Understanding how your malpractice insurance covers scope of practice

It is common for doctors of optometry to have questions regarding whether their scope of practice is covered by their malpractice insurance policy.  AOAExcel consulted with Kevin Johnson, Senior Vice President of AOAExcel’s endorsed business partner, Lockton Affinity, to shed some light on pertinent questions regarding scope of practice coverage as well as scope expansion.

What does an OD need to do to ensure that their entire scope of practice is covered by their malpractice policy?

First look at their insurance policy. The policy should contain language to confirm whether or not scope of practice is covered.  The policy should be specific about what is and isn’t covered.  Second, if they’re not sure how to interpret an insurance policy, reach out to their current insurance agent and ask them if their policy provides scope of practice coverage and if so, ask where that is found in their insurance policy packet.

What does an exclusion mean for a policy?  What are some common exclusions an optometrist might find in their policy?

An exclusion means that an action or event is not covered by the policy, so it is excluded from having any insurance coverage for the policy holder.  As far as common exclusions, the most important one that we try to identify is a surgery exclusion.  The exclusions vary in how they are worded.  Some of the more concerning exclusions include having no coverage if surgery penetrates tissue or any part of the body.  If you have a foreign body in your eye, sometimes it can be in the second or third layer of the eye, which by the letter of the law could be potentially excluded because it is considered surgery.

Can you explain the difference between a full policy and a certificate of insurance?  How easy is it for an OD to obtain a copy of their full policy?

A full policy is the entire insurance document, which can be quite lengthy (sometimes from 80 to 100 pages).  The full policy can include everything from the declarations page to any endorsements that are added to the policy specific to your individual risk.  This document will contain all of the relevant policy language.

A certificate of insurance is usually a one-page document that is going to have very high-level information and will contain the name of the insured, the name of the insurance company, who is providing the coverages, and the applicable limits for the coverages that are outlined on the one-page document.  The certificate is provided as evidence of coverage.

Either document should be easy to obtain and an OD should get a copy from their current agent, either online or sent in print.  If the documents aren’t provided at the beginning, they should be requested.

What are the consequences for an optometrist when their policy doesn’t cover a claim?

In the worst-case scenario, it could be catastrophic.  If the coverage doesn’t cover a claim and the claim is severe (for instance, the patient suffers loss of vision or something along those lines) or if the personal liability insurance has an exclusion that doesn’t offer coverage, at that point the optometrist might potentially have to come out of pocket to cover those damages for their patient based off the incident. 

What questions should an OD be asking their insurance broker regarding their policy?

We’ve received this question quite a lot from optometrists over the years.  The first question we always have an OD ask their insurance broker is “Does your current coverage provide scope of practice?”  As their state scope changes and evolves, if an OD has scope of practice built into the policy form, they don’t have to call in every time the state changes.  If it’s not set up that way in the policy, then the OD needs to check in with their insurance agent every time the scope changes. 

Other questions include “Is there a surgery exclusion on my malpractice insurance and if there is, what specifically does it exclude?” and “What is considered surgery based off the policy document that I have?” 

Keep in mind that if you’re unsure if your current insurance has adequate coverage for scope of practice, AOA members may receive a complimentary policy review to clarify their policy’s scope of practice coverage and exclusions.

In the upcoming year, some states may be passing legislation to expand their scope of practice.  When scope of practice expands, what steps does an OD need to take to ensure their professional liability policy covers these changes?

In the Lockton Affinity policy available to AOA members, scope of practice language is already built in.  As the state changes and as use of lasers become more prominent, anyone under the Lockton Affinity policy doesn’t have to call in and confirm the coverage.  For other policies and other agencies, if their policy form doesn’t contain language for scope of practice, they would need to call in to confirm every time their state changed the scope of practice to confirm they are covered. We encourage those people to have that in writing from their insurance agent.   

When scope of practice is expanded in a particular state, how is it spelled out in writing in an OD’s malpractice policy?

On other policies, we’ve seen language that is very specific and outlines the specific procedures and duties that the optometrist is doing.  It lays out clearly what is covered.  The other end of the spectrum is the AOA coverage, where we don’t go that way; we tie it into the scope of practice in the individual state, so it is a much more broad and general way to insure optometrists across the country.

What I would encourage anyone to do is contact their current agent to check and see what their policy language looks like relative to scope of practice and if it doesn’t have that language in there, then make sure that they are in communication with their current agent to have something in writing, either added as an amendment or endorsement to the policy to specifically lay out what part of the scope of practice in their state is covered or get in it writing from the agent or from their insurance carrier on what is or isn’t covered by the scope and also keep doing that as the scope changes.

If you’re concerned that your current policy doesn’t have sufficient coverage, AOA members can receive a complimentary policy review from Lockton Affinity.  Your policy will be reviewed for surgery exclusions and to make sure that you have adequate limits.  You can also get an instant quote on your malpractice insurance policy.  For more information, visit AOAExcel.