Pediatrician held guilty of professional misconduct for certifying elderly person as diabetic and hypertensive"

"Big Blow to Insurance Company for repudiating claim based on fake medical certificate and Disciplinary Action initiated against Doctor for prescribing such fake Medical Certificate." 

Adv. Rohit Erande ©

Case Details :

ICICI PRUDENTIAL LIFE INSURANCE CO. LTD.V/s. Dattatrey Gujar

R.P. No. 3858/2017

Coram : Hon'ble Mr. Dr. S.M. Kantikar, Presiding Member

Hon'ble Mr. Dinesh Singh

Judgment Link :

http://cms.nic.in/ncdrcusersWeb/GetJudgement.do?method=GetJudgement&caseidin=0%2F0%2FRP%2F3858%2F2017&dtofhearing=2019-06-14

Facts in Short :

1. The dispute relates to repudiation of the complainant’s insurance claim. The Insurance Company repudiated the claim of the Complainant U/Sec.45 of the Insurance Act alleging that the the Complainant deliberately withheld information about his diabetes and its continuing treatment. The Complainant-Respondent took the mediclaim policy and after taking the policy, after 4 years Complainant  suffered the stomach pain and after necessary investigations he found to have renal problem and had to undergo kidney transplant and as the claim was repudiated  he filed the claim.

2. As the claim was repudiated, Complainant approached District Forum and claimed for Rs.5,53,375/-.+ Rs.2,00,000/- towards damages The District Forum relying on Judgment of Hon. Apex Court in the case of Amlendu Sahu v/s Oriental Insurance Co. Ltd., 11 (2010) CPJ 9 (SC), held that in case of claims which are rejected on technical grounds,  it is just for the Insurance company to pay to the Complainant 75 %  of the insurance claim amount and accordingly directed the Company to pay Rs.4,15,030/- to the Complainant, as being deficient in service. This order was confirmed by the State Commission too. 

Hence the Company approached National Commission.

Held :

1. The National Commission upheld the order of District Forum as the reasoned one and dismissed the Revision Petition filed by the Insurance Compay, but came heavily on the Insurance compnay and the Doctor. 

2. However, the opposite party Insurance Co. repudiated the claim by relying principally on one certificate  issued by one Dr. Rajendra G. Chandorkar which stated  that Mr. Dattatrey (the insured) was a known patient of diabetes and hypertension for the last 10 years.  The verbatim of the certificate is reproduced as under:

“This is to certify that Mr. Dattatray B. Gurjar is a regular pt. of mine and regularly comes for follow up regarding minor illness like cold / cough and fever.  He is a known pt. of Diabetes & Hypertension, since last 10 years.”

3. The National Commission came heavily and observed that  said Dr. Rajendra Chandorkar is a pediatrician,  he is neither a physician, nor an endocrinologist, to certify a person as a ‘diabetic and hypertensive for past 10 years’. It was also observed that  nothing is on record that the said Dr. Chandorkar has either examined or treated the complainant for diabetes or hypertension in the past 10 years and thus Ex facie, a suspicious medical certificate was issued. It is not viewed favourably. It therefore observed that  prima facie amounts to professional misconduct under the Code of Medical Ethics Regulation, 2002 of the Medical Council of India..

4. The Commission further held that the medical record of Bombay Hospital does not,  explicitly and categorically, confirm that the complainant was diabetic and hypertensive prior to 2008. Logically, and medically, time or onset of diabetes and / or hypertension cannot be accurately predicted. It further held that the complainant could possibly have started suffering from diabetes and / or hypertension subsequent to the year 2008, and it cannot be anyhow averred, on the basis of an ex facie suspicious certificate, that he was suffering from the same prior to 2018.

5.  Lastly the Commission observed that it would not like to turn a blind eye on the issuance of the ex facie suspicious medical certificate by the said Dr. Rajendra G. Chandorkar to unduly help the opposite party Insurance Co. in taking its principal ground for repudiation of the insurance claim. Issuance of such medical certificate is unethical and amounts to professional misconduct, which needs suitable action from the concerned professional regulatory body. To check such unethical medical practices we, thus, direct the Registrar of this Commission to refer this matter to the Maharashtra Medical Council, Mumbai, for the appropriate necessary action against Dr. Rajendra G. Chandorkar, as per the Council’s rules and wisdom.

6. The Commission dismissed the Revision and imposed additional fine of Rs.5 lakhs on the Insurance Company for using such certificate to repudiate the insurance claim which amounts to an unfair and deceptive act and  unfair trade practice.

From Doctors point of view, it is an this is very important judgment. Issuance of Medical Certificate is the routine matter for all the Doctors. But a care has to be taken. Now the observations made by the Ld. Commission raises certain questions and it is regarding What a Doctor of particular speciality can do and what he cannot. I remember a judgment of National Commission which held that "MD Medicine cannot practice as a Cardiologist". and another one wherein MBBS Doctor was fined for practicing as an Anesthetist without a PG Degree, even though he had  40 years of experience.  In the instant case, I feel even though Doctor had MBBS Degree, as he was practicing as a Pediatrician, the Commission must have held that he was unfit for issuing certificate. But if that Doctor would have really examined the patient, then would it be a different situation ?

Thanks and Regards,

Adv. Rohit Erande.

Pune. ©