Advisory on CLINICAL RISK MITIGATION
ADVISORY- CLINICAL RISK MITIGATION The aim of this document is to provide Medical Unit Heads insight into preventive measures to be taken to mitigate risk of potential litigation/ legal claims. The NABH Guidelines and other accreditation bodies already provide a comprehensive set of rules to be adhered to. The recommendations and SOPs in this document are formulated from a compliance/ legal perspective to strengthen the existing practices that hospital units apply in a clinical setting. With the advent of Google providing limitless access to information, heightened awareness, and disgruntlement at rising medical costs, we are witnessing exponential rise in the number of medical negligence cases being filed and legal notices being issued by patients. Based on the trends observed for over a decade, an analysis of the legal notices received, medical negligence cases/complaints filed, principles applied by courts and consumer commissions in such cases to conclude whether or not there was medical negligence in the treatment provided, we have compiled these broad sets of guidelines. This document encloses Annexures A to C which are referenced below in the relevant sections. RECORDING OF HISTORY OF PATIENTS- ON ADMISSION/ EMERGENCY ROOM/ OPD. Care should be taken in recording medical history, since very often Insurance companies reject claims as the declarations in insurance documents do not match the history recorded in the medical records. If a patient is incapacitated and cannot provide his/her history and the attender does so, the attending physician/nurse should confirm from the attender that he/she is aware of the medical condition of the patient and pre-existing diseases. If the patient is being admitted/ consulting with an Apollo physician after being treated at a different hospital, they should provide the previous medical records, discharge summary, test reports, etc, and the findings should be referred to, and be recorded. Very often patients state they were treated elsewhere but do not provide sufficient documentation and this practice should be discouraged. Also, it is recommended that if the attending physician sees certain lacuna in the treatment provided elsewhere, this is also to be recorded. DOCUMENTATION General recommendations Entries in medical records entered retrospectively by a physician should specifically state that they have been recorded retrospectively, with the accurate date and time. Patients may be treated by multiple specialists, and in such situations, there must be a record of each specialist’s time of visit, advice given, and such advice must take into consideration the advice of any specialist who previously saw the patient. If a recommendation is made, the reason why such recommendation is not being carried out should be recorded by subsequent specialists. Ideally specialists should not provide suggestions on treatment a doctor of a different speciality should provide. All they can suggest is the patient be seen by a physician of a particular specialty. Overwriting in medical records must be strictly avoided. Notes of any internal discussions, or subjective comments should not be recorded in patient medical records. The medical record of the patient has to be handed over to the patient/authorised attender at the time of discharge or if requested by the patient/authorised attender within 72 hours of the receipt of the request for the same. OPD Consultations: General consent to be documented. More detailed and comprehensive examination notes, that include, diagnosis, prescription of medicines, confirmation that the risks and benefits have been explained, follow-up tests, to be recorded. If this practice is not already in place, it is recommended OPD notes, prescription, should find a place in the patient’s EHR. Discharge summary: A comprehensive and accurate summary of patient’s history, initial diagnosis, subsequent diagnosis, treatment provided including accurate reference to surgery notes, reference to the prior medical history of the patient and the medical records that were provided at the time of admission. If the treating physician diagnoses a certain pre-existing condition that was not provided at the time of admission and found during treatment, the same is to be recorded and the complications in the treatment that arose as a consequence should also to be recorded. Medical records are to be verified before handing over to the patient/authorised attendant. There must be made a record of who and when, what time, the medical records were handed over to at the time of discharge. Any follow up visit required by patient post discharge must be recorded, the risks of not following post discharge advice, and risks of not attending follow-ups to be added as well. This should include diet, physical activity, medication, etc. in a manner more specific to a patient instead of the format presently used. A record of the insurance details if applicable is also to be made, along with who has given the history for the insurance purpose. III. COUNSELLING PATIENTS/ FAMILY MEMBERS Undoubtedly counselling sessions with a patient and family is an important part of patient management. The need for counselling arises in several situations as per the discretion of the treating physician, Unit Medical Head. It is recommended that in situations which are grave and high risk, or crucial decisions are to be made in a treatment plan, recording of DAMA, DNR etc., an audio-video recording of the counselling session is carried out, which then becomes an integral part of medical records. The patient/authorised representative has to be informed about the recording of the counselling session, and such record should reflect the date, time, and place of recording. CONSENT PROCESS The Consent Form Checklist drafted by Badsha Legal, is attached herewith as ANNEXURE A. Please rely on this document to ensure that a valid consent is obtained from the patient/attender/guardian, signed off by the treating physician, witness. The patient should indicate at the time of admission the details of an authorised attendee who has the right to make decisions on behalf of the patient in the event of the patient being unable to do
Advisory on Health Insurance
Gateway to a Seamless Health Insurance Claims The Insurance Regulatory and Development Authority of India (“IRDAI”) issued a new master circular on 29th May 2024. The main focus of the new circular is to make the process of claiming health insurance both simple and beneficial to the policy holder. The changes are as follows: Policy Holder/Prospect/Customer: The Insurers are to extend their products, add-ons/riders to: all ages; all types of existing medical conditions; pre-existing diseases and chronic conditions; all systems of medicine and treatments including Allopathy, AYUSH, and other systems of medicine; every situation of treatment including domiciliary hospitalisation (where the policyholder is considered to be hospitalised even when getting treatment at home), outpatient treatment (OPD), Day Care and Homecare treatment; viz. all regions, all occupational categories, persons with disabilities and any other categories. all types of Hospitals and Health Care Providers to suit the affordability of the policyholders/prospects. Policyholders shall not be denied coverage in case of emergency situations. Products in compliance with various laws: The Insurers are to provide products in accordance with the followings laws: a) The Mental Healthcare Act, 2017; b) The Rights of Persons with Disabilities Act, 2016; c) The Surrogacy (Regulation) Act, 2021; d) The Transgender Persons (Protection of Rights) Act, 2019, and e) The HIV and AIDS (Prevention and Control) Act, 2017 Products to cover Technological Advancement & Treatments: The insurers shall attempt to cover the latest technological advancement & treatments such as : Uterine Artery Embolization and HIFU Balloon Sinuplasty Deep Brain stimulation Oral chemotherapy Immunotherapy- Monoclonal Antibody to be given as injection Intra vitreal injections Robotic surgeries Stereotactic radio surgeries Bronchial Thermoplasty Vaporisation of the prostate (Green laser treatment or holmium laser treatment) k. IONM – (Intra Operative Neuro Monitoring) Stem cell therapy: Hematopoietic stem cells for bone marrow transplant for haematological conditions to be covered. Any other treatment using advanced technology, as per the product design. Cashless Claim: The IRDAI has suggested that insurance companies must strive to facilitate 100% cashless claim settlement within a specified time frame. The time frame has been brought down to one hour for Insurance companies to decide on cashless authorization and three hours after discharge authorization request from the hospital. In no case should the policyholder be made to wait to be discharged from the hospital. Document Collection and TPAs: The IRDAI has stated that the policyholder will no longer be required to submit any documents for claim settlement. The collection of required documents will be carried out by the Insurance Company and Third Party Administrators (TPAs). The Performance of TPAs will have to be monitored and payments are to be made to the TPAs only upon full discharge of satisfactory service. The clawback of remuneration/charges are to be paid to TPA based on customer feedback, which shall be passed on to the policyholders. Contesting Claims: The circular states that except for established fraud after a moratorium period of 60 months of continuous coverage, no policy or claim of health insurance can be contested on the ground of non-disclosure and/or misrepresentation. No Claim Bonus: No claim bonus is provided when a policyholder doesn’t make a claim during the policy period. Customers will now be provided with flexibility to choose products, add ons and riders instead of assuring higher sum as a reward as followed previously. The Insurer can provide an option to the policy holder to choose such no claims bonus by increasing the sum assured or providing a discount in the premium amount. Repudiation of Claims: Every single claim repudiated is now subject to a review committee which will have to make a decision on the same. Additionally, in case of death of a policyholder during treatment, the insurer will have to release the mortals and process the claim immediately. Renewal of Policy: On failure of renewal of policy, an insurer will have to provide a 30 days grace period for premium paid annually, half-yearly and quarterly instalment with all the credits accrued under the policy. In case of policies where premiums are paid on a monthly basis, a grace period of 15 days would be applicable. In case where the policy is renewed during grace period, all the credits (sum insured, No Claim Bonus, specific waiting periods, waiting periods for pre-existing diseases, moratorium period etc.) accrued under the policy will remain protected. The same shall be applicable for both indemnity and benefit products. Interestingly, the new circular has stated that health insurance is renewable and cannot be denied claiming that the claim was made in preceding years until a clear case of fraud or non-disclosure or misrepresentation is established. No fresh underwriting is required unless there is an increase in the sum insured. Refunds: Policyholders will be able to get a refund of premium/proportionate premium for unexpired policy period, if the policyholder decides to cancel his/her policy during the term. Ombudsman Award: The insurer will be liable to pay Rs 5,000 per day to the policy holder in case ombudsman awards are not implemented within 30 days. Portability: Customers are provided with a stricter time frame to port to another insurer. In the event of the insurance company withdrawing a particular product, the policyholder will have to be given options to migrate to other suitable products or a one-time option to renew the product if the renewal falls within 90 days from the date of withdrawal.