Policyholder Services

Coverage Options for Aging Insureds

By Kimberly Wynkoop, OMIC Legal Counsel

Digest, Fall 2010

While we have looked at liability issues arising from the treatment of geriatric patients elsewhere in this issue of the Digest, this article will address coverage options for our aging insured ophthalmologists.

Rest assured, OMIC does not have any age restrictions in place that prevent insureds from continuing to be insured with OMIC or that limit the surgical activities covered as long as the insured maintains competency and has no health issues that affect his or her ability to practice safely. However, as they near retirement, some insureds choose to reduce their work hours or the types of procedures they perform. OMIC offers coverage options to respond to these changes in practice.

OMIC’s policy can be endorsed to reduce the coverage classification of the insured from full surgery (Surgery Class 3) to Surgery Class 2, Surgery Class 1, or No Surgery. Premiums decrease as coverage classifications are reduced. Following is a summary of the procedures allowed in each reduced coverage classification. For the full list, see Section XI. Part II. of your policy.

Surgery Class 2 excludes coverage of the performance of any surgical procedures, except for various (non-refractive, non-retinal) laser procedures, punctal closure with cautery, wedge resection for suspected non-cancerous tumors, various tarsorrhaphy, temporal artery biopsy, various non-invasive, non-ablative cosmetic procedures, and injections other than intracameral/intravitreal, in addition to the procedures permitted in Surgery Classes 1 and No Surgery.

Surgery Class 1 excludes performance of any surgical assisting or surgical procedures, except for removal of sutures, fluorescein angiography, tear duct probing or irrigation done under local anesthetic, repair of minor lid or conjunctival lacerations, biopsy of lid tumors or the conjunctiva, removal of cysts and other non-cancerous skin lesions and tumors, removal of corneal epithelium, incision and drainage, hair removal procedures, intramuscular, intravenous, and subconjunctival injections, injection of Botox or fillers, stromal puncture, micropigmentation, superficial chemical peels, microdermabrasion, removal of papillomas and chalazions, cryotherapy of the lid, and non-incisional entropion or ectropion repair, as well as non-surgical procedures.

No Surgery excludes performance of any surgical assisting or surgical procedures. Coverage applies only to non-surgical ophthalmology, which includes diagnosis and non-surgical treatment of diseases (other than screening for or treating retinopathy of prematurity), prescription of glasses or contact lenses, mechanical epilation, punctal closure with plugs, and removal of superficial foreign bodies from the cornea and conjunctiva.

Physicians who treat retinopathy of prematurity and/or provide ROP screening services for infants at or discharged from Level 2 or Level 3 NICus must carry Surgery Class 3 coverage. Physicians with a limited surgical or non-surgical practice who restrict ROP services to occasional screening of low risk infants may qualify for special rating consideration.

OMIC’s policy can also be endorsed to provide part-time coverage with a corresponding premium discount. Discounts are available to ophthalmologists who practice 20 hours or fewer per week or 10 hours or fewer per week at Surgery Classes 1 and 2 or No Surgery. The premium is based on the insured’s practice class, geographic location, limits of liability, and maturity year of the insured. A part-time premium discount may also be offered to qualified insureds at Surgery Class 3 who practice 20 hours or fewer per week and perform 100 or fewer surgical procedures per year, subject to review of their practice patterns, claims experience, and other factors affecting potential liability.

Surgery Class 3 physicians who perform ROP services, full cosmetic facelifts, liposuction, or rhinoplasty are not eligible for the part-time discount. Insureds are still eligible for a part-time discount if they are insured elsewhere for any additional practice activity.

OMIC does require insureds (at any age) to report health conditions that may potentially affect their ability to practice safely. Section VIII.3. of the policy requires, in part, that insureds notify OMIC, in writing, within thirty days (1) of undergoing or being advised to undergo treatment for alcohol, drug, or other substance abuse, or for psychiatric illness or (2) after suffering an illness or physical injury which impairs, or is likely to impair, the insured’s ability to practice ophthalmology for thirty days or more.

Finally, OMIC offers a valuable benefit to insureds who terminate coverage at any age due to death, disability, or retirement. Section X. of the policy explains that the premium for an extended reporting period endorsement (tail coverage) is waived if the insured has been continuously insured by OMIC for at least five years at the time of retirement. The tail endorsement is provided as soon as

OMIC receives confirmation of the insured’s retirement and the earned policy premium through the date of termination has been paid. Tail premium is likewise waived upon the death, permanent total disability, or judicial determination of incompetency of the insured, regardless of the length of time insured. In this case, the tail endorsement will be provided as soon as OMIC receives written notice of the applicable situation and the earned policy premium through the date of termination has been paid. The tail premium waiver applies only once per lifetime.

Contact your underwriter to discuss any of these coverage options at (800) 562-6642, ext. 639