Chapter 3: Legal Liability and Insurance

1. Chapter 3: Legal Liability and Insurance

2. Legal Concerns • Negligence suits involving coaches, athletic trainers, school officials and physicians have increased in frequency and amount of damages awarded • Liability • Being legally responsible for the harm one causes another person • Must be certain you are aware of all rules and regulations relative to healthcare in a given state

3. Standard of Reasonable Care Negligence: the failure to use ordinary or reasonable care. Standards of reasonable care Assumes that a person is of ordinary and reasonable prudence Bring commonsense approach to the situation Must operate within the appropriate limitations of ones educational background

4. Torts Legal wrongs committed against a person (liability results) May emanate from Nonfeasance Fail to perform legal duty, i.e. fail to refer Malfeasance Performs action that is not his/hers to legally perform, i.e. perform advanced treatment leading to complications Misfeasance Improperly perform something the person has a legal right to do

5. Negligence Care giver does something a reasonably prudent individual would not. Care giver fails to do something a reasonably prudent individual would not. Athletic trainer has a duty to provide coverage to athletes (obligation)

6. Individual possessing higher level of training will possess higher level of competence • Once the individual assumes duty of caring for athlete that person has an obligation to provide appropriate care • Obligation to provide services vs. Scope of employment • Good Samaritan Law • Provides limited protection against legal liability to one that provides care should something go wrong

7. Statutes of Limitation Specific length of time an individual can sue for injury resulting from negligence. Varies by state but generally ranges from one to three years Clock begins at the time the negligent act results in suit or from the time injury is discovered following negligent act Minors generally have an extension

8. Assumption of Risk Athlete is made aware of inherent risks involved in sport and voluntarily decides to continue participating Expressed in written waiver or implied from conduct of athlete once participation begins Can be used as defense against an athlete’s negligence suit

9. Does not excuse overseers from exhibiting reasonable care and prudence in regards to conduct of activities or foreseeing potential hazards • Many and varied interpretations (particularly with minors) • Often a waiver will stand in court except in incidents of fraud, misrepresentation or duress

10. Product Liability • Liability of any or all parties involved in manufactured product for damages caused by product • Includes manufacturer of components, assemblers, wholesaler, and retail store owner • Products with inherent defects are subject to liability suits • May be based on negligence, strict liability or breach of warranty fitness

11. Manufacturer of equipment has duty to design and produce equipment that will not cause injury • Express warranty • Manufacturer’s written guarantee – product safety • Equipment warning labels • Informs athlete of possible dangers inherent with product use • National Operating Committee on Standards for Athletic Equipment (NOCSAE) • Minimum standards for equipment to ensure safety

12. Insurance • Major changes in insurance have occurred in light of managed care • Major increases in the number of lawsuits and cost of insurance • Medical insurance is a contract between the company and policyholder • Company agrees to pay portion of medical bills following payment of a deductible

13. General Health Insurance • Policy that covers illnesses, hospitalization and emergency care • Sometimes offered through academic institutions for students (athletics) • Secondary insurance provided through institutions to cover costs above primary insurance coverage • Schools and universities must ensure that athletes have primary insurance coverage (in place or arranged for)

14. Reimbursement • Primary mechanism of payment for medical services in the U.S. • Policyholder insurance company reimburses health care providers for services rendered • Number of different options • Pre-arranged systems • Payment for preventive care • Other systems developed to contain costs

15. Health Maintenance Organization • Provide preventive measures and dictate where individual can receive care • Permission must be gained to see someone outside of the plan (except in emergencies) • HMO will pay 100% of costs if care rendered within the HMO plan providers • Athletic trainers must have working knowledge of HMO limits and restrictions

16. Preferred Providers Organization • Provide discount health care and also limit where treatment can be obtained • Must be aware of what facilities are approved for the program in order have cost completely covered • May include additional types of coverage (physical therapy) • PPO pay on a fee-for-service basis

17. Point of Service • Combination of HMO and PPO • Based on HMO model but allows for care outside of the plan • Flexibility is allowed for certain conditions and circumstances

18. Indemnity Plan • Most traditional form of billing for health care • Fee-for-service plan that allows insured party to seek care without restrictions • Provider charges patient or third-party payer • Charges are set on fee schedule

19. Capitation • Form of reimbursement where members make standard payment monthly regardless of services rendered • Managed care plans utilize this practice

20. Accident Insurance • Low cost plan to cover accident on school grounds to student • Protects student against financial loss from medical and hospital bills • Provides for additional protection for institution above regular policy • Will cover costs associated with hospital care, surgery, and catastrophic injuries

21. Catastrophic Insurance • Catastrophic injuries in athletics are relatively rare, but are staggering to all involved • Organizations (NCAA, NAIA, NFSHSA) provide additional coverage to deal with lifetime extensive care • Ensuring that all athletes and faculty/staff coverage is in place is critically important

22. Filing of claims, at times, is the responsibility of the athletic trainer • Can be very time consuming taking the athletic trainer away from other responsibilities • Additional staff may be necessary to deal with added responsibilities

23. Insurance to Protect the Professional • Protect against damages that may arise from injuries occurring on school property • Covers against claims of negligence on part of individuals • Because of rise in lawsuits, professionals must be fully protected, particularly in regards to negligence • Will cover negligence in civil case – not criminal complaint

24. Insurance to Protect the Professional (continued) • Errors and omissions liability insurance has evolved to protect individuals against suits claiming malpractice, negligence, errors and omissions (each person should still have personal liability insurance)

25. Insurance Billing • Must file claims immediately and correctly • To facilitate, collect insurance information at the start of the academic year • Letters should be sent home to fully explain the coverage available and necessary procedures • Standard forms are the norm, but accurate and thorough completion is critical