CRITICAL DECISIONS ON CRITICAL CONDITIONS CLAIMS BY Emiliano B. Canonigo, Jr., MD., FPCP, FPCC.
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Transcript of CRITICAL DECISIONS ON CRITICAL CONDITIONS CLAIMS BY Emiliano B. Canonigo, Jr., MD., FPCP, FPCC.
CRITICAL DECISIONS ON CRITICAL CONDITIONS CLAIMS
BYEmiliano B. Canonigo, Jr., MD., FPCP,
FPCC
Critical Illness
CI claim – Case 1 56 years old, clean medical history CI policy issued 14.01.1999 at standard rate 28.12.2000: severe chest pain admitted to
the CCU(Dr. Q, Cardiologist)
> CI claim for Heart Attack
What do you do?
CI Definition for Heart Attack
> The first occurrence of heart attack or myocardial infarction which means the death of a portion of the heart muscle, as a result of an acute interruption of blood supply to the myocardium.
> The diagnosis must be based on a history of:*Typical chest pain*New ECG changes proving infarction* Diagnostic elevation of cardiac enzymes
> Angina is specially excluded
The Infarcted Heart
Diseased Coronary vessel
CI claim – Case 1 APS of Cardiologist• On and off chest pains for the last two weeks
precipitated by effort relieved by rest• PTA severe chest pain lasting for 30 mins
associated with shortness of breath• On admission – chest pain relieved with nitrate
drip, EKG – ST depression with T wave inversion
• No enzymes done
WHAT WILL YOU DO? DECIDE?
Considerations:
CI claim – Case 1 APS of Interventionist - Cardiologist
• Angiogram performed on the 7th HD revealed 95% stenosis of the LAD, 50% stenosis of the distal RAD
• Angioplasty with stenting of proximal LAD• Troponin levels (done on the day after
angiogram) 1.0 (nv < 0.2)
MD’s diagnosis: Acute Myocardial Infarction
SETTLE OR DENY ?
CI claim – Case 1
DECISION: Settle as Acute MI or Deny Claim?
• No EKG evidence • Enzymes elevate but done only after PTCA
– procedure could raise Trop T• Chest pain typical relieved with nitrate drip
and no recurrence
DECISION?
CI claim – Case 1
POINTS OF ARGUMENT
No EKG evidence non Q MI?Enzymes only after PTCA Trop T - 10
daysChest pain relieved Typical
YOU DECIDE!
CI claim – Case 2 CI policy issued 23.3.1999 at
standard rate 4.2.2000: headache and left side
weakness (Dr. CB, neurologist)
36 years old, clean medical history> CI claim for stroke
CI Definition of Stroke
• A cerebrovascular incident which results in permanent neurological deficit.
• The diagnosis must be supported by new changes on CT or MRI scan.
• The diagnosis must be certified by a neurologist
CI Definition of Stroke
Exclusions:o Infarctions of brain tissue or
intracranial bleeding as a result of bodily injury caused by violent external means or accident, is specifically excluded.
o Transient ischaemic attacks are excluded
CI Claim – Case 2
• APS of Neurologist- December 1998: episode of
headache, but no definitive diagnosis.
- May 1999:headache with left-side weakness.
CI Claim – Case 2
Follow-up:• Headaches resolved• Left limbs recovered after 2-4
weeks with mild residual numbness of the left arm.
CI Claim – Case 2
CONSIDERATIONS:• Doctor states that this is a
permanent condition and it has persisted more than 180 days.
• MRA and Digital subtraction angiography revealed AV malformation
DECISION?
CI claim – Case 2• MR angiogram of brain (5.2.2000)o Strongly suggestive of a venous angioma,
an arteriovenous fistula is also a possibilityo Cigar-shaped lesion (3x1 cm) in the right
posterior parietal region:old hematoma
Digital subtraction angiography (18.2.2000)- Right temporo-parietal arterio-venous malformation.
YOU DECIDE!
CONCLUSION
WARS HAD BEEN WAGED AND KINGDOMS HAVE FALLEN BECAUSE OF POOR OR INADEQUTE
DEFINITION
There is a need to review the definition for CRITICAL CONDITIONS
CONCLUSION CHECK FOR DIAGNOSTIC
ACCURACY CHECK FOR NEGATIVE
PROGNOSTIC INDICATORS ESTIMATE WITHIN SPECIFIC
DIAGNOSTIC CATEGORIES CHECK FOR CO-MORBIDITY
SPECIFIC ISSUES
Little knowledge is a dangerous thing so we attend conferences like this to learn more and live more dangerously
Thank You !