The Indian Medical Council has expressed its disapproval of doctors’ ethical behaviour. The Ethics Committee of MCI found one doctor to have committed medical malpractice and issued a strong warning to be more cautious during the process as well as to be more vigilant in treating and monitoring his patients both during and after the operation. When evaluating claims for compensation for medical negligence, the Supreme Court noted that the conclusions of the Medical Council of India’s report on doctors’ professional conduct were pertinent. The Court further noted that the issue of negligent intent does not arise when damages for professional negligence are sought.

Dr Prem Lata, Legal Head VOICE

Case: Harnek Singh vs Gurmit Singh (SC) CA 4126-4127/2022 | 18 May 2022

The complainants in Harnek Singh v. Gurmit Singh case filed a petition with the State Consumer Disputes Redressal Commission seeking monetary damages in the amount of Rs. 62, 85,160 from the hospital, the doctors, and the surgeons for negligence and a lack of services. The opposing parties were ordered to pay Rs. 15, 44,000 in total (jointly and severally) as well as Rs. 10,000 in costs. The National Consumer Disputes Redressal Commission accepted the opposing parties’ appeal and overturned the SCDRC’s ruling that the complainants had not established negligence.

While the proceedings were pending before the SCDRC, the complainants had also made a complaint to the Punjab State Medical Council against the professional misconduct of the doctors/surgeons/hospitals. As this complaint got summarily disposed of, they filed appeals before the Medical Council of India. The Ethics Committee of MCI held one doctor medically negligent and issued a strict warning to be more careful during the procedure and to be more diligent in treating and monitoring his patients during and after the operation.

The complainants/appellants argued before the Apex Court in their appeal that the NCDRC made its ruling without considering the MCI finding. The SC bench said, with reference to the information in the MCI report, that the MCI’s assessment of and conclusions regarding the respondent’s professional behaviour are highly relevant. It observed- “The above-referred findings of the MCI on the conduct of Respondent 1 leave no doubt in our mind that this is certainly a case of medical negligence leading to deficiency in his services. We are of the opinion that the NCDRC has committed an error in reversing the findings of the SCDRC and not adverting to the evidence on record including the report of the MCI. The decision of the NCDRC deserves to be set aside and we hold that the complainants have made out a case of medical negligence against Respondents 1 and 2 and are entitled to seek compensation on the ground of deficiency of service.”

As a result, the court ordered the respondents to compensate the complainants with a total payment of Rs. 25, 00,000, along with interest calculated at 6% annually from the date of the SCDRC judgement.

Medical Professionals Collaborate with Insurance Firms to deny legitimate Claims

Consumer forums have observed that doctors on the insurance firms’ panel are deviating from their areas of competence and providing legal opinions rather than medical ones. When deciding whether to treat a claim as a case of a pre-existing disease or not, insurance companies consult the medical opinions of the doctors on their panel. These opinions are based on the panel doctors’ experience in the relevant field, their examination of the case history, the medications prescribed, and some independent research from reputable sources. Instead of offering a medical opinion, they are interpreting the pre-existing condition or exclusion clause in the law.

In one such instance, Dr. Satya Paul v. National Insurance Co. Ltd., the complainant’s claim was denied on the grounds that his pre-existing condition made him subject to the provisions of clause 4.3 of the insurance policy’s conditions. After reading the mediclaim policy’s terms and conditions, the Consumer Forum came to the conclusion that clause 4.3 applies in situations when an illness already exists. The insurance provider in this case repeatedly referred to the clause, claiming that the treatment was received within the first year of the contract, but they never explained how the condition was pre-existing. The Consumer Forum pinpointed the opinion of doctors on panel of the insurance company which the court found was just not medical opinion but legal opinion as well. Dr Batra`s report states as hereunder – “Diagnosis immature senile cataract, left-right. Mrs Sharma in this case has undergone cataract surgery within first year of the policy. Such treatment is specifically excluded vide exclusion clause 4.3 of the policy Hence this claim is not admissible as per the terms of the policy”.                                                                                                   

Further Dr Rajesh Chhabra has also given medical opinion as under – “This case in which the patient was admitted in the hospital with IMSC for phacoemulsification was justified for hospitalization. But since policy of the claimant is in the first year, so according to the terms and conditions of mediclaim policy, this comes under exclusion clause, so case should be closed as no claim. All other papers in the file are in order and are of diagnosed disease.”

Both the doctors have nowhere said that this disease was pre-existing They have not mentioned about any previous history or any report from any doctor, from any hospital or referred to any medicines taken by the patient for the said disease before undergoing for the operation of the diagnosed disease. Without establishing the disease pre-existing, this clause is not applicable at all. Apart from this, it is noted by the consumer forums that the doctors on panel are instead of giving medical opinion, are giving legal interpretation to the clauses which is actually to be done by the department concerned. This is the quasi-judiciary function to be done by either the legal department or personnel and administrative department and doctors on panel are in no way authorized to touch this area. It is the company to see whether the claim is tenable or not while interpreting the rules. Here it is seen that doctors are making legal opinions and interpreting the terms and taking the decisions also which doctors on panel are not supposed to do. Doctors are to give their professional/medical opinion about the disease, about the diagnosis, about the medicines taken, about the history of the ailment on the bases of their experience in the medical line. Both the doctors have done nothing on their part and virtually decided the claim not tenable though they have no authority to do so. It was the observation of the forum that the words were put into their mouths and they have tried to authenticate the decision by a professional opinion. A suggestion has been made for the doctors on panel by the Consumer forum to limit their opinion to their role and maintain the grace of the noble profession.

Regular Claim Rejection by Insurance Companies

During the last two decades, it has been observed that almost each and every mediclaim has been turned down on one or the other pretext by the insurance companies except a few in which the claimant managed to get the claim by offering bribe to the dealing man. The claim is invariably rejected on the plea of pre-existing disease and for concealment of fact at the time of filling up the prescribed form. This has also been seen by the consumer forums that the questionnaires of the said form are framed in such a manner that there cannot be any straight answer. At times, such forms are filled up by the agents of the insurance company who aims at bringing more and more cases/clients and they assure the insured to relax for everything and thousands of people are made to believe that they are totally secured once they have opted for mediclaim policy. In this process, whatever information has been given by the insurer, at the time of settling the claim, it is said to be untrue by the insurance company and the claim is rejected for giving the wrong statement and concealment of fact.

At the time of admission, the patient is typically asked a number of questions regarding his health. He typically responds informally, and the hospital records his response in the discharge report. This is the patient’s assertion, not the hospital’s conclusion based on test results. The medical professionals’ diagnoses and recommended treatments are the actual findings. Insurance firms exploit such allegations to their advantage when denying legitimate claims. When information is provided, a claim is made against any sickness that is alleged to have already existed. If there is cough and cold at any point of time, it is considered lungs problem pre-existing judging it the symptoms for the said disease. Uneasiness in breathing for any simple reason becomes heart ailment. If the hospital states in the patient’s discharge statement that they have had any problems for the past year or two,  then even a minor ache is related to a serious illness, without keeping any records of the tests, diagnosis, or other diagnostic procedures, etc.

In response, the Apex Court declared in its ruling that “Such summary from the hospital cannot be accepted as cogent proof for declaring the ailment pre-existing unless shown by medical tests or medicines used in the past for the aforementioned disease having knowledge of the same.”

In Asha Rani Goal v. National Insurance Company, a case from 2002, the Supreme Court flatly refused to accept a declaration obtained from the patient at the time of admission as genuine proof of a pre-existing condition.