{"id":13262,"date":"2019-08-20T12:56:28","date_gmt":"2019-08-20T12:56:28","guid":{"rendered":"https:\/\/insuropedia.in?p=2151"},"modified":"2026-02-20T07:14:25","modified_gmt":"2026-02-20T07:14:25","slug":"when-and-how-to-raise-a-claim-under-doctors-pi-policy","status":"publish","type":"post","link":"https:\/\/securenow.in\/insuropedia\/when-and-how-to-raise-a-claim-under-doctors-pi-policy\/","title":{"rendered":"When does claims occur under DPI and how to raise a claim?"},"content":{"rendered":"<div id=\"bsf_rt_marker\"><\/div><h4>A Doctor\u2019s Professional Indemnity insurance policy covers instances of death, physical injury, or disability due to medical negligence or unintentional errors. The policy covers legal costs in case of lawsuits. It also bears settlements associated with such cases.<\/h4>\n<p>The Doctor&#8217;s PI Policy claims are of the type known as legal liability. This policy covers only civil liability claims. The claim will not be payable if there is criminal liability involved.<\/p>\n<h2 data-path-to-node=\"5\">Key Takeaways<\/h2>\n<ul data-path-to-node=\"6\">\n<li>\n<p data-path-to-node=\"6,0,0\"><b data-path-to-node=\"6,0,0\" data-index-in-node=\"0\">Immediate Intimation is Mandatory:<\/b> In 2026, insurers are strict about timelines. You must notify the company the moment you receive a legal notice or summons. Delaying this notification can give the insurer grounds to reject your claim.<\/p>\n<\/li>\n<li>\n<p data-path-to-node=\"6,1,0\"><b data-path-to-node=\"6,1,0\" data-index-in-node=\"0\">The Duty of Care Principle:<\/b> A successful claim requires proof that the incident happened while you were professionally responsible for the patient. If the negligence is proven to have caused suffering or death, the policy covers the resulting financial fallout.<\/p>\n<\/li>\n<li>\n<p data-path-to-node=\"6,2,0\"><b data-path-to-node=\"6,2,0\" data-index-in-node=\"0\">Continuous Coverage Matters:<\/b> Your <b data-path-to-node=\"6,2,0\" data-index-in-node=\"34\">Retroactive Period<\/b> is your most valuable asset. It allows you to claim for an incident that happened 3 years ago, provided you have been renewing your policy without a single day&#8217;s break.<\/p>\n<\/li>\n<li>\n<p data-path-to-node=\"6,3,0\"><b data-path-to-node=\"6,3,0\" data-index-in-node=\"0\">AOA:AOY Calculation:<\/b> Every payout is deducted from your total annual limit (<b data-path-to-node=\"6,3,0\" data-index-in-node=\"76\">AOY<\/b>). For example, if your AOY is \u20b91 Crore and you settle a case for \u20b940 Lakhs (AOA), you only have \u20b960 Lakhs left for any other claims that might arise during the same year.<\/p>\n<\/li>\n<li>\n<p data-path-to-node=\"6,4,0\"><b data-path-to-node=\"6,4,0\" data-index-in-node=\"0\">Written Records are Proof:<\/b> When raising a claim, your first interaction must be in writing. This creates the &#8220;documentary proof&#8221; required for auditors and legal teams to start the reimbursement or cashless defense process.<\/p>\n<\/li>\n<\/ul>\n<h2><strong>Conditions<\/strong><\/h2>\n<p>A civil liability claim will fall under this policy when the patient or the family provides prima facie evidence of the doctor\u2019s negligence that resulted in injury or death.<\/p>\n<p>Besides, the negligence should have occurred while the doctor was on duty to care for the patient. The claim also covers negligence causing death or suffering to the patient.<\/p>\n<h2><strong>How to raise a claim under a Doctor&#8217;s PI Policy?<\/strong><\/h2>\n<p>In case of <a href=\"https:\/\/securenow.in\/profession\/doctor-professional-indemnity-insurance\">liability<\/a>, the insurance company should be immediately notified. The insured must submit all notices and summons received.<\/p>\n<p>The doctor can either hire a legal defense or ask the insurance company to do so. However, the policy should cover the same.<\/p>\n<p>The incident should take place during the policy period of the retroactive period. The latter is the period when the doctor has had continuous coverage.<\/p>\n<p>The insured should make the first claim in writing for documentary proof. The AOA (Any One Accident) limit determines the claim amount.<\/p>\n<p>The claim amount is removed from the AOY (Any One Year) limit. This is termed <u>AOA: AOY<\/u> under the policy.<\/p>\n<p>The insurance company will accept multiple claims provided the aggregate amount does not cross the policyholder\u2019s AOY limit.<\/p>\n<h3 data-path-to-node=\"2\">Summary: The DPI Claim &amp; Coverage Framework<\/h3>\n<div class=\"horizontal-scroll-wrapper\">\n<div class=\"table-block-component\">\n<div class=\"table-block has-export-button\">\n<div class=\"table-content not-end-of-paragraph\" data-hveid=\"0\" data-ved=\"0CAAQ3ecQahgKEwjhoOnS4suSAxUAAAAAHQAAAAAQ0BU\">\n<table data-path-to-node=\"3\">\n<thead>\n<tr>\n<td><strong>Feature<\/strong><\/td>\n<td><strong>Requirement \/ Definition<\/strong><\/td>\n<td><strong>2026 Practical Application<\/strong><\/td>\n<\/tr>\n<\/thead>\n<tbody>\n<tr>\n<td><span data-path-to-node=\"3,1,0,0\"><b data-path-to-node=\"3,1,0,0\" data-index-in-node=\"0\">Civil Liability<\/b><\/span><\/td>\n<td><span data-path-to-node=\"3,1,1,0\">Unintentional negligence or error.<\/span><\/td>\n<td><span data-path-to-node=\"3,1,2,0\"><b data-path-to-node=\"3,1,2,0\" data-index-in-node=\"0\">Covered<\/b>: Includes legal fees and settlements.<\/span><\/td>\n<\/tr>\n<tr>\n<td><span data-path-to-node=\"3,2,0,0\"><b data-path-to-node=\"3,2,0,0\" data-index-in-node=\"0\">Criminal Liability<\/b><\/span><\/td>\n<td><span data-path-to-node=\"3,2,1,0\">Intentional harm or illegal acts.<\/span><\/td>\n<td><span data-path-to-node=\"3,2,2,0\"><b data-path-to-node=\"3,2,2,0\" data-index-in-node=\"0\">Excluded<\/b>: Insurers do not pay for criminal defense.<\/span><\/td>\n<\/tr>\n<tr>\n<td><span data-path-to-node=\"3,3,0,0\"><b data-path-to-node=\"3,3,0,0\" data-index-in-node=\"0\">Prima Facie Evidence<\/b><\/span><\/td>\n<td><span data-path-to-node=\"3,3,1,0\">Initial proof of negligence or injury.<\/span><\/td>\n<td><span data-path-to-node=\"3,3,2,0\">Required to trigger the insurer&#8217;s defense team.<\/span><\/td>\n<\/tr>\n<tr>\n<td><span data-path-to-node=\"3,4,0,0\"><b data-path-to-node=\"3,4,0,0\" data-index-in-node=\"0\">AOA Limit<\/b><\/span><\/td>\n<td><span data-path-to-node=\"3,4,1,0\">Any One Accident (Per claim cap).<\/span><\/td>\n<td><span data-path-to-node=\"3,4,2,0\">The maximum payout for one single lawsuit.<\/span><\/td>\n<\/tr>\n<tr>\n<td><span data-path-to-node=\"3,5,0,0\"><b data-path-to-node=\"3,5,0,0\" data-index-in-node=\"0\">AOY Limit<\/b><\/span><\/td>\n<td><span data-path-to-node=\"3,5,1,0\">Any One Year (Annual aggregate cap).<\/span><\/td>\n<td><span data-path-to-node=\"3,5,2,0\">The total &#8220;pot&#8221; available for all claims in a year.<\/span><\/td>\n<\/tr>\n<tr>\n<td><span data-path-to-node=\"3,6,0,0\"><b data-path-to-node=\"3,6,0,0\" data-index-in-node=\"0\">Retroactive Period<\/b><\/span><\/td>\n<td><span data-path-to-node=\"3,6,1,0\">Continuous years of prior coverage.<\/span><\/td>\n<td><span data-path-to-node=\"3,6,2,0\">Protects against claims for surgeries done years ago.<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<h3><strong>Exclusions<\/strong><\/h3>\n<p>The policyholder should also be aware of the <u>exclusions<\/u> in this policy and avoid making claims for them. Moreover, the insurer rejects such claims.<\/p>\n<p>A Doctor&#8217;s PI Policy covers a medical practitioner&#8217;s personal financial liability. This policy is available for various types of medical establishments and consultants like General Physicians, and specialists such as Radiologists, Pediatricians, Cardiologists, and various kinds of Surgeons and Dentists.<\/p>\n<p>However, policyholders should acquaint themselves with instances that lead to a successful claim under the policy and the relevant process. This will help in settling a claim successfully.<\/p>\n<h3 data-path-to-node=\"8\">Frequently Asked Questions (FAQs)<\/h3>\n<h4 data-path-to-node=\"9\"><b data-path-to-node=\"9\" data-index-in-node=\"0\">Q1: What exactly is &#8220;Prima Facie&#8221; evidence in a medical claim?<\/b><\/h4>\n<p data-path-to-node=\"9\"><strong>A)<\/strong> It refers to the initial &#8220;on the face of it&#8221; evidence that suggests a mistake was made\u2014such as an X-ray showing a forgotten surgical instrument or a report showing a wrong dosage. This evidence is needed to start the legal claim process.<\/p>\n<h4 data-path-to-node=\"10\"><b data-path-to-node=\"10\" data-index-in-node=\"0\">Q2: Can I hire my own lawyer or must I use the one provided by the insurer?<\/b><\/h4>\n<p data-path-to-node=\"10\"><strong>A)<\/strong> Most policies in 2026 allow you to choose. You can hire a lawyer you trust and seek <b data-path-to-node=\"10\" data-index-in-node=\"160\">reimbursement<\/b>, or you can use the insurer\u2019s specialized <b data-path-to-node=\"10\" data-index-in-node=\"216\">medico-legal panel<\/b>, which is often more convenient as the insurer pays them directly.<\/p>\n<h4 data-path-to-node=\"11\"><b data-path-to-node=\"11\" data-index-in-node=\"0\">Q3: What happens if I have three small claims in one year?<\/b><\/h4>\n<p data-path-to-node=\"11\"><strong>A)<\/strong> You can make multiple claims throughout the policy year as long as the <b data-path-to-node=\"11\" data-index-in-node=\"130\">total aggregate amount<\/b> (including all legal fees and settlements) does not exceed your <b data-path-to-node=\"11\" data-index-in-node=\"217\">AOY (Any One Year)<\/b> limit.<\/p>\n<h4 data-path-to-node=\"12\"><b data-path-to-node=\"12\" data-index-in-node=\"0\">Q4: Will the policy pay if a patient dies, but I am cleared of negligence?<\/b><\/h4>\n<p data-path-to-node=\"12\"><strong>A)<\/strong> Yes. Even if you win the case and are found &#8220;not negligent,&#8221; the policy still pays for your <b data-path-to-node=\"12\" data-index-in-node=\"167\">Defense Costs<\/b> (the lawyer&#8217;s fees and court expenses incurred while proving your innocence).<\/p>\n<h4 data-path-to-node=\"13\"><b data-path-to-node=\"13\" data-index-in-node=\"0\">Q5: Is there any scenario where a civil claim would be rejected?<\/b><\/h4>\n<p data-path-to-node=\"13\"><strong>A)<\/strong> A claim can be rejected if the procedure was outside your declared specialty, if you were intoxicated, or if the incident occurred before your <b data-path-to-node=\"13\" data-index-in-node=\"208\">Retroactive Date<\/b> (the start of your continuous insurance history).<\/p>\n<p><script type=\"application\/ld+json\">\n{\n  \"@context\": \"https:\/\/schema.org\",\n  \"@type\": \"FAQPage\",\n  \"mainEntity\": [\n    {\n      \"@type\": \"Question\",\n      \"name\": \"What exactly is \\\"Prima Facie\\\" evidence in a medical claim?\",\n      \"acceptedAnswer\": {\n        \"@type\": \"Answer\",\n        \"text\": \"It refers to the initial \\\"on the face of it\\\" evidence that suggests a mistake was made\u2014such as an X-ray showing a forgotten surgical instrument or a report showing a wrong dosage. 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You can hire a lawyer you trust and seek reimbursement, or you can use the insurer\u2019s specialized medico-legal panel, which is often more convenient as the insurer pays them directly.\"\n      }\n    },\n    {\n      \"@type\": \"Question\",\n      \"name\": \"What happens if I have three small claims in one year?\",\n      \"acceptedAnswer\": {\n        \"@type\": \"Answer\",\n        \"text\": \"You can make multiple claims throughout the policy year as long as the total aggregate amount (including all legal fees and settlements) does not exceed your AOY (Any One Year) limit.\"\n      }\n    },\n    {\n      \"@type\": \"Question\",\n      \"name\": \"Will the policy pay if a patient dies, but I am cleared of negligence?\",\n      \"acceptedAnswer\": {\n        \"@type\": \"Answer\",\n        \"text\": \"Yes. Even if you win the case and are found \\\"not negligent,\\\" the policy still pays for your Defense Costs (the lawyer's fees and court expenses incurred while proving your innocence).\"\n      }\n    },\n    {\n      \"@type\": \"Question\",\n      \"name\": \"Is there any scenario where a civil claim would be rejected?\",\n      \"acceptedAnswer\": {\n        \"@type\": \"Answer\",\n        \"text\": \"A claim can be rejected if the procedure was outside your declared specialty, if you were intoxicated, or if the incident occurred before your Retroactive Date (the start of your continuous insurance history).\"\n      }\n    }\n  ]\n}\n<\/script><\/p>\n<p><b>About The Author<\/b><\/p>\n<p><strong>Saloni Mishra\u00a0<\/strong><\/p>\n<p><span style=\"font-weight: 400;\">MBA Insurance Management<\/span><\/p>\n<p><span style=\"font-weight: 400;\">With an illustrious career in the insurance sector, <\/span><span style=\"font-weight: 400;\">Saloni<\/span><span style=\"font-weight: 400;\"> is a distinguished writer specializing in articles concerning doctor professional indemnity policies for SecureNow. Leveraging 12 years of hands-on experience, <\/span><span style=\"font-weight: 400;\">she<\/span><span style=\"font-weight: 400;\"> understands the intricate nuances of professional indemnity insurance tailored specifically for medical professionals. Her articles offer invaluable insights into the significance of doctor professional indemnity coverage, addressing the unique risks and challenges healthcare practitioners face. Renowned for their expertise and attention to detail, <\/span><span style=\"font-weight: 400;\">Saloni<\/span><span style=\"font-weight: 400;\"> is committed to providing readers with informative and actionable content that empowers them to make informed decisions regarding their insurance needs.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>A Doctor\u2019s Professional Indemnity insurance policy covers instances of death, physical injury, or disability due to medical negligence or unintentional errors. The policy covers legal costs in case of lawsuits. It also bears settlements associated with such cases. The Doctor&#8217;s PI Policy claims are of the type known as legal liability. This policy covers only [&hellip;]<\/p>\n","protected":false},"author":5,"featured_media":0,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"om_disable_all_campaigns":false,"_lmt_disableupdate":"no","_lmt_disable":"no","_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[484,976],"tags":[624],"class_list":["post-13262","post","type-post","status-publish","format-standard","hentry","category-doctors-professional-indemnity","category-claims-doctors-professional-indemnity","tag-doctors-professional-indemnity"],"acf":[],"modified_by":"SecureNow","_links":{"self":[{"href":"https:\/\/securenow.in\/insuropedia\/wp-json\/wp\/v2\/posts\/13262","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/securenow.in\/insuropedia\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/securenow.in\/insuropedia\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/securenow.in\/insuropedia\/wp-json\/wp\/v2\/users\/5"}],"replies":[{"embeddable":true,"href":"https:\/\/securenow.in\/insuropedia\/wp-json\/wp\/v2\/comments?post=13262"}],"version-history":[{"count":17,"href":"https:\/\/securenow.in\/insuropedia\/wp-json\/wp\/v2\/posts\/13262\/revisions"}],"predecessor-version":[{"id":35430,"href":"https:\/\/securenow.in\/insuropedia\/wp-json\/wp\/v2\/posts\/13262\/revisions\/35430"}],"wp:attachment":[{"href":"https:\/\/securenow.in\/insuropedia\/wp-json\/wp\/v2\/media?parent=13262"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/securenow.in\/insuropedia\/wp-json\/wp\/v2\/categories?post=13262"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/securenow.in\/insuropedia\/wp-json\/wp\/v2\/tags?post=13262"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}