Sharing medical information of patient by doctors ,how for ethical & reliable  

G. Vijaya Kumari of Vijayawada filed a case against SBI Life Insurance Company Ltd for rejecting request for waiver of home loan under SBI RIN Raksha home loan scheme on the basis of insurance investigation stating the reason suppressing material information at the time of taking policy .It’s interesting to note that the insurance company itself had issued certificate of good health and then issued the policy as per their rules. In this particular matter State Commission of Andhra Pradesh (decided the matter in august 2018)  went up to the extend warning the doctors and hospitals not to share patient information to insurance companies unless required by the court of law. Maintaining confidentiality of a patient’s medical aspects is not only the duty of a doctor but also a constitutional obligation. Court observed that while selling the policies, the insurance companies do not take care as to whether the intending purchaser is eligible for the policy or not. They in fact lure them through agents and sell policies only to improve their financial top line .But when they come to settlement of claims, they engage in all sorts of exercise, suspecting bona fides of the insured.

The Commission said that Doctors/hospitals should treat medical records and patient information as highly private and sensitive, to maintain doctor-patient confidentiality, and should adhere to regulations of Indian Medical Council of India

The question here to deal for us is –

Can the insurance companies be barred to conduct investigation and search for case history of the patient in the suspected cases of pre -existing disease

Keeping in mind the various judgments pronounced on mediclaim cases by the Apex court, we can surely say that insurance companies as well as doctors  need to respond as to why any investigation when issued certificate about the  good health of insured .Either their certificate is incorrect or investigation is used as a tool for rejecting the claim. Even otherwise if we see the pattern of investigation ,it is a short cut and eye wash by just managing  hospital records by the insurance companies from the doctors and often with no affidavits or any other cogent evidence.

In the present case claimant’s husband Seshagiri Rao had obtained Rs 22 lakh as housing loan from SBI. The insured covered the loan with a policy under SBI RIN Raksha Home Loan Scheme, by paying a premium of Rs 64,057. Seshagiri Rao died in 2014 due to Cancer and his wife requested Bank for waiver of the home loan .The claim was rejected for not disclosing true facts but gave no substantial proof. State commission directed SBI to settle the claim and refund the property documents with compensation to the tune of one lakh and cost of litigation Rs 25,000/-

Case study of various judgments go to show that hospital’ case record cannot be considered as final proof of a patient having any ailment prior to taking insurance for various reasons.

Firstly at the time of admitting the patient, it is routinely asked -how long you had been facing this problem.Patient generally tells about period of symptoms he had which may or may not be leading to disease known to him. There are many symptoms common in many diseases, hence a lay man cannot diagnose correctly. Such statements of patients are brought on record which becomes a part of history sheet later on understood as disease. This has been observed in number of cases and courts have pin pointed this mistake

Recently a very interesting case had come up before the National commission in the matter between Life Insurance Corporation Of India And P.R. Sumanagala,Revision Petition No. 2942 Of 2009 Against Order Dated 18.2.2009 In Appeal No. 627 Of 2003 Of Kerala State Consumer Disputes Redressal Commission—Decided On 15.2.2018

In this case claim was rejected on the basis of medical records and medical attendant’s certificate, with reasons shown as hereunder-

·         Insured was a diabetic patient for the past 15 years with irregular treatment as per the discharge summary of the medical college.

·         Treatment history supplied by the Holy Ghost Mission Hospital showing patient a known diabetic on regular treatment.

·          The Medical Attendant’s Certificate confirms that acute renal failure was secondary cause of death and the primary cause is mentioned as diabetes militias and the renal failure was result of long standing diabetes.

For reaching to this conclusion, no treatment record or any other evidence has been produced by the company that could prove insured getting treatment for diabetes prior to filling of proposal form. All treatment records filed by insurance were treatment record of hospital where he finally died .As per established norms in medical science,  kidney failure can be due to many reasons and it is not known when did it starts. Wife of insured asserts that insured was totally healthy

All the above allegation were later on found wrong during the cross examination of Doctor K Vijay kumar who signed the medical attendant’s certificate. He accepted in his cross-examination that he has not treated the patient and it was recorded that he was diabetic for 15 years on the basis of patient’s statement and symptoms he told. He has also admitted that kidney failure can be due to causes other than diabetes and there were no test to determine the duration of diabetes. Even in history recorded on 22 nd, May, 1998 at Kottayam Medical College mentions that he is not a diabetic or a hypertensive.

If this is the state of investigation report, how can it be a cogent evidence for rejecting the claim? This case further confirms that observations made by Andhra state commission is on right direction  that doctors and hospitals are giving reports under pressure of insurance companies.

It appears to us that insurance companies are cutting short their job and doing all eye wash in almost all cases where as there are clear procedure and criteria spelled out in number of cases dealt by the apex court

L.I.C. and Ors. v. Asha Goel, I (2001) SLT 89=(2001) 2 SCC 160, the Apex Court has reiterated that burden of proving that the insured had made, false representations and suppressed material facts is on the Corporation The position of law was stated that three conditions must fulfill for application of exclusion clause and for bringing the case under pre-existing disease. Second part of Section 45 is:

(a) The statement must be on a material matter or must suppress facts which were material to disclose;

(b) The suppression must be fraudulently made by the policy holder; and

(c) The policy holder must have known at the time of making the statement that it was false or that it suppressed facts which it was material to disclose.

Mulla's Indian Contract and Specific Relief Acts `any fact the knowledge or ignorance of which would materially influence an insurer in making the contract or in estimating the degree and character of risks in fixing the rate of premium is a material fact

Life Insurance Corporation of India v. Dr. P.S. Aggarwal, I (2005) CPJ 41 (NC). It has been held:

“ The onus to prove that there was material concealment of any disease, which directly proved fatal, was on the petitions Insurance Company. In addition to above, the petitioner was supposed to prove that at the time of taking policy, the person who gave the information, knew about such a disease and he withheld it with an intention to defraud the Insurance Company’

Here two things are very important to note- concealment of any disease which is directly proved fatal and not like a statement ‘the renal failure may be a result of long standing diabetes’ Knowledge of disease to the insurer is core fact to be proved by the company who alleges concealment.

In the matter before National Commission ,RP No. 2157 of 2014, New India Assurance Company Limited v. Rakesh Kumar, decided on 1.7.2014 (NC) has also been held -

“In some cases of diabetes, there are no symptoms. People can live for months, even years, without knowing they have the disease and it is often discovered accidentally after routine medical check-ups

It is further held-

‘even if the complainant was diabetic, he may not be having any knowledge of his disease and the Insurance Company has not proved beyond doubt that the insured had knowledge of his illness of diabetes prior to filling of the proposal form as no treatment record prior to date of filling up the proposal form has been produced. ‘Now coming to the ultimate findings, it is ample clear that investigation conducted by insurance companies and case history obtained from the doctors and Hospitals bear no substantial strength unless it is proved through other cogent evidence that the patient had consulted some doctors and had taken medicines for the particular disease, had the knowledge of the ailment which was a material fact suppressed by him at the time of submitting information to the insurance company. The observations made by the Andhra State commission shall go long way and it has support from earlier decided cases by the Apex court, the supreme court of India.

Dr Prem lata