Insurance company when refuses to indemnify negligent doctor

 

Yet another dimension in medical negligence cases. Hon’rable National Commission gives no relief to erring doctor who was found negligent while treating a patient and insurance company refused to indemnify the doctor who did not bother to inform the insurance company about the negligence case filed against him.

 A complaint was filed by one Mr. Narayan Chandra Saha before a consumer forum in west Bengal against a doctor for negligence and succeeded in it,doctor  was slapped with an amount of Rs 2, 67,750 as compensation by a Consumer forum in west Bengal. He filed an execution petition and after receiving the notice, doctor sent it to the insurance company for making the payment to the complainant as he had taken professional indemnity policy from New India Insurance Co. Insurance company refuses to pay the same as they were not informed by the doctor about the case filed against him, neither they were made party in the case.

Doctor after refusal by the insurance company comes before the consumer forum alleging deficiency in services on the part of insurance company .Consumer forum allowed the complaint. An appeal filed by the Insurance company against the order of consumer forum and State commission reverted the order of consumer forum favouring insurance company. Doctor now filed revision petition before the National commission

National commission in this matter of  Tarunjit Roy(Dr) versus New India Insurance Company went into detail of the case, checked thoroughly the points discussed by the State commission also. National commission is of the view that the clauses referred as terms & conditions specified in the insurance agreement are of vital importance for dealing with the question as to whether insurance company is deficient in services by repudiating the claim of the doctor when the Doctor has taken professional indemnity policy and has paid the premium.

For reaching to some logical conclusion National Commission checked with Clause 8.1 to 8.3 of the policy which requires following acts to be done by the insured doctor;

“The insured shall give written notice to the company as soon as reasonably practicable of any claims made against the insured and give all such additional information as the company may require. Every claim, writ, summons or process and all documents related to the events shall be forwarded to the company. Further, company will have right but in no case obligation to participate in the proceedings .Company shall not have any obligation to make payment if insured settles the claim on his own.”

In the present case, insured doctor sent the communication on 17.1.2008 in writing only after the award has been passed against him. No claim, summons or notice was sent to the company neither it was a party to the proceedings which is a clear violation of the terms .By doing so, insured have deprived the company of his right to watch the proceedings in CF case No 39/99 or to know the manner case has been defended by the doctor. Not only this, insured doctor did not file any appeal against the order passed by the forum .It was other OP in the same matter who filed an appeal No 233/A/2005 before the State Commission and succeeded. After an appeal is filed no information about the award was given to the Insurance Company. Further, when execution was filed by the complainant Narayan Chandra, Saha for realizing the awarded amount, insurance company was still kept in dark .Under the above circumstances, insurance is in no way deficient in services if they repudiate the claim at this stage.

 

We now hereby clarify a few things for consumers to understand and Consumers are not to fear any more    –

1.      Regarding reluctance of doctors to give opinion against doctor, it’s not always the patient who is asked to bring expert opinion It is the redressal agency also who send papers for expert opinion from Govt Hospitals and even from medical associations.

2.      If complete documents are not available with consumer, he may request the consumer forum to direct the doctors or hospital to produce the relevant documents and disclose the name of treating doctor for making him party if not known to the consumer.

3.      Medical literature if produced before the court must be of established norms under the medical science and not mare views of any doctor.

4.      Patient must disclose every fact about the ailment in order to get right method of treatment.

5.      Insurance companies if made party to the case with defendants, it is no more a matter to worry for them as both have to play their own roles and interest of consumer shall be taken care by the consumer protection agencies i.e. Consumer Commission for getting them justice.

6.      Getting panic and taking law of the land in hands weaken the case of consumer before the court of law by giving opportunity to the wrong doers to temper the documents well before time.

 

 

Dr Prem Lata

Ex-Member Consumer Commission

 

 

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