Chapter 3: Legal Liability and Insurance
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Transcript of Chapter 3: Legal Liability and Insurance
Chapter 3: Legal Liability and Insurance
© 2010 McGraw-Hill Higher Education. All rights reserved.
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
• 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
Standard of Reasonable Care
• 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
Torts
• C A R E G I V E R D O E S S O M E T H I N G A R E A S O N A B LY P R U D E N T I N D I V I D U A L W O U L D N O T.
• C A R E G I V E R FA I L S T O D O S O M E T H I N G A R E A S O N A B LY P R U D E N T I N D I V I D U A L W O U L D N O T.
• AT H L E T I C T R A I N E R H A S A D U T Y T O P R O V I D E C O V E R A G E T O AT H L E T E S ( O B L I G AT I O N )
Negligence
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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
• SPECIF IC LENGTH OF T IME AN INDIV IDUAL CAN SUE FOR INJURY RESULT ING FROM NEGLIGENCE. • VARIES BY STATE BUT GENERALLY RANGES FROM ONE TO THREE YEARS• CLOCK BEGINS AT THE T IME THE NEGLIGENT ACT RESULTS IN SUIT OR FROM THE T IM E INJURY IS D ISCOVERED FOLLOWING NEGLIGENT ACT• M INORS GENERALLY HAVE AN EXTENSION
Statutes of Limitation
• ATHLETE IS MADE AWARE OF INHERENT R ISKS INVOLVED IN SPORT AND VOLUNTARILY DECIDES TO CONTINUE PARTIC IPATING• EXPRESSED IN WRITTEN WAIVER OR IMPLIED FROM CONDUCT OF ATHLETE ONCE PARTIC IPATION BEGINS• CAN BE USED AS DEFENSE AGAINST AN ATHLETE’S NEGLIGENCE SUIT
Assumption of Risk
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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
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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 ownerProducts with inherent defects are subject to
liability suitsMay be based on negligence, strict liability or
breach of warranty fitness
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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
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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
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General Health InsurancePolicy that covers illnesses, hospitalization and
emergency careSometimes offered through academic institutions for
students (athletics)Secondary insurance provided through institutions to
cover costs above primary insurance coverageSchools and universities must ensure that athletes
have primary insurance coverage (in place or arranged for)
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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
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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
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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
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Point of Service
Combination of HMO and PPOBased on HMO model but allows for care outside of
the planFlexibility is allowed for certain conditions and
circumstances
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Indemnity Plan
Most traditional form of billing for health careFee-for-service plan that allows insured party to
seek care without restrictionsProvider charges patient or third-party payerCharges are set on fee schedule
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Capitation
Form of reimbursement where members make standard payment monthly regardless of services rendered
Managed care plans utilize this practice
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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
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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
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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
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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
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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)
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Insurance Billing
Must file claims immediately and correctlyTo facilitate, collect insurance information at the start
of the academic yearLetters should be sent home to fully explain the
coverage available and necessary proceduresStandard forms are the norm, but accurate and
thorough completion is critical