Preventive Medicine Medical Professional Liability Insurance Supplement Medical Professional Liability Insurers Retrench as Tort Reform Comes Under Fire Inside: Hospitals Launch Cell Captives for Physician Members Shock Health Care Verdicts Drive Reinsurers to Rewrite Limits State and Territory Rankings of U.S. MPLI InsurersPage 2 Copyright A.M. Best Company 2022 All Rights Reserved. Observers See Prolonged Pain For Medical Professional Liability Market By David Pilla Profitability remains difficult for a medical profes- sional liability insurance market beset by inadequate rates, depressed demand and the challenges of the COVID-19 pandemic, according to market partici- pants. “One of the key things has been rate inadequacy, or I’ll say rate adequacy concerns, from our standpoint,” said David Blades, associate director, AM Best. “What we’ve seen in recent years is rate inadequacy has impacted the underwriting results.” Blades said there has been a precipitous rise in the combined ratio, showing the unfavorability of un- derwriting results in past couple of years. For 2019 to 2020, the combined ratios have been in the 112 to 113 range, he said. “We feel there’s still a lot of uncertainty in the market- place in terms of what we can expect and how the pan- demic will fully impact health care professionals and the insurers who provide their insurance for them,” said Blades. “We look at those factors in totality. We’ve seen that, from our standpoint, it made sense for us to maintain the negative outlook.” Blades’ comments came during an AM Best webinar on the MPL market, which examined underwriting and operating results, pandemic-related challenges in the health care industry and regulatory and industry developments. AM Best has a negative market segment outlook on the MPL insurance market, as explained in its annual report on MPL insurers. This segment could be facing one of its most difficult periods in the past decade or more, partly due to the COVID-19 pandem- ic, the report said. Despite a slight improvement in net income in 2020, U.S. MPL insurers saw their sixth-consecutive year of underwriting losses, according to AM Best’s report (BestWire, May 12, 2021). Even before COVID-19, social inflation was a concern for the MPL market with runaway verdicts and settle- ment values, Timothy J. Kenesey, president and chief executive officer, MedPro Group, said in the webinar. “There was a real sense that the tort bar was on the attack,” he said. “I think that the industry was starting to show signs that it was being impacted by that.” At the same time, Kenesey said rates were coming down when they should have been rising to reflect increasing claims severity, social inflation and rising costs. Even before the pandemic, he said the market was taking in a dollar and paying out $1.12 or $1.15. “The challenges we faced prior to COVID, we don’t think of as going away,” said Kenesey. “There was a pause, but we believe that severity and social inflation and then the pressure on increased settlement values is with us.” Claims costs are rising in the MPL market as doctors grapple with technology shifts made more urgent by COVID-19 and emerging issues such as cyber and medical marijuana, according to the founder and CEO of broker MedPLI (BestWire, Jan. 15, 2021). “The rates in the market are trending upward, CEO Max Schloe- mann said earlier this year. “We see not only more claims but costs to defend those claims are rising. Legal defense costs are going up and there have been a few large payouts. Insurance carriers have to offset those losses.” AM Best will continue to monitor reserves posted for recent accident years, the company said in its report. Loss frequency declined significantly in 2020 as non- essential procedures were either delayed or never performed due to the pandemic. However, the drop in frequency is likely to be short-lived as the segment may see an influx of pandemic-related claims for failure to diagnose, failure to protect patients, denial of care, allocation of scarce resources, and misdiagnosis of nonpandemic illness and disease due to canceled or delayed appointments, the report said. AM Best has maintained its negative outlook on the segment for 2021, in part on depressed demand over the past few years, with fewer independently practicing physicians, said Blades.Copyright A.M. Best Company 2022 All Rights Reserved. Page 3 “There are many stand- alone MPL companies,” Sharon Marks, associate director, AM Best, told BestWire. “Looking at the top 20 writers exhibit in the AM Best report, you can see that 14 of the top 20 writers are stand-alone MPL companies (Berkshire Hathaway, CNA, Liberty Mutual, Chubb, Berkeley, and Alleghany are the ex- ceptions). “Many of the MPL com- panies that we speak to feel that the trend of consolidation in the health care industry is poised to continue,” said Marks. “In- flation concerns and rising medical inflation could eventually push consolidation further. As health care providers continue to consolidate, they are looking for MPL carriers that have scale and breadth of operations to handle the increased complexity, which could fur- ther pressure on smaller MPL carriers that have more limited capacity.” “The diminishing percentage of independent medical practitioners has resulted in depressed demand for MPL product, as larger groups and hospitals are more likely to use captives or other self-insurance mecha- nisms, which takes them out of the commercial mar- ket,” said Marks. Kenesey said merger and acquisitions activity among MPL providers is seeing a pause even as he noted the recent closing of Norcal by ProAssurance. ProAssurance Corp. recently completed its acquisition of Norcal Insurance Co. following Norcal’s demutual- ization. The base consideration for the transaction at closing is $441 million. Proassurance last year said the deal would enhance ProAssurance’s scale and capa- bilities, expand access to the high-quality California physician market and deliver an expected $18 million in pretax synergies (BestWire, Feb. 21, 2020). “From the industry standpoint, it would actually sur- prise me if you saw a significant pace of M&A for MPL carriers, at least as it relates to 2021,” Kenesey said. “On the broker side and on the health care provider side, I think that the pace of acquisitions is going to continue robustly” although he said whether it’s hospital merg- ers or physicians joining together, the pace may have slowed a bit during the pandemic. Insurers need to think about whether consolidation is important to succeed, although MPL insurers can benefit from scale, said Kenesey. Many of MPL companies AM Best has spoken with indicated they have received relatively few COVID-19 claims so far, particularly for carriers writing mainly physician business, Marks said during the webinar. But in the conversations with these companies, she said many also indicated they’re being cautious and recog- nizing the benefit of those favorable frequency trends in their accident year 2020 loss ratio picks, given the uncertainty of the pandemic’s ultimate impact. Marks said 2020 also saw a slowdown in claims clos- ing rates as well as a decline in claims closed with payment, which contributed to a reduction in paid loss development. “We saw a decline in the amount of Page 4 Copyright A.M. Best Company 2022 All Rights Reserved. overall favorable development reported by the segment in 2020,” she said. “Looking at the longer term trend in the calendar year loss ratios, you can clearly see the deterioration over the prior five-year period, and that reflects not only the long-term trend of declining favorable prior-year development that we’ve talked about for a number of years now, but also the impact of rising loss costs and concerns about read adequacy rate and the concerns about rising severity,” said Marks. On the regulatory front, nearly 35 states have adopted some form of civil liability protections focused on care affected by the pandemic, said Brian Atchinson, presi- dent and CEO, Medical Professional Liability Associa- tion. He said the MPLA expects virtually all of those to be challenged in court but is cautiously optimistic that most will survive legal challenges. “One of the concerns is that many of them have expiry dates,” said Atchinson. “We’re starting to now see states start to extend those a year at a time. That could im- pact the climate for claims and for the business. We’ve paid close attention and we’ve worked with certainly a number of those states.” Atchinson said the MPLA hoped the federal govern- ment “might step in and do this across the board last year. When they didn’t, we provided the model legis- lation to all of the states, many of which worked with that to adopt those. We’re looking broader than that.” Many companies tend to look at calendar year losses rather than accident year, said William J. McDonough, president and CEO, Constellation. Looking at acci- dent year losses, he said four or five years ago, it was clear that prices need to change but companies haven’t responded in the way they should have. “We are starting to produce pricing that is more rea- sonable than it’s been in the past, but we’ve got a fairly long way to go,” he said. “When I look at this market, I see about a 2% or so increase in prices in the last year or two. That probably needs to be 10% to 15%, ulti- mately.” Over the next few years, pricing will strengthen, and it’s going to be beneficial for as long as the market deals with severity that has changed dramatically, as well as an aggressive plaintiff bar, said McDonough. He noted plaintiff attorneys tend to aggregate cases more than the defense bar. “We’ve got to be smarter, as carriers, in responding to this using national trial counsel when it’s appropriate and getting prepared for these cases much more ag- gressively than maybe we have in the past,” he said. The MPLA also has concerns about telemedicine, Atchinson said. While there have been federal exec- utive actions and some state actions expanding the widespread usage and availability of telemedicine throughout the pandemic, he said that area is “rife with inconsistencies and uncertainty in terms of what will be the ongoing availability and usage.” “No one ever thinks that genie’s going to go back in the bottle, but we still have great concerns about the legal elements of telemedicine,” he said. Admiral Insurance VP: MPLI Clients Experiencing Rapid Expansion of Services By John Weber Greg Ferrell, vice president, professional liability, Ad- miral Insurance, said the health marketplace is encour- aging growth and aggregation for insureds. He spoke with AM Best TV at the Wholesale & Specialty Insur- ance Association Conference in San Diego. View the video version of this interviewat: http://www. ambest.com/v.asp?v=ferrell1121 Following is an edited transcript of the interview. Q: Let’s talk a little bit about medical professional liability. What are you noticing in the market these days?Copyright A.M. Best Company 2022 All Rights Reserved. Page 5 A: A lot of growth, a lot of expansive growth, aggrega- tion of exposure. We’re seeing insureds growing organ- ically, which from our standpoint, is phenomenal, but you do have to be able to adjust for those insureds as they go. It’s a marketplace that’s continuing to do what I think we’ve seen it do the last three to four years, which is double-digit growth year over year. Q: What’s changing in the way of MPLI, if anything at all? A: I think that the changes we’re seeing are much more on the insured side, not necessarily from the provision of coverage. We’re looking at insureds that are expanding their services, that are expanding what they do. They’re getting into new areas. They’re taking advantage of the marketplace that allows them to do that. We as carriers have to do our diligence in determining what that exposure is, what it means to us, and how we address it going forward. Q: How important is communication, especially between the carrier and the broker, when it comes to MPLI? A: I would say line item one, and probably 1A and 1B. Understanding, especially earlier on, what may be the pressure points of exposure are, what that insured is receptive to or not receptive to, but ultimately, the baseline, what are we intending to cover, what are they expecting us to cover? What we’re providing is a promise, and if we don’t un- derstand — both parties don’t understand — what that promise is, it’s dead in the water from the jump. Q: Do you think it’s being articulate the way it should be? A: At points, yes. I do think, though, as things change, and they move rapidly, it is hard for everyone to keep up in that process. It really is about the upfront communication and the consistency of it, I think, as much as anything else. Q: Where is MPLI headed? A: More growth, more growth. Certainly, more expan- sion of what the ultimate insureds are doing. You’re going to see further aggregation of insureds, especially at the entity level, and certainly, more capital coming into the markets. It’s very profitable, and it’s growing. View this and other interviews at http://www.ambest.tv 2021 Best’s Rankings: US MPLI Direct Premiums Written Grows 3.3% By Timothy Darragh Direct written premiums for U.S. medical profession- al liability insurers increased 3.3% to $10.1 billion in 2020, while among the top 100 MPL insurers, direct premium written grew 3.6% to $9.9 billion, according to a new Best’s Rankings Report. Berkshire Hathaway Insurance Group led the pack with $1.71 billion in direct premiums written, up 3.3%. Eight of the top 10 MPL insurers saw direct premi- ums written grow in 2020, with No. 3, Liberty Mutual Page 6 Copyright A.M. Best Company 2022 All Rights Reserved. Insurance Cos., realizing the highest growth of 20.7% to $262.9 million. ProAssurance Group recorded the largest decline in the top 10 — a 7.5% drop to $796 million. The three-page report lists the top 100 U.S. MPL writ- ers, 2020 direct premiums written and change from 2019, market share and adjusted loss ratios for 2018- 2020 and the share of MPL in the companies’ total book of business. Berkshire’s MedPro Acquires Swiss Re Corporate Solutions’ Medical Professional Liability Business By David Pilla Berkshire Hathaway Inc.’s MedPro Group said it agreed to acquire the renewal rights to Swiss Re Cor- porate Solutions’s health care professional liability book of business effective Oct. 11. The agreement includes hospital and senior care ac- counts underwritten by SRCS from the United States as well as U.S. hospital and international health care professional liability accounts underwritten by SRCS from London and other offices around the world, said MedPro in a statement. “Current SRCS policyholders will be eligible to receive renewal offers from MedPro and its affiliates upon the expiration of their policies,” MedPro said. “To help ensure seamless service, several key members of the SRCS health care team are joining MedPro.” “On July 31, 2019, Swiss Re Corporate Solutions announced the decision to discontinue its health care professional liability (medical malpractice) exposure that was previously covered by North American Ca- pacity Insurance Company, an SRCS company,” said Swiss Re in an email to Best’s News Service. “SRCS has reached an in-principle agreement to transfer the re- newal rights for that line of business to MedPro Group. Impacted policyholders will be eligible to receive re- newal offers from MedPro Group upon the expiration of their policies.” The transaction shows MedPro’s dedication to the “challenging” U.S. health care liability market “and, increasingly, around the world,” said Jean-Paul Rebil- lard, president, MedPro Specialty, in a statement. He said SRCS’s “health care professional liability clients and approach to underwriting and service complement our industry-leading specialty business that provides solutions to health care organizations of all types.” A MedPro spokesman said the company has no further comment. MedPro Group has over $1.6 billion in premiums, the company said. Berkshire Hathaway was the largest MPLI writer by 2018 direct written premiums, accord- ing to AM Best. Swiss Re was the 72nd-largest, with $16.1 million in direct written premiums in 2018. In September SRCS said it was “significantly reduc- ing” its exposure in the Australian aviation insurance market as part of a global strategy to improve profit- ability (Best’s News Service, Sept. 3, 2019). The com- pany earlier said it was pulling out of the marine cargo insurance market in London (Best’s News Service, Aug. 21, 2019). Most underwriting entities of Berkshire Hathaway Inc. have current Best’s Financial Strength Ratings of A++ (Superior) and A+ (Superior). Swiss Re Corporate Solutions Ltd. is rated A+ (Superior). Risk AdviserThe Fallout of High-Value Verdicts Paul Horgan Jury awards have gotten out of hand. Insurers and their corporate customers need to pressure legislators to rein in nuclear verdicts.Copyright A.M. Best Company 2022 All Rights Reserved. Page 7 In June 2021, jurors handed down a $222 million ver- dict against a power company in Kansas, where a plant operator was killed in a steam accident. The same month, a plaintiff in Illinois who suffered paralyzing injuries when a bar employee forcibly re- moved him and dropped him on his head, fracturing his vertebrae, won a $51 million verdict against the bar owner. These are just two recent examples of what is known as a “nuclear verdict,” an exceptionally high jury award that exceeds what most would consider reasonable. These types of verdicts are becoming more common and are being driven, in part, by aggressive and ef- fective plaintiff’s attorneys and jurors’ beliefs that big corporations must be punished for their misdeeds. These factors, coupled with other societal trends, make up what is commonly called “social inflation.” Some of these societal trends hinge on the value of money. When a single lottery winner can take home more than $100 million and CEOs can earn more than $10 million a year, it’s not hard to convince a jury that someone who was wronged by a big corporation is due a hefty payout. Making matters worse is the ad- vent of a litigation finance busi- ness model in which third-party investor groups provide capital to law firms involved in personal injury and liability litigation in return for some financial recovery once the lawsuits are resolved. Plaintiff’s attorneys are putting their money behind advertising, appearing on television, in print publica- tions, online and on giant billboards seeking oppor- tunities for actions on everything from auto accidents and medical malpractice to opioid and pesticide use. Those highway billboards aren’t cheap, but they’re proving to be worth the investment for plaintiff’s attor- neys. The insurance industry has taken notice. It is, after all, the insurance providers that help provide defense counsel for many of these cases. And the rising price of losing big is putting a strain on corporations and their insurers. So, what can be done to counter this trend? The good news is that defense counsel have learned from the highly successful tactics of plaintiff’s attor- neys and, as such, are employing some of the same techniques to win arguments inside the courtroom. To effect change at the state and federal levels, the insurance industry has aligned itself with other groups, including the U.S. Chamber Institute for Legal Reform and the American Tort Reform Association. But the insurance industry and a handful of like-minded organi- zations can’t do it alone. Corpo- rations that are most impacted by social inflation and subject to nuclear verdicts will need to be the face of tort reform. The rising cost of liability lawsuits is costing companies billions of dollars, and the issue won’t go away until it becomes a priority for the business community. That’s why it is critical for corporations to exert pressure on their state and federal legisla- tors to put an end to this. Just a few years ago, the top verdicts in the United States were measured in the millions of dollars, accord- ing to data compiled by TopVerdict.com. Today, it’s in the billions. And the median settlement of the top 50 U.S. verdicts rose from $28 million in 2014 to $58 mil- lion in 2018, according to a report,Insurance Market- place Realities 2020, from Willis Towers Watson. This represents an unsustainable trend for corporations and their insurance providers. It’s a trend that will cause insurance rates to rise and capacity to shrink. Without a strong defense, nuclear verdicts will become the norm, and the fallout will be devastating.Page 8 Copyright A.M. Best Company 2022 All Rights Reserved. Coverys Launches Specialty MGA AEC Europe in Barcelona By Renee Kiriluk-Hill Coverys European Holdings has launched managing general agent AEC Europe in Barcelona, expanding its specialty MGA operations. AEC Europe underwrites professional indemnity, directors and officers, medical professional liability and cyber. A panel of insurers, reinsurers and Lloyd’s syndicates provide capacity, it said in a statement. Coverys European has appointed Ana de Oliveira, who was previously a professional lines senior underwriter at ANV Global Services, to lead AEC Europe. The MGA will offer instant quotes, electronic place- ment, improved policy administration and real-time risk and claims insights. Coverys Euro- pean Holdings Ltd. invests in specialty MGAs across continental Europe and the United Kingdom. Operating entities of Coverys parent Medical Profes- sional Mutual Insurance Co. currently have a Best’s Financial Strength Rating of A (Excellent). Insurers’ Defense-Related Loss Costs Rising For Lines of Business 1Most Susceptible to Litigation Defense and cost containment (DCC) expenses for certain lines of property/casualty insurance business are elevated compared with other lines; in particular, medical professional liability and product liability, according to a new AM Best report. DCC expenses include defense, litigation and medi- cal cost containment—essentially,the cost of settling a claim. The Best’s Special Report, “Defense-Related Loss Costs Rising for Lines Most Susceptible to Heavy Litigation,” notes that as insurance claims become increasingly severe and more complex, insurers have put more focus on working with risk professionals and other stakeholders to limit defense costs. According to the report, the higher DCC expenses attributable to medical professional liability policies have been associated with expert witness fees, costs to secure medical records and other allocated costs involved in defending physicians. A drop in the med- ical professional liability segment’s DCC ratio in 2020 likely reflected a benefit from court closures due to the pandemic. In the product liability line, some of the costlier cases have involved protracted litigation typically stemming from product and food recalls. “A number of factors have led to a higher amount of recalls, including enhanced regulatory scrutiny and improved technology,” said Christopher Graham, se- nior industry analyst, industry research and analytics, AM Best. “These are positive developments for some industries but a negative for insurers given the height- ened potential for lawsuits.” According to the report, the ratio of net DCC expenses to annual incurred losses overall has dropped in the last decade, even on the lines most prone to high-pro- file lawsuits, which in addition to product liability and medical professional liability, can include worker’s compensation and auto liability. “Predictive analytics for claims handling has helped speed up the claims process and, in turn, has limited claim expenses,” said David Blades, director, industry research and analytics.Copyright A.M. Best Company 2022 All Rights Reserved. Page 9 Alabama - Medical Professional Liability 01. ProAssurance Indemnity Company, Inc. https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=3826 02. MAG Mutual Insurance Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=1936 03. Inspirien Insurance Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=12609 04. Centennial Casualty Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=11506 05. Ironshore Specialty Insurance Co https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=13866 06. Southwest Physicians Risk Retention Grp https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=13903 07. Medical Protective Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=591 08. Columbia Casualty Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=3538 09. ProAssurance Casualty Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=2698 10. Professional Security Insurance Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=12670 11. National Fire & Marine Insurance Co https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=2428 12. American Casualty Company of Reading, PA https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=2127 13. State Volunteer Mutual Insurance Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=3706 14. Doctors Company, An Interinsurance Exch https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=3686 15. Red Clay Risk Retention Group, Inc. https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=14007 16. Health Care Industry Liab Recip Ins RRG https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=76172 17. Hilltop Specialty Insurance Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=12631 18. Medical Security Insurance Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=10744 19. Hallmark Specialty Insurance Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=10838 20. Coverys Specialty Insurance Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=22370 21. TDC Specialty Insurance Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=10763 22. Pharmacists Mutual Insurance Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=320 23. ProAssurance Insurance Co of America https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=1832 24. Liberty Insurance Underwriters, Inc. https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=3794 25. Admiral Insurance Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=3026 26. NCMIC Insurance Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=4848 27. NORCAL Insurance Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=3644 28. Steadfast Insurance Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=3557 29. Cincinnati Insurance Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=258 30. Aspen American Insurance Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=14149 31. Landmark American Insurance Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=12619 32. Evanston Insurance Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=3759 33. Capitol Specialty Insurance Corporation https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=1960 34. OMS National Insurance Company, RRG https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=10718 35. Ophthalmic Mutual Insurance Co (A RRG) https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=10844 36. Church Mutual Insurance Company, S.I. https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=259 37. Illinois Union Insurance Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=3510 38. Fair American Insurance and Reins Co https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=3727 39. Allied World Surplus Lines Insurance Co https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=11719 40. Kinsale Insurance Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=14027 41. General Star Indemnity Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=3806 42. Endurance American Specialty Ins Co https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=13033 43. Cincinnati Indemnity Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=10650 44. National Guardian RRG , Inc https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=11103 45. Preferred Professional Insurance Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=3699 46. ACE American Insurance Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=2257 47. Continental Insurance Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=2118 48. Caring Communities, a Reciprocal RRG https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=71152 49. Cincinnati Casualty Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=4289 50. Allied World Insurance Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=13865 51. Great Divide Insurance Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=11231 52. Sunland Risk Retention Group Inc https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=14370 53. Hudson Insurance Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=3081 54. Arch Specialty Insurance Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=12523 55. NORCAL Specialty Insurance Company https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=3744 56. American Assoc of Orthodontists Ins RRG https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=11808 57. National Union Fire Ins Co Pittsburgh PA https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=2351 58. Applied Medico-Legal Solutions RRG, Inc. https://consumers.ambest.com/CompanyProfile.aspx?BL=36&ambnum=76155 Insurers Writing Medical Professional Liability Insurance U.S. States and District of Columbia, Ranked by Market ShareNext >