This is the first in a series of articles addressing critical issues in risk management and insurance for skilled nursing facilities.
Owners and operators of skilled nursing facilities know that a claim or lawsuit against their facility is not a matter of if, but when. Procuring the proper insurance is critical to effectively managing and mitigating these risks. A professional liability insurance policy should provide coverage for the facility and its directors, administrators, and employees from claims of negligent care.
Unfortunately, merely purchasing a professional liability policy without further scrutiny can leave a facility uninsured for certain claims. These policies incorporate exclusions and conditions that insurers could cite to attempt to limit coverage, particularly for claims that allege intentional injury to a patient resident. For example, an injured patient could allege that her injury was not the result of mere negligence, but instead resulted from retaliation by the facility or the facility’s employee in response to a prior complaint. These retaliation claims pose an increased risk to a facility and its insurance coverage, regardless of whether they are alleged as an intentional tort under a state’s common law or as a violation of a state’s anti-retaliation statute.
In states where retaliation is specifically barred by statute, state laws can create additional liability and damages exposure for claims brought by residents who file formal complaints or bring regulatory actions against nursing facilities alleging retaliation. Earlier this year, for example, the Illinois Legislature passed a new anti-retaliation statute for nursing facilities, House Bill 2474, that broadens the scope of anti-retaliation protections. The Illinois bill, which has passed both houses and been sent to the governor’s office for signature, does not require a formal complaint, but can be triggered by a resident taking more informal action, such as making a request to the facility related to the resident’s care. In addition to potential liability for consequential damages, Illinois HB 2474 also makes nursing facilities liable to the plaintiff for attorneys’ fees and additional damages “in an amount equal to the average monthly billing rate for Medicaid recipients in the facility.” The damage provisions of Illinois HB 2474 differentiate it from other broad anti-retaliation statutes. For example, Minnesota expanded its Patients’ Bill of Rights in 2020 to protect nursing facility residents from retaliation for a host of actions, including advocating “for necessary or improved care or services” (M.S.A. § 144.6512). However, Minnesota’s statute does not provide for a private cause of action for residents to sue the facility.
Even if a state’s anti-retaliation statute does not specify additional damages or provide a private cause of action, retaliation claims brought as common law torts can nevertheless pose the risk of enhanced damages based on the facility’s perceived culpability – a risk not found in ordinary negligence actions.
Retaliation claims are a significant and thorny example of circumstances where allegations of negligent and intentional conduct can intertwine. Unless a statute identifies certain acts that constitute retaliation per se, the patient must necessarily prove an intent to retaliate – retaliation cannot be the result of mere negligence. But ordinary negligence and intentional retaliation could manifest in factually identical ways – with intent being the only distinguishing factor. For example, a resident allegedly injured in a fall while being helped out of bed by a facility employee could assert negligence. But if that same resident had complained to management about the quality of their care prior to the fall, the resident could also allege retaliation, asserting that they were allowed to fall in retaliation for the complaint.
Insurers could seize on retaliation allegations to deny coverage under several exclusions, including exclusions for expected and intended conduct and for willful violations of laws or regulations. Depending on the scope of the policy exclusions, insurers could assert that otherwise insured negligence claims are excluded retaliation claims.
To maximize the potential coverage for claims of retaliation or other intentional conduct bolted on to ordinary negligence claims, insureds should understand that the expected and intended exclusion does not exclude claims that an insured acted intentionally; the insurer must also prove that the insured intended to cause the alleged harm. Unfortunately, a retaliation claim arguably alleges that intent to cause harm if the actions can be attributed to the insured entity or individual.
Insureds can take four steps to mitigate anticipated insurer defenses to coverage for retaliation claims:
- First, insureds should seek language limiting the intentional conduct exclusion. The best limiting language would require a final adjudication of intentional conduct at trial (and after exhaustion of all appeals). Insurers could not invoke this exclusion in cases settled before trial.
- Second, insureds should confirm that any exclusions based on alleged willful statutory violations do not inadvertently encompass statutory retaliation claims.
- Third, because insurers may attempt to allocate liability among the negligence and retaliation claims to reduce their obligations for a settlement prior to trial, insureds should insist on favorable allocation provisions that do not leave the allocation to insurers’ discretion but instead require reasonable allocation based on an objective assessment of the claim.
- Finally, insureds should insist on policy provisions requiring the insurer to defend (or preferably pay the defense of) all asserted claims – including arguably excluded claims – as long as at least one claim potentially falls within coverage.
These four steps will provide insureds with additional insurance protection against statutory retaliation claims by limiting the defenses that insurers could otherwise assert in response to these claims. And as always, policyholders should scrutinize their professional liability insurance policies during renewal to maximize the coverage available to them. Many coverage enhancements do not impact premium – but they do require insureds’ diligence and awareness of coverage quagmires before binding insurance, as this discussion of retaliation claims shows.