MLMIC regularly receives questions from its physician insureds in regard to the Company’s Merit Rating Plan. This article is intended to present an overview of the Plan and address some of the most frequently asked questions.

The MLMIC Physician And Surgeon Professional Liability Merit Rating Plan is designed to identify and surcharge those physician policyholders whose conduct, methods of practice, or claim experience are predictive of the likelihood of future claims in excess of the norm of their specialty and territory. Such insureds, if insured at base rates, are considered an unreasonable burden to other policyholders and thus will be subjected to the review process.

Who Is Reviewed?
A policyholder will be automatically reviewed if his or her license has been revoked or suspended in any State, if probation has been invoked in any state, or if privileges have been revoked, suspended, or restricted in any manner by a hospital. In regard to reviews based on claim experience, a policyholder will be reviewed if their claims experience falls within the Company’s criteria that take into account, specialty, territory, number of claims, and indemnity payments. (See “The Merit Rating Plan”* pg. 2) A physician member of the Company’s Claims Review Committee may recommend a policyholder for review if it is judged that the methods of practice have fallen below acceptable standards in one or more claims or suits.

Methods Of Review?
The Professional Medical Liability Insurance and Defense Board, a committee of MSSNY that meets at its headquarters in Lake Success, reviews policyholders who are identified for review, and are members of the Medical Society of the State of New York. The MLMIC Claims Review Committee reviews nonmembers of MSSNY. This committee meets at the company’s New York and Syracuse offices. Upon completion of the review, which may include a personal interview, the Defense Board or the Claims Review Committee, may make one of the following recommendations:

1. The policyholder shall be cancelled at the end of the current policy year

2. The policyholder shall continue at base rates because the circumstances indicate that his/her experience is not truly predictive of the likelihood of future claims in excess of the norm for the policyholder’s specialty and territory. Another review may be recommended at a subsequent date

3. The policyholder be surcharged in an amount that in the Board’s or Committee’s judgement is appropriate. Surcharges are not to be more than 200% or less than 10% of the base rate, and will be reviewed annually

4. In lieu of a surcharge, or in addition thereto, the Board or Committee may require the policyholder to attend one or more Risk Management programs sponsored by the Company or a continuing medical education program suitable to the policyholders perceived deficiencies.

It should be noted that any physician who is cancelled by MLMIC and subsequently refused by two other New York State admitted professional liability carriers, will be able to secure insurance coverage through the Medical Malpractice Insurance Pool (MMIP), 212-576-9800.

Is There An Appeal Process?
It is important to note, that unlike any other admitted insurer in New York State, MLMIC entitles its insureds to peer review once a decision has been rendered through the review process of the Merit Rating Plan. Thus, if a physician is in disagreement with the recommendation reached, and the decision was reached without an interview, he or she can notify the Company in writing that they would like to appeal. The Company will then schedule them to appear before the Defense Board or Claims Committee where the peer review process will take place.

Physicians should understand that this interview process is an opportunity for them to “tell there side of the story” to a panel of their peers. In some cases, when a physician is well prepared and is able to clearly and succinctly explain his/her side of the story, an adverse decision may be rescinded or modified.

Where Can I Obtain Additional Information?
MLMIC underwriting and claims staffs are available to address questions and/or concerns in regard to the Merit Rating Plan. Contact them at the MLMIC New York office at 800- ASK-MLMIC (275-6564), the MLMIC Syracuse office 800-356-4056, or the MLMIC Long Island office at 516-794-7200.

The MLMIC publication THE MERIT REVIEW PLAN* is also available to all insureds upon request.


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