34ZZRWhen is an allied health exceptional claims indemnity payable?

34ZZR When is an allied health exceptional claims indemnity payable?

Criteria for payment of indemnity (1) The Chief Executive Medicare may decide that an allied health exceptional claims indemnity is payable in relation to a liability of a person (the practitioner) if: (a) a claim for compensation or damages (the current claim) is, or was, made against the practitioner by another person; and (b) a qualifying allied health claim certificate is in force in relation to the current claim; and (c) the liability is a qualifying allied health liability of the practitioner in relation to the current claim (see section 34ZZS); and (d) because of the practitioner’s contract limit in relation to the contract of insurance identified in the qualifying allied health claim certificate, the contract does not cover, or does not fully cover, the liability; and (e) the amount that, if the practitioner’s contract limit had been high enough to cover the whole of the liability, the insurer would (subject to the other terms and conditions of the contract) have been liable to pay under the contract of insurance in relation to the liability exceeds the actual amount (if any) that the insurer has paid or is liable to pay under the contract in relation to the liability; and (f) the aggregate of: (i) the amount (if any) the insurer has paid, or is liable to pay, in relation to the liability under the contract of insurance; and (ii) the other amounts (if any) that the insurer has already paid, or has already become liable to pay, under the contract in relation to the current claim; and (iii) the amounts (if any) that the insurer has already paid, or has already become liable to pay, under the contract in relation to any other claim against the practitioner that relates to an incident, or series of related incidents, covered by subsection (2) (being other claims that were first notified to the insurer no later than the time the current claim was notified to the insurer); equals or exceeds the relevant allied health threshold identified in the qualifying allied health claim certificate; and (g) a person has applied for the indemnity in accordance with section 37A.

Note 1: For how paragraphs (e) and (f) apply:

(a) if there are deductibles—see section 8B; or
(b) if an allied health high cost claim indemnity is paid or payable—see section 34ZZJ; or
(c) if the insurer is a Chapter 5 body corporate—see subsection (6); or
(d) if the claim relates to a series of incidents some, but not all, of which occurred in the course of the provision of treatment to a public patient in a public hospital—see section 34ZZT; or
(e) if the claim relates to a series of incidents some, but not all, of which occurred after the allied health termination date—see section 34ZZU.

Note 2: For the purpose of subparagraphs (f)(i) and (ii), payments and liabilities to pay must meet the ordinary course of business requirement set out in subsection (5).