Why Healthcare services should not be included within the purview of Consumer Protection Act

Medicos Legal Action Group is a Registered Trust formed by few doctors from all over the Country to look after interests and welfare of MBBS doctors and take legal action where needed. We  had  recently  filed  a  PIL, against inclusion of doctors under  the  purview of CPA 2019,  in  Bombay  High Court  and  thereafter  a  SLP  in  Honorable  Supreme Court where  our  petitions  have  been  dismissed  at  both  places. Though  we  have  lost  our  judicial campaign   we  remain  strongly  of  the  view  that maintaining  status  quo with  healthcare  remaining  under  the  purview  of  Consumer Protection Act  is  against  the  interest  of consumers, doctors as  well  as   the  nation.  

 

Consumer Protection Act introduced nearly 3 decades ago has been used to prosecute medical professionals for errors causing damage to patients under their care. This  legislative  and  judicial conversion  of  Doctors  into  traders resulted  in cases  of  alleged  medical  negligence  being  filed in  courts and what was a trickle in 1990s has turned into a deluge in the past few years. Each and every negative or sub optimal outcome of medical treatment is now perceived as negligence. This  has  caused  doctors  to start  practice of defensive  medicine  and  what  could  be  treated  clinically  is  now  investigated first, and  what  could  be  managed  at  home  is  now  managed  in  Intensive  Care  Units. Doctors who used  to  take  on  challenging  cases  with  a  firm  hand  and  a  strong  heart  now  treat  only  low  risk  patients  and  refer  others  to  higher  institutions. Doctors  who  are  senior  and  experienced do not consider taking  the  risk worthwhile  and the  younger  generation  of  doctors not  as  experienced. Younger  doctors  are  also  leaving  the  profession  or  the  country  demoralized  with  the  situation.

 

The Consumer courts are neither equipped nor is the summary nature of the process suited to adjudicate complicated issues related to medical treatment. The argument that medical negligence cases should not be decided by non medical courts was dismissed by honourable SC in IMA vs V P Shantha and Ors in 1995. The SC in this judgment however  had  made it clear that only outright cases of medical negligence like amputation of wrong limb, leaving swab or clamp in body, giving wrong anesthetic gases would be covered under Consumer Protection Act. Cases which required evidence of experts were not to be covered under CPA. What is standard medical practice in other hospitals or by other average surgeons was also held not to be negligence. 

 

 

However as we see it today dose of medicine, wrong diagnosis, method of treatment, conservative vs radical surgery, extension of surgical procedure depending on intra operative findings all have been adjudicated by consumer courts with the help of expert evidence even via video conferencing. Dragging doctors to consumer Fora with increasing frequency is a trend with disturbing consequences. This is not to deny any need for accountability. The process under CPA however is flawed and urgent remedial measures need to be made failing which private medical facilities which fulfill bulk of healthcare needs of the country will be forced to shut shop. Govt does not have the resources, inclination, or manpower to provide universal state sponsored healthcare. 

 

The quantum of compensation being awarded by courts today in cases of medical negligence is bordering on absurd with serious implications for medical profession and patients alike. Medical professionals as  mentioned earlier have now started practicing defensive medicine. While taking medical decisions doctors have to contend with an additional factor of what the courts view will be. The hand that holds the scalpel has become shaky . The sword of compensation claims of exorbitant amounts sufficient to exhaust a doctors lifetime (and maybe next 7 lives) earnings, is now hanging over every doctor’s head. 

 

For the patients also it is not good news because for every patient who claims compensation in crores, millions of other patients will pay for his indulgence by paying extra amounts charged by doctors to cover such eventualities. What is more absurd is the fact that as per law there is no cap on this amount and what was unthinkable 10 yrs ago is now a fact and  similarly 1000 crores may be unthinkable today but may become a fact 5 years later. 

 

Since compensation awarded is based on earning capacity of the victim , a rich industrialist could be awarded 100s of crores as per consumer Protection Act. Here the penalty is not commensurate with the crime whereas natural justice demands that for any crime the punishment has to be proportionate. Human life cannot be valued differently. So a CBD  injury during laproscopic cholecystectomy  will  be  awarded  different  penalty against  the same  surgeon and  same  hospital  depending  on  the  earning  capacity  of  the  patient.  

 

There is another horrendous aspect of this judgment. India is a resource poor country and in any large public hospital (which  is  also  covered  under  the  purview  of  Consumer Protection Act) emergency it is common to see many patients being ventilated by patient’s relatives using ambu bag while waiting for a ventilator / ICU bed. If two patients need a ventilator in a hospital and only one is available what will the doctor do. One patient is rich and can ask for compensation in crores, the other a pauper whose death will result in a nominal compensation. Is the doctor supposed to choose the rich and hence bring a bias into treatment decisions because of this  law. This is a frightening but real prospect not faced earlier by medical men. Are medical treatment and resources in India going to be the prerogative of the rich ? 

 

During treatment of a fatal disease, treatment given may lead to death earlier than the disease itself would have caused it. But this is the cornerstone of medicine. While handling an aneurysm it may burst causing bleeding to prevent which surgery was being done in the first place. By this argument no neurosurgeon should operate a head injury , no malignancy should be operated, no pancreatic abscess drained because in doing so death may occur. Despite actions of doctors being done in good faith unforeseen and adverse outcomes are now on basis of res ipsa loquitur condemned as negligence sometimes criminal. How is this comparable with killing or maiming normal healthy individuals either intentionally or contributing to it by negligence of a drunk driver of motor vehicle. 

 

Medical profession is unique and cannot and should not be compared with other service providers as defined in Consumer Protection Act. As practiced in India it is nothing short of miracle and thanks to the dedication, work ethics and empathy of doctors we have cure rates similar to most developed countries for most of the diseases. Experience in surgery and various procedures due to sheer volumes is far more of Indian doctors than some of the foreign dignitaries who come to give lectures in conferences. 

 

This is despite the fact that in India doctors have to battle and compete with Government sponsored quackery. Myths and misconceptions are deep rooted in Indian psyche. Working in such environment would be impossible for the foreign and NRI doctors and to try to impose standards and protocols of USA in India is nothing short of absurd. If we want ideal medical treatment it can only be provided in ideal treatment environment. 

 

The  recently  notified  Consumer  Protection  Amendment  Act 2019 has  removed  any  ceiling  on  the  quantum  of  compensation which can be asked  for  in  a  District  Commission. This has  increased  the  apprehension  of  doctors  regarding  increasing  number  and  the  amount  of  compensation  demands in future. The  increase  in  pecuniary  jurisdiction of various Commissions along  with  removal  of  penalty  for  frivolous  complaints  is  expected to  increase  litigation  against  doctors  manifold. Nearly  all  cases  of  alleged  medical  negligence  are  now  expected  to  be  filed  in  District  Commissions  and  the  introduction  of  the  Section 41 (CPA 2019) requiring 50% of compensation awarded to be deposited  before  going  in  for  appeal  will  also  ensure  that  cases  will  no  longer  be  taken  up  for  appeal, specially  so  since  indemnity  insurers  refuse  to  pay  interim payments. Since  judgments  of  State Consumer Courts, National Commission  and  High Courts & Supremet  Court  are  reported, they  are  in  public  domain, likely  to  be  examined. The  District  Commissions  judgments  are  not  reported  and  hence  all  Judgments  in  cases  of  alleged  medical  negligence  with  tend  to  be  arbitrary  and  without  any  fear  of  accountability.

 

The  V P Shantha  judgment, while  including  healthcare  services  within  the  purview  of  CPA 1986  had  considered  the  issue  of  “Contract  for  service”  vs  “Contract of personal service”  while  expanding  the  definition  of  “services”  within the meaning of the Act. A `contract for services' implies a contract whereby one party undertakes to render services e.g. professional or technical services, to or for another in the performance of which he is not subject to detailed direction and control but exercises professional or technical skill and uses his own knowledge and discretion. A `contract of service' implies relationship of master and servant and involves an obligation to obey orders in the work to be performed and as to its mode and manner of performance. The  honourable  court  had  held however  that  there can be a contract of personal service if there is relationship of master and servant between a doctor and the person availing his services.

 

However the  Samira  Kohli  judgment  of  2008  also  from  Supreme  Court  by Honorable  justice B. N. Agarwal, Justice P. P. Naolekar, & Justice R. V. Raveendran stated  clearly that It may be that during a  surgery  under  anesthesia an  additional procedure  may  be  required and  the additional procedure is beneficial and in the interests of the patient. It may also be that postponement of the additional procedure (say removal of an organ) may require another surgery, whereas removal of the affected organ during the initial diagnostic or exploratory surgery, would save the patient from the pain and cost of a second operation. Howsoever practical or convenient the reasons may be, they are not relevant. What is relevant and of importance is the inviolable nature of the patient's right in regard to his body and his right to decide whether he should undergo the particular treatment or surgery or not. Therefore unless the unauthorized additional or further procedure is necessary in order to save the life or preserve the health of the patient and it would be unreasonable (as contrasted from being merely inconvenient) to delay the further procedure until the patient regains consciousness and takes a decision, a doctor cannot perform such procedure without the consent of the patient. This  obviously  now  means  that  a  doctor he is now subject to detailed direction and control and  cannot exercise his  own professional or technical skill and use his own knowledge and discretion (Servant ?) but  has  to  do  what  is  directed  by  the  patient (master ?). Since  “Contract of personal  service”  was  excluded  in  definition  of  “services”  in  Consumer Protection Act 1986  and  also  in  CPA 2019  would  not  doctors  be  excluded  now  since  they are   subject to detailed direction and control  by  his  master/patient and also cannot exercise  professional or technical skill or use his own knowledge and discretion. 

 

There is no denying the need for accountability of doctors as  well  as  other professionals. The honorable supreme court has however granted stay on applicability of CPA on advocates in 2009. We  argue  that  the  current  system  where  a  doctor  is  prosecuted  in  multiple  courts  and  commissions  simultaneously on  same  facts  and  with  same  complainants  is  undesirable. We  also  strongly  feel  that  unlimited  compensation claims  are  unjustified  because  doctors  do  not  charge  their  fee  commensurate  to  the  risk  they  undertake. If  a  patient’s  earning  capacity  is  the  criterion  for  award  of  compensation , then  so  also  should  the  fee  for  services  be  linked  to  earning  capacity  of  patient (Hence  risk  undertaken). Ideal  situation  would  however  be  that  the  indemnity  insurance premium of  doctors  and  hospitals  should  be  uniform (like  motor vehicle insurance) based  on  their  specialization  for  unlimited compensation. After  this  any  compensation  awarded  should  be  paid  by  insurer  as  a  no  fault  compensation  without  naming  and  shaming  the  doctor  concerned.   

 

We at  MLAG  hereby offer  a  solution  whereby  doctors  remain  accountable, consumer  gets  reasonable  compensation  for  his  loss and  regulatory  authorities  retain the powers  to  temporarily or permanently remove the  name  of a  Registered  medical Practitioner  from  the  State Medical Register.  

 

We  request the  Government  to  introduce  a  special  Act by placing a “Medical Injury Compensation Bill” in Parliament  which  would  encompass  all  aspects  of  alleged simple & gross medical negligence, professional misconduct, impropriety  and  other legal  issues  related  to  practice  of  medical profession. 

 

Salient features of the bill being suggested could be as follows 

 

1) It should cover all aspects of Compensation and punishment in cases of Medical Error and injury thereof exclusively. 

 

2) It should cover criminal negligence as defined in Jacob Mathew vs State of Punjab and Martin F Dsouza vs Mohd Ishfaq judgments by  giving  powers  of  Judicial Magistrate  First  Class  to  the  Tribunal / Commission  or  Fora  formed  under  this  Act.

 

3) It should over ride all other laws currently in place being  a  Special Act  concerned  with  a  specific  problem. 

 

4) Multiple avenues of litigation should be barred. All litigation on this issue should be under this Act. Currently doctors who are accused are being prosecuted by different agencies like MCI  or  State  Medical Councils, Consumer Courts, Criminal Courts and may also now include the Authority under CEA for same issue. This leads to 3-4 different places where a doctor keeps running to on different dates trying to defend a single case of alleged medical negligence each moving at a different pace. Also sometimes when a medical board has been formed the doctor appears before this said medical board in addition. The legal process before 3-5 different courts , fora, boards and commissions is more severe punishment for a practicing doctor than a 2 month imprisonment or suspension of registration. Complaint  should  be  filed  under  this  act  only.

 

5) Introduce a Cap on maximum compensation which can be awarded in case of medical error and injury thereof. This could be based on the fee charged for treatment. Consequent Loss of Earning of an individual should be compensated through Life and other health Insurances which all individuals should take. Earning capacity of Individual should be delinked from compensation awards since fee paid is not linked to earning capacity. A person whose life is worth 10 crores would anyway be having life insurance to the tune of 10 crores and hence accidental (may be medical accident) death would anyway recompense the nominee for the financial loss. 

 

6) It should provide mechanism for independent medical opinion taken from experts  working in similar establishments. An expert from a tertiary care institute may view events differently from an average practicing doctor in a similar area of work. Negligence has been defined now as doing something which an average practicing doctor would not do or not doing something which an average practicing doctor would do. 

 

7) The commission should comprise of at least one MBBS doctor preferably who  also  has  done  LLB    or  may have been  practicing  in the region for more than 20 yrs outside tertiary institutes, one  doctor  of  the  specialty to  which  the  case belongs  besides a  president  who  may  be  judicial officer. 

 

8) It should provide mechanism of penalizing complainants for frivolous complaint. The penalty so imposed should be linked to the compensation asked for and not an arbitrarily low figure. It should be sufficient to act as a deterrent for the mischievous. 

 

9) It should provide for provision  to  ab intio  dismiss  complaint  filed  alleging  medical  negligence  if  the  complainant  has  indulged  in  violence  at  the  medical establishment  which  can  be  proved  by  the  establishment The  commission  under  the  act  should  also  be  the  authority  to  take  action  against  perpetrators  of  violence  against  hospitals and Doctors the  provisions  could  be  similar  to  the  Epidemic Diseases  Amendment Act 2020.

 

10) Mechanism for rates of medical treatment charges commensurate with earning capacity of patient should be made and any negligence thereafter should be compensated based on declared income and rates charged. 

 

11)  The  State  Medical Council  on  application made  by  the  complainant  after  decision  of  the District Commission  under  the  Medical Injury  Compensation Act would  thereafter  decide  regarding  any  action  for  misconduct  based  on  decision  of  the  District Commission after  giving  opportunity to  the  doctor  to  defend  himself.

 

12)   The  decisions  of  all  commissions  formed  under  this  Bill  would  be  reportable       

 

 

We request all  doctors  and  medical  Associations  and  Organizations to kindly initiate a discussion on this bill so that a consensus may be generated. 

 

 

Dr Neeraj Nagpal                                                                                       07-06-2022  

Convenor Medicos Legal Action Group 

Ex President IMA Chandigarh 

9316517176 

hopeclinics@yahoo.com