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Bulletin 333

Medical Liability Claim Reports

Every insurer providing professional liability insurance to osteopathic or allopathic physicians, or to any other health care provider, is required to submit claim reports and reports of disposition to the Superintendent of Insurance pursuant to 24 M.R.S.A. §§ 2601-2608. "Health care provider" is defined at 24 M.R.S.A. § 2502(2) as:

any hospital, clinic, nursing home or other facility in which skilled nursing care or medical services are prescribed by or performed under the general direction of persons licensed to practice medicine, dentistry, podiatry or surgery in this State and which is licensed or otherwise authorized by the laws of this State.

The Bureau has redesigned the Medical Liability Claim Report Form. The new form is attached to this bulletin as Appendix A and applies to new and open claims September 1, 2005. Insurers with open claims as of September 1, 2005, for which Section 1, Report of Claim of the existing form was completed, must complete the new form in its entirety at the time Section 2, Report of Disposition, is submitted. Claims for which a Report of Disposition has been reported prior to September 1, 2005 do not need to be resubmitted on the new form.

The new form makes the following changes to the existing form:

* Added an entry for wrongful death assertion
* Added a field for professional license number
* Added boxes to identify the type of provider (MD, DO. PA, dentist or podiatrist)
* Expanded the reporting of Findings of the Pre-litigation Screening Panel
* Added additional instructions to clarify the form

Insurers are expected to make copies of the reporting form for future submissions. The reporting form and instructions are available at the Bureau of Insurance’s web site [insert link to Bulletin with attached forms]. Please follow the Bureau instruction sheet to ensure the reporting of accurate and consistent information. Claim report forms must be submitted in paper form as the Bureau is not able to accept electronic filings that can assure confidentiality.

If you have any questions on the form or the reporting requirements, you may call 1-800-300-5000 (instate) or 207-624-8475 and ask to speak to the Property Casualty Actuary.
July 18, 2005 _______________________________
Alessandro A. Iuppa
Superintendent of Insurance

NOTE: This bulletin is intended solely for informational purposes. It is not intended to set forth legal rights, duties or privileges nor is it intended to provide legal advice. Readers are encouraged to consult applicable statutes and regulations and to contact the Bureau of Insurance if additional information is needed.


Please complete the applicable sections as completely as possible. Note comment section for additional comments.
Mail to: Bureau of Insurance
Department of Professional and Financial Regulation
Property and Casualty Division
34 State House Station
Augusta, Maine 04333-0034
Tel: 207-624-8475 Fax: 207-624-8599

REPORT OF CLAIM: The original Report of Claim section should be completed and filed after the insurer receives information that the insured’s liability for malpractice is asserted from either an insured, a patient of an insured, or an attorney. This report should NOT be submitted when the insurer is only notified of an incident that may give rise to a claim.

REOPENED CLAIM: If a claim that was closed with a report of disposition has reopened, check the box on the Date of Report line.

Date of Report: Should be the date the liability claim report is prepared by the insurer.

Claim Number: Should be the numbering system the insurer employs to identify the claim against the insured. Each codefendant listed in the lawsuit should be assigned a separate, distinct claim number to clearly identify it. One report should be submitted for each codefendant listed in the lawsuit and insured by the insurer.

Policy Number: Policy number assigned to the insured.

Class Description/Specialty: The description assigned as part of the classification system for the insured’s practice or specialty.

Classification of Risk: ISO or insurer code number for the insured’s practice or specialty.

Place of Occurrence: This is the actual physical location where the occurrence took place, i.e. ABC Hospital, Dr. Doe’s Office, emergency room, operating room, patient's room, etc.

Date of Occurrence: Date given to you in notification of claim or liability.

Date Claim Asserted: This is the date the insurer receives a Notice of Claim or a letter from a lawyer or other person representing the insured asserting a claim is being initiated.

Amount Claimed by Claimant, if known: Please either indicate the dollar amount that the plaintiff has initially requested or indicate "open" if no amount has been stated. Do not enter loss reserve.

Is wrongful death asserted as a claim? Please report whether a wrongful death claim has legally been asserted.

Insured's Information: Information relating to the insured. If a hospital, nursing home or other healthcare facility, it should give the actual name of the facility. This name may be followed on the title line with the name of the corporation if available.

Description of Occurrence: This information should be as brief and understandable as possible. It should clearly state the charge against the insured. If there is not enough room for the description, continue in the comment section.

Professional License Number: Indicate the license number of the professional and whether the insured is a medical doctor (MD), Doctor of Osteopath (DO), or Physician's Assistant (PA), a Dentist, or a Podiatrist.

Codefendant(s) and Claim Number(s): - We would like to receive this information as soon as it is available to you. Please indicate the name of the codefendant(s) and whether the named physician is an MD, DO, PA, Dentist, or Podiatrist. Fill in the names of any known codefendant(s) and their claim number(s), whether insured by the insurer or listed on the notice of claim. Codefendant means any party insured by your company also named in the claim asserted, as well as any party insured by another insurer named in the claim asserted. If codefendant is not insured by your company, fill in "other insurer" in space for codefendant claim number. If there is not room in the space provided to list all the codefendants, you may use the comment section or you may list that information on a separate page and attach it to this report. Separate claim reports need to be filed for each insured codefendant in both the report of claim and in the report of disposition.


The Report of Claim Disposition should be completed and filed within 60 days of the disposition. A Report of Disposition is required when there is a final judgment or award to the claimant, a settlement involving payment of money or services, or a final disposition not involving any payment of money or services. Dismissal is by action of a Court or Judge.

Date of Report: Should be the date the liability claim report is prepared by the insurer.

Date Suit Filed: Date suit filed with the court.

Docket Number: Docket Number assigned by the court.

Date of settlement, judgment, award, or closing of file: If there is a date of settlement, judgment, or award, please use this date. If none, then please use the date the file closed.

Amount of Award/settlement: If none, say $0.00. This refers only to the award, judgment or settlement against the named insured in Report of Claim. Do not include any award or settlement pertaining to any codefendant.

Allocated Claims Expense: If none, say $0.00.

Reviewed By Pre-litigation Screening Panel - Code Numbers If “No” Please make sure this part is always completed.

1. Screening panel option waived by both parties.
2. Case dropped or abandoned by the plaintiff.
3. Case settled before it was heard by the panel.
4. Case dismissed.
5. Other. Use comment section to explain reason.

Outcome of Pre-litigation Screening Panel - Please fill in the number of panel members who voted yes and the number of panel members who voted no on the three findings listed. If the case was dismissed by the panel chair for whatever reason as outlined in Title 24 M.R.S.A, § 2853, please check this option.

Reason for Disposition: Please indicate the applicable number. If No. 7 - Other, fill in the line below it and/or use the comment line if there is not enough room.

DISPOSITION OF A REOPENED CLAIM: If closing a reopened claim, check where indicated to the right on Report of Disposition line.

Please fill out the insurance company information each time you complete the form, giving the insurance company name and address, name of contact person and his/her Email address, telephone number, telephone extension number, and fax number.

A copy of this form must be retained in the insurance company’s files and be readily retrievable at the Superintendent’s request.

Notice to Insurance Companies
All insurers providing professional liability insurance to any health care provider in Maine are required to file liability claim reports with the Superintendent of Insurance pursuant to Title 24 M.R.S.A. §2601 et. seq. Insurers and their agents or employees are immune from liability for any cause of action that may be asserted against them as a result of filing the required reports. The Superintendent maintains as confidential all data derived from these reports that permits identification of insured or any incident giving rise to a claim.

Mail to:
Bureau of Insurance
Department of Professional & Financial Regulation
Property and Casualty Division
34 State House Station
Augusta, Maine 04333-0034
Tel: 207-624-8475
Fax: 207-624-8599

Appendix A

Medical Liability Claim Report Form - Word or Adobe PDF

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Last Updated: September 27, 2010