The estimation of the amount of compensation for the damage on the person for many years has been calculated basing on the table of the decree of the Ministry of Labor and Social Policy from 2002. ...This is a solution based on the common practice, not on the basis of legally binding rule. The above table is the only published document in the legal act (although it applies to the labor law). This is why it is very often referred to as a base to assess the accident consequences. Analyzing the argumentation of the court judgements/ decisions which are taken against the insurance companies, one can draw a conclusion that estimation based on the table concerning only health damage is not sufficient and adequate enough in the further justification of the court verdict. In relation to this situation the need to prepare the rules of assessment incorporating not only the fact of the narrow spectrum of damage, but also different elements of the damage emerged. The two scientific associations: Polish Association of Insurance Medicine and Polish Association of Forensic Medicine and Criminology have prepared a tool which supports the process of the estimation of the damage on the person. After many years of hard work and gaining experience a new HBT system was built. This system allows to assess the damage in multidimensional, advanced way. It also lets the final result with similar amount to be presented. Thanks to this it establishes forecasting and repetitiveness needed very much in the compensation claims area.
The objective of this work is a preliminary analysis of claims concerning nosocomial infections advanced by patients against public inpatient institutions.
646 patient claims against medical ...institutions resulting from their civil liability were analyzed. All the claims included expert opinions issued by the Medical Department of PZU SA between the year 2003 and 2005. In the analyzed material, the majority of claims (85.3%) involved public hospitals. The value of the presented material is high, as PZU SA is practically the only insurance company that insures public hospitals against civil liability for medical procedures. Therefore, conclusions from the present analysis may be used to formulate certain generalized statements in the case of claims made by patients against public hospitals in Poland. Nosocomial infections constituted 32% of all patient claims against public hospitals. The majority of claims indicated Staphylococcus aureus infections (37%). Other common infections associated with patient claims were HBV and HCV infections, with HBV infections predominating at surgical and internal disease wards, while HCV infection claims were more common among gynecology and obstetrics patients. Staphylococcus aureus infections were dominant in orthopedic and traumatology wards. Some objective reasons may hinder formulation of an expert opinion, such as finding the causal association between the infection and the timing of hospitalization, or between the infection and the culpability of medical personnel. Medical opinions passed by doctors of the Medical Department in most cases remained ambiguous. New legal regulations that require obligatory reporting and registration of nosocomial infections provide a chance that some of these difficulties may be overcome in the near future.
The paper presents and analyses problems which are encountered by an insurance company in connection with the opinions issued by experts appointed by a court in civil cases and concerning the ...evaluation of the results of accidents or damages in civil liability insurance. Every year, the group of physicians employed by the Office of Medical Services of Insurance at the PZU Zycie SA and PZU SA, issues opinions for about 3000 appeal and complicated cases from all over Poland. In some of the cases, an individual holding an accident insurance policy or an injured person in the case of civil liability insurance disagrees with the findings of the insurance company and brings the case to a civil court. About 7% of the opinions issued by the Office in 2005 were polemics with court experts, concerning their manner of classifying the results of an accident or an event which resulted in damage to an individual. Among the 200 opinions, there are several important and recurring problems, which are presented in the paper. The main doubts concern: 1. insufficient analysis of the circumstances of an event and drawing hasty conclusions about the cause-and-effect relationship, 2. claiming the certain occurrence of a cause-and-effect relationship, despite substantial doubts, 3. absence of analysis of general conditions of insurance, which in voluntary insurance may contain various exemptions and restrictions, 4. insufficient analysis of medical documentation containing information about some deviations before the event, 5. determining by the experts the degree of permanent loss of health despite the absence of functional impairment revealed in an examination, 6. determining permanent results of an accident based solely on unverifiable subjective complaints, 7. deciding about the percentage of permanent detriment to health in most cases on a slightly higher level than was decided by a physician who took such a decision for the insurance agency.
The aim of this study is to answer the question: whether it is possible to elaborate and apply in the certification an objective method of evaluation of permanent stress related injuries to the spine ...considering the impact of degeneration illness? PZU Group caters for about 5000 stress related spinal injuries yearly. Until the year 2001 there had been no standard of medical assessment in these types of injuries. Extreme differences in evaluation of similar cases by various doctors had been found. In 2001 the Medical Department of PZU Group organized 4 medical workshops for 386 doctors. We analyzed the particular case of stress related spinal injury on a following basis:--severity of degenerative illness,--power of the force causing spine overloading. As a summary of these analyses the table, which enables to assess the impact of illness upon complete and permanent impairment to one's health, was created. In the same year we introduced this table for the estimation of stress related spinal injuries for all our clients. In a follow-up study analysis of 329 cases examined in accordance with the above mentioned table concerning the most severe stress related spinal injuries in the years 2002 and 2003 were presented. The result of the research is that currently there are no extreme differences in evaluation of similar cases and in 2001 about 90% of the cases the degree of permanent impairment to one's health for similar cases is comparable. It seems possible to elaborate and to put effectively into certification practice an objective method of stress related spinal injury evaluation which determines the influence of external and pathological causes. In addition, other problems concerning certification of spine injuries were revealed e.g. necessity of making the decision about taking responsibility for conclusions drawn for objective of medical treatment documentation of the insured and not from certificates issued exclusively for insurance needs.
Consequences of knees injuries constitute a substantial number of personal claims within the PZU Group. In 2004 physicians cooperating with PZU gave about 53 thousand opinions, concerning injuries to ...the knee in adults and about 14 thousnd in children and adolescents. In accidental and TPL insurances physicians are obligated to treat separatly consequences of accidents due to impact from illness or earlier injuries. The lack of a good method of how to distinguish these often leads to the disaccords between the physician, client and insurance company. The aim of this research is to indicate and to define the medical problems during rating of permanent impairment, based on the analysis of hundreds of difficult claims. This may help to start a discussion on how to perform objective and repetitive method of rating permanent accidental impairment in the knee ailments. In our opinion, current rules of rating permanent impairment after injury in a damaged organ, do not guarantee a detailed assessment of accidental loss of knee function during medical examination.
The aim of the study is to present and analyze the types of bodily injuries which are the causes of the most often issued medical certificates in the population of insured against accident. The ...following study encompasses the years 2001-2003 where certificates issued by about 1500 doctors cooperating with partnerships of PZU Group were analyzed. In this period 1 300 000 permanent impairments which were stated on the basis of PZU's Group Norm Table of Percentage Evaluation of Health's Permanent Impairments were registered in the computer data base. On the basis of available data the following issues were characterized: 1) what are the most often evaluated injuries?, 2) what average values of permanent health impairment were issued by doctors in particular cases?, 3) in what percentage doctors classified health impairment to particular groups of after-effect severity and, 4) in what percentage health impairment was not stated? For the needs of the following study the human body was divided into particular parts: 1) head with neck and central nervous system, 2) sight, 3) ear, 4) chest, 5) abdomen and urinary system, 6) spine and spinal cord, 7) limb with hip joint, 8) leg, 9) knee joint, 10) region of ankle joint, 11) foot, 12) arm with shoulder, 13) arm, 14) hand, 15) injuries of peripheral nervous system Hands are the most often evaluated part of the body by doctors. Injuries of hands constitute 20% of all evaluated parts of the body. The average value of permanent impairment to health is 3.1%. In 6.7% cases of hand injury evaluation, doctors did not state a permanent impairment to health. The most severe injuries--amputations constituted 9.6% of cases.
