The following information shall be reported on a closed claim survey form:

1. A. Name of insurer;
2. B. Name of insurer group;
3. C. Claim file identification (ID);
4. D. Name of person completing the form;
5. E. Telephone number, including area code, of person completing the form;
6. F. Date form completed;
7. G. Date of injury;
8. H. Date injury reported to insurer;
9. I. Date claim closed;
10. J. Whether the claim was previously reported;
11. K. Age of injured person at time of injury;
12. L. Gender of injured person at time of injury;
13. M. Type of injury, such as wrongful death, permanent disability, or other bodily injury;
14. N. Description of injury;
15. O. Name of health facility where injury occurred;
16. P. Type of medical professional liability policy, such as occurrence, claims made—basic, or claims made—tail;
17. Q. Type of patient, such as inpatient, emergency room outpatient, or other outpatient;
18. R. Physician Insurance Services Office Incorporated (ISO) classification or equivalent classification;
19. S. Type of health care provider, such as physician-no surgery, surgeon, psychiatrist and related specialties, nurse, nurse midwife, optometrist, pharmacist, chiropractor, podiatrist, psychologist, dentist, hospital, other health care facility, or nurse anesthetist;
20. T. Physician and surgeon classification, including name of specialty;
21. U. Health care provider name;
22. V. Health care provider license number;
23. W. Policy limits for each claim or medical incident;
24. X. Policy limits for annual aggregate;
25. Y. If known, the facility, office, or county where the injury occurred;
26. Z. Whether the claim is a zero payment claim file;
27. AA. Full name and location of the court where the suit was filed and the case was tried;
28. BB. Case or docket number;

29. CC. Whether settlement was reached or award was made at one of the following stages:

    1. (1) Arbitration;
    2. (2) Mediation before suit was filed;
    3. (3) After suit was filed, but before trial;
    4. (4) During trial, but before court verdict;
    5. (5) Court verdict;
    6. (6) After verdict; or
    7. (7) After appeal was filed;

30. DD. If settlement was reached or award was made by court verdict, whether the result was:

    1. (1) Directed verdict for plaintiff;
    2. (2) Directed verdict for defendant;
    3. (3) Judgment notwithstanding the verdict for plaintiff;
    4. (4) Judgment notwithstanding the verdict for defendant;
    5. (5) Judgment for plaintiff;
    6. (6) Judgment for defendant;
    7. (7) Judgment for plaintiff, after appeal;
    8. (8) Judgment for defendant, after appeal; or
    9. (9) Any other;
31. EE. If there was no final judgment or settlement, the date of the final disposition;
32. FF. If there was no final judgment or settlement, the reason for the final disposition;
33. GG. If case did go to trial, whether the case was tried by a jury or tried by a judge;
34. HH. Total amount paid to the claimant;
35. II. Amount paid by the insurer;
36. JJ. Amount paid by the insured due to retention or deductible;
37. KK. If known, the amount paid by an excess carrier;
38. LL. If known, the amount paid by the insured due to settlement or award in excess of policy limits, not including deductible or retention amounts;
39. MM. If known, the amount paid by the insurer due to settlement or award in excess of policy limits, not including deductible or retention amounts;
40. NN. If known, the amount paid by other defendants or contributors;
41. OO. A summary of the occurrence from which the claim or action arose;
42. PP. A description of the misdiagnosis or alleged misdiagnosis made, if any, of the patient's actual condition;
43. QQ. A description of the procedure giving rise to the claim;
44. RR. A description of the principal injury giving rise to the claim;
45. SS. The amount of past medical expenses claimed by the plaintiff;
46. TT. The amount of future medical expenses claimed by the plaintiff;
47. UU. The amount of past lost wages claimed by the plaintiff;
48. VV. The amount of future lost wages claimed by the plaintiff;
49. WW. The amount of noneconomic damages claimed by the plaintiff;
50. XX. The amount of other damages claimed by the plaintiff;

51. YY. Whether a structured settlement or periodic payment was used, and if so:

    1. (1) The amount of immediate payment;
    2. (2) The present value of the projected total future payout, that is, the price of the annuity, if purchased;
    3. (3) The projected total future payout; and
    4. (4) The cost of the structure;
52. ZZ. If a neutral expert was used, the findings of a neutral expert witness regarding future medical expenses;
53. AAA. If a neutral expert was used, the findings of a neutral expert witness regarding future loss of earning;

54. BBB. If case was tried to verdict:

    1. (1) The amount awarded for past medical expenses;
    2. (2) The amount awarded for future medical expenses;
    3. (3) The amount awarded for past lost wages;
    4. (4) The amount awarded for future lost wages;
    5. (5) The amount awarded for noneconomic damages; and
    6. (6) The amount awarded for other damages;
55. CCC. The total allocated loss adjustment expense;
56. DDD. Of the total allocated loss adjustment expense, the amount representing fees paid to defense counsel;
57. EEE. Of the total allocated loss adjustment expense, the amount of expenses not included in the defense counsel fees;
58. FFF. Whether there was a claim made for extra contractual damages;
59. GGG. The amount claimed for extra contractual damages;
60. HHH. Whether a suit was filed or claim was made for extra contractual damages; and

61. III. Where the suit for the extra contractual damages claim was filed, including:

    1. (1) The full name of the court where the suit was filed and the case was tried;
    2. (2) The case number or docket number;
    3. (3) Whether the claim settled or was tried;
    4. (4) If tried, whether the trial was before a judge or jury;
    5. (5) The amount paid for the extra contractual damages claim; and
    6. (6) Whether the claim was previously reported to the Commissioner.

Authority: Insurance Article, §§4-401 and 4-405, Annotated Code of Maryland

Effective date: May 22, 2006 (33:10 Md. R. 882)

Regulation .02B amended effective January 1, 2018 (44:4 Md. R. 256)