Policyholder Services



2016 OMIC policy excludes less, covers more

KIMBERLY WYNKOOP, OMIC Senior Legal Counsel, and JOSHUA TOSCHES, OMIC Assistant

OMIC’s staff, Underwriting Committee, and Board of Directors are continually reviewing OMIC’s policy to provide the broadest coverage possible while protecting the company and its owner-insureds from unreasonable risk. In its latest review, the Board determined that OMIC is in the position to safely remove certain exclusions to cover more for our insureds and the work they do. The following summary explains several of the coverage expansions made to the OMIC professional and limited office premises liability policy effective January 1, 2016.

Refractive surgery

The OMIC policy contains a “special procedures” exclusion that, until the January 1, 2016, edition, excluded coverage for any claims arising out of the performance of refractive surgery unless specifically covered by endorsement. To qualify for coverage, the physician had to complete a procedure-specific supplemental questionnaire, undergo special underwriting review, and adhere to specific underwriting requirements. Upon approval, the policy was endorsed to include coverage for the underwritten procedure. This application and approval/endorsement process applied to each type of refractive surgery procedure the physician performed.

The OMIC Underwriting Committee and Board of Directors reviewed this process. Recognizing that refractive surgery has become an integral part of residency training at most institutions, that refractive procedures have become more mainstream in ophthalmology, and that OMIC’s claims trends indicate detailed underwriting of such procedures is not necessary, OMIC will only exclude, and require applications and endorsement for coverage of, intraocular refractive surgery procedures (e.g., phakic implants for refractive purposes and refractive lens exchange). Extraocular refractive surgery procedures, such as LASIK, PRK, and CK, are now automatically covered.

Oculofacial plastic surgery

On the advice of oculofacial plastic surgeons who serve on OMIC’s Board and Committees, the Board reviewed and modified various ocolufacial plastic surgery exclusions. They determined that several excluded or conditionally covered procedures were routinely performed by fellowship-trained oculofacial plastic surgeons and that some of the excluded activities were less risky than other permitted procedures. The claims data also indicated that coverage of these procedures would not substantially increase OMIC’s risk. The Board determined that certain “special procedures” no longer need to be excluded from coverage, specifically harvest of a rib graft and placement of arch bars on teeth. The Board also determined that septoplasty could be included under rhinoplasty, and that genioplasty, mentoplasty, and chin implants could be included under full facelifts for cosmetic purposes. This means that if an insured applies for coverage of rhinoplasty and is approved, septoplasty will also automatically be covered; likewise the various procedures under full facelifts for cosmetic purposes.

The Board also determined that the exclusion of certain procedures “not to treat eye conditions and/or diseases,” specifically endoscopic sinus surgery, facial reanimation, harvest of a bone graft, and harvest of ear cartilage, was no longer necessary. The policy contains a “scope of practice” exclusion, stating that the policy does not cover treatment that is not within the ordinary and customary scope of practice of ophthalmologists. The “not to treat eye conditions and/or diseases” exclusion was originally included in the policy to allow for the performance of procedures that might otherwise not have been considered ordinary and customary for the practice of ophthalmology. The exclusion showed that the listed procedures were indeed meant to be covered, but only if performed to treat eye conditions or diseases. However, upon recent review, the Board determined that the reference to treatment of eye conditions or diseases could be confusing, since such listed procedures may be performed by ophthalmologists for other reasons, such as to treat facial trauma involving the orbit. In addition, today OMIC would clearly consider the performance of such procedures by oculofacial plastic surgeons within the ordinary and customary scope of ophthalmology. By removal of the exclusion, endoscopic sinus surgery, facial reanimation, harvest of a bone graft, and harvest of ear cartilage are now automatically covered under the policy, whether or not performed to treat an eye condition or disease.

Postoperative care

Until its 2016 revision, OMIC’s policy contained an exclusion denying coverage for claims arising from incidents occurring postoperatively unless specified conditions concerning who performed the postoperative care were satisfied. Since OMIC reviews applicants’ comanagement practices during the underwriting process, the Board determined that this was sufficient to manage the risk and that the postoperative care exclusion was no longer necessary. Therefore, it was removed in its entirety from the policy.

A hard copy of the policy is sent to insureds upon renewal. For an electronic copy of the policy, sign into MyOMIC at omic.com. Select “Coverage Q&A and Benefits,” then “Insurance Documents.”

 

Please refer to OMIC's Copyright and Disclaimer regarding the contents on this website

Leave a comment



Six reasons OMIC is the best choice for ophthalmologists in America.

#3. Best at defending claims.

An ophthalmologist pays nearly half a million dollars in premiums over the course of a career. Premium paid is directly related to your carrier’s claims experience. OMIC has a higher win rate taking tough cases to trial, full consent to settle (no hammer) clause, and access to the best experts. OMIC pays 25% less per claim than other carriers. As a result, OMIC’s base rates have consistently averaged approximately 15% lower than multispecialty carriers in the U.S.

61864684