursing home or that of the administrator of the nursing home, assuming she has coverage) should pay the court-ordered judgment?
4. How would you decide the case?
Note:
Please combine all these responses into a single Microsoft Word document for submission. Submit only completed assignments. Be thorough in your responses to adequately address all aspects of each question.