CLAIMS ADMINISTRATION AGREEMENT (Hereinafter called the “Agreement”) between ADMINISTRATORS FOR THE PROFESSIONS, INC. (Hereinafter called “AFP”) and PHYSICIANS’ RECIPROCAL MANAGERS, INC. (Hereinafter called the “Company”)
Exhibit
10(dddd.3)
(Hereinafter
called the “Agreement”)
between
ADMINISTRATORS
FOR THE PROFESSIONS, INC.
(Hereinafter
called “AFP”)
and
PHYSICIANS’
RECIPROCAL MANAGERS, INC.
(Hereinafter
called the “Company”)
The
Company extends claims authority to AFP as follows:
All
claims shall be administered by Administrators for the Professions, Inc. (“AFP”)
on behalf of the Company.
It is
agreed that AFP shall be responsible for and administer claims arising under the
Company’s policies which constitute the Business, subject to the requirements
and limitations set forth below:
A.
|
All
subject claims shall be handled by AFP until their final disposition,
except as otherwise indicated in this Agreement, and in compliance with
all applicable laws, regulations and guidelines. AFP shall establish and
maintain claim files on each claim reported and advise the insured of
procedures to be followed when a claim
arises. |
B.
|
Reporting
Requirements |
1. |
AFP
must report all claims on monthly bordereaux which reflect the status and
change of status for each claim. Each claim so reported will reflect an
individual Company claim number assigned by AFP and in a format acceptable
to the Company. Such bordereaux will be provided to the Company as
specified in Section F., Monthly Reporting, subsection - Claims
Bordereaux. Additionally, AFP shall prepare detailed written reports on
any particular claim as may be requested by the
Company. |
2. |
All
claims involving any one of the following criteria outlined below will be
considered a “Catastrophic Occurrence.” |
a. |
Incidents
involving a fatality. |
b. |
Brain
damage injuries (skull fracture, concussion, loss of consciousness,
etc.) |
c. |
Spinal
injury with potential for paraplegia or
quadriplegia. |
d. |
Dismemberment
or other serious disfigurement potential. |
e. |
Injuries
involving nerve damage. |
f. |
Burn
injuries. |
g. |
Injuries
involving a fracture or multiple fractures. |
h. |
Serious
vision and/or hearing impairment injuries. |
i. |
Environmental
claims. |
j. |
Any
claim involving extra contractual obligations, excess, or direct claims
against the company or State Insurance Department
inquiries. |
k. |
Any
claims or loss involving class actions. |
l. |
Any
claim alleging sexual abuse or molestation. |
m. |
Any
claim valued in excess of $500,000
indemnity. |
3.
|
All
Catastrophic Occurrences, as defined in Section A(2), will be subject to
the following additional reporting
requirements: |
a. |
AFP
will report such claims to the Company immediately upon notice or receipt
by AFP and on a monthly basis, as described in Section
F. |
b. |
AFP
will report these claims, regardless of its opinion as to likelihood of
liability for each such Catastrophic
Occurrence. |
c. |
AFP
will also provide a written report concerning the development of these
Catastrophic Occurrence Claims on a regular basis, at intervals not to
exceed 90 days or sooner upon notice of material
development. |
C.
|
AFP’s
Authority |
1. |
All
claims shall be autonomously handled by AFP and shall have authority to
initiate or transact a settlement or compromise, or make full payment of
the indemnity demands for such claims. |
2. |
AFP
shall provide immediate written notice to the Company of any claim in
which coverage is denied to an Insured without the advice of outside
counsel. A complete copy of the claim file shall accompany such notice and
all subsequent correspondence received or produced information shall
immediately be forwarded to the Company. |
3. |
AFP
shall provide immediate written notice to the Company of any claim
immediately upon AFP reasonably determining that the expected indemnity
value will equal or exceed $500,000. A complete copy of the claim file
shall be sent to the Company upon their
request. |
4. |
AFP
is authorized to incur such reasonable expenses allocable to individual
claims as are necessary for the proper administration of this
Agreement. |
D. |
Indemnity
Payments |
AFP shall
arrange for and make indemnity payments, in compliance with Section C., above,
and in conformance with the following:
1. |
Claim
payments do not require written authority and approval from the
Company. |
2. |
Indemnity
payments will be made by the Company at the request of AFP within 48 hours
of receipt from the reinsurer of the indemnity amount
requested. |
E. |
Expense
Payments |
AFP shall
arrange for and make payment of expenses reasonably incurred by it, pursuant to
Section C. of this Agreement, and in conformance with the following
restrictions:
1.
|
Expenses
not incurred directly by AFP: |
a. |
Expense
payments do not require written authority and approval from the
Company. |
b. |
Expenses
directly incurred by AFP. |
c. |
Expense
payments will be made by AFP from the fiduciary account and such payments
will be deducted from the monthly premium remitted to the Company and the
reinsurer as their interests appear. If, however, expense payments are
more than the premium for the month, the Company will remit to AFP the
additional amount required within 48 hours of receiving payment from the
reinsurer. |
2.
|
Expenses
Directly Incurred by AFP. |
a. |
Labor
Expenses of AFP: |
$750.00
per claim file per year, or if open for part of a year, prorated from the first
day of the month of opening to the first day of the month following the month of
closing. Payment shall be made monthly and in advance, the first payment to
include the month of opening and the month that follows.
b. |
Other
AFP Expenses: |
AFP shall
be entitled to reimbursement by the Company and its reinsurer as their interests
appear for the cost of the following internal expenses incurred by its
employees:
i. |
Fees
to obtain records, x-rays and study models; |
ii. |
Fees
for copying records, x-rays and study
models; |
iii. |
Fees
for expert review of file; |
iv. |
Fees
for clinical examination of
plaintiff/claimant; |
v. |
Fees
for outside investigator for background investigation, i.e., fraud,
criminal; |
vi. | Fees for service of legal papers or subpoenas; |
vii. | Court reporter bills for deposition and/or trial transcripts; |
viii. | Fees to obtain prior transcripts for experts, both ours and our adversary's; |
ix. | Fees to obtain material related to investigation, i.e., legal research and/or medical research; |
x. | Fees to obtain information from governmental agencies related to Insured or claimants; |
xi. | Fees to Insureds for attendance at trial as provided for under the policy, and |
xii. | Any other specific expenses approved, in writing, by the Company. |
F. |
Monthly
Reporting |
1. |
Claims
Bordereau |
a. |
AFP
shall provide a separate Inception-to-Date and a Month-to-Date Claims
Bordereaux, on a diskette (on a format agreed upon by AFP and the Company)
as well as a hard copy by the 25th of
every calendar month or the last prior working day. Such Claims Bordereaux
shall include the following information: |
1. |
Inception-to-Date
Claims Bordereau |
a. |
AFP
Claim Number |
b. |
Company
Claim Number |
c. |
Policy
Number |
d. |
Named
Insured |
e. |
Policy
Effective Date |
f. |
Policy
Expiration Date |
g. |
Retroactive
Date |
h. |
Status
of Claim (open/closed) |
i. |
Claimant
Name |
j. |
Date
of Loss |
k. |
Report
Date of Loss |
l. |
ITD
Balance of Outstanding Reserves |
m. |
ITD
Balance of Losses Paid |
n. |
ITD
Balances of Expenses Paid (Outside) |
o. |
ITD
Balances of Expenses Paid (Inside) |
p. |
ITD
Subrogation Recoveries |
q. |
ITD
Subrogation Expenses |
r. |
ITD
Amount of Claim (sum of l-r) |
2. |
Month-to-Date
Claims Bordereau |
a. |
AFP
Claim Number |
b. |
Company
Claim Number |
c. |
Policy
Number |
d. |
Named
Insured |
e. |
Policy
Effective Date |
f. |
Policy
Expiration Date |
g. |
Retroactive
Date |
h. |
Status
of Claim (open/closed/changed) |
i. |
Claimant
Name |
j. |
Date
of Loss |
k. |
Report
Date of Loss |
l. |
MTD
Outstanding Reserves |
m. |
MTD
Losses paid |
n. |
MTD
Expenses Paid (Outside) |
o. |
MTD
Expenses Paid (Inside) |
p. |
MTD
Subrogation Recoveries |
q. |
MTD
Subrogation Expenses |
r. |
MTD
Amount of Claim (sum of l-r) |
G. |
Recovery |
AFP shall
diligently pursue all avenues of possible recovery, i.e., subrogation or
recovery or recoupment of loss or expense paid. All recoveries must be made
payable to the Company and its reinsurer as their interests appear. The amount
of the Recovery paid shall be included in the bordereaux which reflects activity
for the month that the Recovery was received by AFP. AFP shall provide any
additional details concerning a recovery as may be requested by the
Company.
H.
|
Service
of Suit |
The
Company hereby appoints AFP agent for service of process on any suit or
proceeding involving a claim or loss arising out of a policy issued by
Professional Medical Administrators, L.L.C. on behalf of the
Company.
I.
|
Compensation |
AFP’s
full compensation for rendering claims services for the Business as provided
herein shall be its direct incurred labor expenses detailed in Section E.2.a.,
above.
AFP and
the Company, intending to be bound, have executed this Claims Administration
Agreement in duplicate, each of which shall serve as an original:
Physicians’
Reciprocal Managers, Inc.
/s/
Xxxxxx X. Xxxxxxx
Xxxxxx X.
Xxxxxxx
Executive
Vice President
Physicians’
Reciprocal Managers, Inc.
Administrators
for the Professions, Inc.
/s/
Xxxxxxx Xxxxxx
Xxxxxxx
Xxxxxx
Chief
Executive Officer/President
Administrators
for the Professions, Inc.