Providing or failing to provide health care services to a patient.
Peer review, accreditation and similar professional activities in conjunction with and incidental to the provision of health care services, when conducted in good faith by the insured or an employee of the insured.
Utilization review, quality assurance and similar professional activities in conjunction with and incidental to the provision of health care services, when conducted in good faith by the insured or an employee of the insured.
Each policy issued by the plan shall also provide for supplemental payments in addition to the limits of liability under par. (d)
, including attorney fees, litigation expenses, costs and interest.
The health care liability insurance coverage issued by the plan shall exclude coverage for all of the following:
Employment, religious, racial, sexual, age and other unlawful discrimination.
Acts that occurred before the effective date of the policy of which the insured was aware or should have been aware.
Incidents occurring while and insured's license to practice is suspended, revoked, surrendered or otherwise terminated.
Liability of the insured covered by other insurance, such as worker's compensation, automobile, fire or general liability.
Liability arising out of the ownership, operation or supervision by the insured of a hospital, nursing home or other health care facility or business enterprise.
Liability of others assumed by the insured under a contract or agreement.
The maximum limits of liability for coverage under par. (a)
are the following:
For all occurrences before July 1, 1987, $200,000 for each occurrence and $600,000 per year for all occurrences in any one policy year.
For occurrences on or after July 1, 1987, and before July 1, 1988, $300,000 for each occurrence and $900,000 for all occurrences in any one policy year.
Except as provided in subds. 4.
, for occurrences on or after July 1, 1988, and before July 1, 1997, $400,000 for each occurrence and $1,000,000 for all occurrences in any one policy year.
Except as provided in subd. 5.
, for occurrences on or after July 1, 1997, $1,000,000 for each occurrence and $3,000,000 for all occurrences in any one policy year.
For podiatrists licensed under ch. 448
, Stats., for occurrences on and after November 1, 1989, $1,000,000 for each occurrence and $1,000,000 for all occurrences in any one policy year.
The plan may also issue liability coverage normally incidental to health care liability insurance including all of the following:
The maximum limits of liability for coverage under par. (e)
are $1,000,000 per claim and $3,000,000 aggregate for all claims in any one policy year.
(5) Eligibility for plan coverage.
All of the following are eligible for insurance under the plan:
A medical or osteopathic physician or podiatrist licensed under ch. 448
A partnership comprised of, and organized and operated in this state for the primary purpose of providing the medical services of, physicians, podiatrists, nurse anesthetists, nurse midwives, nurse practitioners or cardiovascular perfusionists.
A corporation or general partnership organized and operated in this state for the primary purpose of providing the medical services of physicians, podiatrists, nurse anesthetists, nurse midwives, nurse practitioners or cardiovascular perfusionists.
An operational cooperative sickness care plan organized under ss. 185.981
, Stats., which directly provides services through salaried employees in its own facility.
An accredited teaching facility conducting approved training programs for medical or osteopathic physicians licensed or to be licensed under ch. 448
, Stats., or for nurses licensed or to be licensed under ch. 441
An entity operated in this state that is an affiliate of a hospital and that provides diagnosis or treatment of, or care for, patients of the hospital.
A nursing home, as defined in s. 50.01 (3)
, Stats., whose operations are combined as a single entity with a hospital, whether or not the nursing home operations are physically separate from the hospital operations.
A health care facility owned or operated by a county, city, village or town in this state, or by a county department established under s. 51.42
, Stats., if the facility would otherwise be eligible for coverage under this subsection.
A corporation organized to manage approved training programs for medical or osteopathic physicians licensed under ch. 448
“Personal injury liability insurance" means any insurance coverage against loss by the personal injury or death of any person for which loss the insured is liable. “Personal injury liability insurance" includes the personal injury liability component of multi-peril policies, but does not include steam boiler insurance authorized under s. Ins 6.75 (2) (a)
, worker's compensation insurance authorized under s. Ins 6.75 (2) (k)
or medical expense coverage authorized under s. Ins 6.75 (2) (d)
“Premiums written" means gross direct premiums less return premiums, dividends paid or credited to policyholders and the unused or unabsorbed portions of premium deposits, with respect to personal injury liability insurance covering insureds or risks residing or located in this state.
Each insurer authorized in this state to write personal injury liability insurance, except a town mutual organized under ch. 612
, Stats., is a member of the plan.
An insurer's membership in the plan terminates if the insurer is no longer authorized to write personal injury liability insurance in this state. The effective date of termination shall be the last day of the plan's current fiscal year. A terminated insurer shall continue to be governed by this subsection until it completes all of its obligations under the plan.
Subject to the approval of the commissioner, the board may charge a reasonable annual membership fee, not to exceed $50.00.
If the funds available to the plan at any time are not sufficient for the sound financial operation of the plan, the board shall assess the members an amount sufficient to remedy the insufficiency. Each member shall contribute according to the proportion that that member's premiums written during the preceding calendar year bears to the aggregate premiums written by all members during the preceding calendar year. The amounts of premiums written shall be determined on the basis of the annual statements and other reports filed by the members with the commissioner. Assessments are subject to any credit plan developed under sub. (8) (a) 4.
When the amount of the assessment is recouped under s. 619.01 (1) (c) 2.
, Stats., each member shall be reimbursed the amount of that member's assessment.
The board shall report to the commissioner the name of any member that fails to pay within 30 days any assessment levied under par. (c)
(7) Board meetings; quorum.
The board shall meet as often as required to perform the general duties of supervising the administration of the plan, or at the call of the commissioner. Seven members of the board shall constitute a quorum.
(8) Powers and duties of the board.
The board may do any of the following:
Invest, borrow and disburse funds, budget expenses, levy assessments and cede and assume reinsurance.
Appoint a manager or one or more agents to perform the duties designated by the board.
Appoint advisory committees of interested persons, not limited to members of the plan, to advise the board in the fulfillment of its duties and functions.
Develop an assessment credit plan subject to the approval of the commissioner, by which a member of the plan receives a credit against an assessment levied under sub. (6) (c)
, based on voluntarily written health care liability insurance premiums in this state.
Take any action consistent with law to provide the appropriate examining boards or the department of health services with appropriate claims information.
Perform any other act necessary or incidental to the proper administration of the plan.
Develop rates, rating plans, rating and underwriting rules, rate classifications, rate territories and policy forms for the plan.
Ensure that all policies written by the plan are separately coded so that appropriate records may be compiled for purposes of calculating the adequate premium level for each classification of risk, and performing loss prevention and other studies of the operation of the plan.
Subject to the approval of the commissioner, determine the eligibility of an insurer to act as a servicing company to issue and service the plan's policies. If no qualified insurer elects to be a servicing company, the board shall assume these duties on behalf of member companies.
Enter into agreements and contracts as necessary for the execution of this section.
By May 1 of each year, report to the members of the plan and to the standing committees on insurance in each house of the legislature summarizing the activities of the plan in the preceding calendar year.
Any person specified in sub. (5)
may submit an application for insurance by the plan directly or through any licensed agent. Each application shall request coverage for the applicant's partnership or corporation, if any, and for the applicant's employees acting within the scope of their employment and providing health care services, unless the partnership, corporation or employees are covered by other professional liability insurance.
Within 8 business days after receiving an application, the plan shall notify the applicant whether the application is accepted, rejected or held pending further investigation. Any applicant rejected by the plan may appeal the decision to the board as provided in sub. (16)
The board may authorize retroactive coverage by the plan for a health care provider, as defined in s. 655.001 (8)
, Stats., if the provider submits a timely request for retroactive coverage showing that the failure to procure coverage occurred through no fault of the provider and despite the fact that the provider acted reasonably and in good faith. The provider shall furnish the board with an affidavit describing the necessity for the retroactive coverage and stating that the provider has no notice of any pending claim alleging malpractice or knowledge of a threatened claim or of any occurrence that might give rise to such a claim.
If the application is accepted, the plan shall deliver a policy to the applicant upon payment of the premium.
Rates shall be calculated in accordance with generally accepted actuarial principles, using the best available data.
Rates shall be calculated on a basis which will make the plan self-supporting but may not be excessive. Rates shall be presumed excessive if they produce long-term excess funds over the total of the plan's unpaid losses, including reserves for losses incurred but not yet reported, unpaid loss adjustment expenses, additions to the surplus established under s. 619.01 (1) (c) 2.
, Stats., and s. Ins 51.80 (3)
, the premium assessment under s. 619.01 (8m)
, Stats., and other expenses.
The board shall annually determine if the plan has accumulated excess funds as described under subd. 3.
and, if so, the board shall return the excess funds to the insureds by means of refunds or prospective rate decreases according to a distribution method and formula established by the board.
In establishing the plan's rates, the board shall use loss and expense experience in this state to the extent it is statistically credible supplemented by relevant data from outside this state including, but not limited to, data provided by other insurance companies, rate service organizations or governmental agencies.
The board shall annually review the plan's rates using the experience of the plan, supplemented first by the experience of coverage provided in this state by other insurers and, to the extent necessary for statistical credibility, by relevant data from outside this state.
The loss and expense experience used in establishing and revising rates shall be adjusted to indicate as nearly as possible the loss and expense experience which will emerge on policies issued by the plan during the period for which the rates were being established. For this purpose loss experience shall include paid and unpaid losses, a provision for incurred but not reported losses and both allocated and unallocated loss adjustment expenses, giving consideration to changes in estimated costs of unpaid claims and to indications of trends in claim frequency, claim severity and level of loss expense.
Expense provisions included in the plan's rates shall reflect reasonable prospective operating costs of the plan.
The board shall establish and annually review plan classifications which, in addition to the requirements under s. 619.04 (5)
, Stats., do all of the following to the extent possible: