CONSUMER PROTECTION ACT FOR MEDICAL PROFESSION IN INDIA
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CONSUMER PROTECTION ACT FOR CONSUMER PROTECTION ACT FOR
MEDICAL PROFESSION IN INDIA MEDICAL PROFESSION IN INDIA
Dr. Bipin PanditDr. Bipin PanditMD.DGO.DFPMD.DGO.DFP
Hon. Gynaecologist at Dr. Balabhai Nanavatii Hospital, V ParleHon. Gynaecologist at Dr. Balabhai Nanavatii Hospital, V ParleHon. Gynaecologist at Dr. L.H. Hiranandani Hospital, PowaiHon. Gynaecologist at Dr. L.H. Hiranandani Hospital, PowaiHon. Gynaecologist at Municipal Maternity Hospital, MarolHon. Gynaecologist at Municipal Maternity Hospital, Marol
Hon. Gynaecologist at L & T Welfare Center Andheri.Hon. Gynaecologist at L & T Welfare Center Andheri.
Chairman Medico-legal committee MOGSChairman Medico-legal committee MOGSPast President of Association Of Medical Consultants MumbaiPast President of Association Of Medical Consultants Mumbai
Committee Member of Indian Education Society.Committee Member of Indian Education Society.Past President Andheri Medical Association (E & W) Past President Andheri Medical Association (E & W)
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Time line Time line
Guidelines for good medical practice across the ages :Guidelines for good medical practice across the ages :
The Code of HammurabiThe Code of Hammurabi ( 2000 B.C. ( 2000 B.C. ) )
Park’s textbook of PSM,16th edition
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Time line….Time line…. The Hippocratic Oath (460-370 B.C.)The Hippocratic Oath (460-370 B.C.)
•“I swear by Apollo the healer, by Asclepius, by Health, by Panacea and by all the gods and goddesses, making them my witnesses that I will carry out to the best of my ability and judgment this oath and this covenant (horkos kai syngraphe)…”
Park’s textbook of PSM,16th edition
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Time line…..
CHARAK’S OATH (200 A.D.)CHARAK’S OATH (200 A.D.)
““Thou shalt be free from envy, not cause another’s death, and pray for the welfare of all creatures. Day and night thou shalt not desert a patient, nor commit adultery, be modest in thy attire and appearance, not to be drunkard or sinful, while entering a patient’s house, be accompanied by a person known to the patient. The peculiar customs of the patient’s household shall not be made public. "
Park’s textbook of PSM,16th edition
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Time line ….. ARABIC CODE OF MEDICAL ETHICS (800-1300 AD)ARABIC CODE OF MEDICAL ETHICS (800-1300 AD)
Adab al – TabibAdab al – Tabib
Park’s textbook of PSM,16Park’s textbook of PSM,16thth edition edition
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Time line …..Time line …..
The Declaration of Geneva 1948
The Indian Medical Council Act 1956
The Consumer Protection Act 1986
The inclusion of medical services in CPA 1995
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Medical Dilemma Medical Dilemma A profession in retreat.A profession in retreat.
Professional dissatisfactionProfessional dissatisfaction
Fuzzy science, awkward art.Fuzzy science, awkward art.
Doctors give hope, not perform miraclesDoctors give hope, not perform miracles..
THE WOUNDED HEALERTHE WOUNDED HEALER..
Abigail Zuger . Dissatisfaction with medical practice. NEJM Vol 350, 69-75, Abigail Zuger . Dissatisfaction with medical practice. NEJM Vol 350, 69-75, Jan. 2004Jan. 2004
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Consumer Dispute Forum
Medical Council
Civil Court Criminal Court
WHERE TO GO ?
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WHY CPA?WHY CPA? MCI
Biased
Can’t award
damages
THE COURTS
Delay
Expensive
The answer – Alternate dispute resolution system –
Easy, quick, accessible, cheap and effective
Sec 3A, 12, CPA 1986
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Consumer Protection Act, 1986Consumer Protection Act, 1986
Empowers the consumer with the Right to :Empowers the consumer with the Right to :
Safety Information Choose Heard Redressal Consumer education
Sec 4 to 8 of The CPA ( Amendment ), 2002
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LODGING A COMPLAINT FORMAT: Written
PERSON : Complainant / Representative PLACE : Consumer Dispute Redressal Fora FEE : Nominal
TIME LIMIT : ≤ 2 yrs
FATE : Accepted
Dismissed
Sec 12 CPA 1986
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Consumer Disputes Redressal AgenciesConsumer Disputes Redressal AgenciesDISTRICT FORUMDISTRICT FORUM
Jurisdiction Upto Rs. 20 lakhs
Composition President + 2 Members
Powers Examines complaintsIssues notices Orders analysis / tests Conducts hearings
Award damages
Sec 9 to 15 of THE CPA ( Amendment ), 2002
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Consumer Disputes Redressal AgenciesConsumer Disputes Redressal AgenciesSTATE COMMISSION STATE COMMISSION
Jurisdiction From 20 lakhs Up to 1Crore
Composition President + ≥ 2 Members
Power Similar to district forum
+
Hearing of appeals
Sec 16 to 19 of The CPA ( Amendment ), 2002
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Consumer Disputes Redressal AgenciesConsumer Disputes Redressal AgenciesNATIONAL COMMISSIONNATIONAL COMMISSION
Jurisdiction > Rs. 1 Crore
Composition President + ≥ 4 members
Powers Similar to State forum
+
Hearing of appeals
Sec 20 to 25 of The CPA ( Amendment ), 2002
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Professional Negligence:
Definition:Definition:
Absence of reasonable care or skill or willful negligence
on the part of the medical practitioner in the treatment
of the patient whereby the health or life of the patient is
endangered.
Parikh’s Textbook of Medical Jurisprudence, Forensic medicine.
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Types of Professional Negligence:Types of Professional Negligence:
Civil Negligence: Malpractice, Deficiency in Service
Criminal Negligence: gross lack of competency, gross inattention reckless behavior
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In In generalgeneral a doctor's a doctor's innocence is presumedinnocence is presumed
The complainant has to prove The complainant has to prove negligence.negligence.
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Proof of NegligenceProof of Negligence
4 D’s4 D’s
The essentials of negligence are four "D"s:
1. There was a Duty towards patients;2. There was Deficiency in duty3. This Directly resulted in (causa causans )4. Damage which may be physical, mental or financial loss to patient or relatives.
Tiwari S.K, Baldwa M. - Medical Negligence. Indian Pediatrics 2001; 38: 488-495
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Res Ipsa Loquitur
““The thing or the fact speaks for itself.”
Error is so self evident that the doctor has to prove his innocence.
E.g., Amputation of right instead of left leg.
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Vicarious Liability
Liability for another’s act.
A doctor is responsible for not only his own negligence
but also for the negligence of his employees, if such an
act occurs under his direct supervision, by the principle
of Respondent Superior.
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A patient’s A patient’s journey journey
through the through the realm of realm of medical medical
malpracticemalpractice
Quality of care
Commitment of medical error
A Doctor’s Defense
Outcome: judgment and awards
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Quality of CareQuality of Care
Patient - Doctor Relationship Patient - Doctor Relationship
( Implied contract ) ( Implied contract )
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The Sacred Patient-The Sacred Patient-Doctor Relationship – A Doctor Relationship – A
thing of the pastthing of the past
Caring and healing.Caring and healing.
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Patient - Doctor Patient - Doctor Relationship Relationship
( Implied contract ) ( Implied contract ) An implied contract between patient (consumer) and An implied contract between patient (consumer) and
doctor( service provider) for a consideration ( fee ).doctor( service provider) for a consideration ( fee ).
Not established :Not established : While giving first aid in emergencyWhile giving first aid in emergency Pre-employment medical examinationPre-employment medical examination Examining a patient under court orderExamining a patient under court order
Parikh’s Textbook of Medical Jurisprudence Forensic medicine
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Requirements of Doctor Requirements of Doctor Patient RelationshipPatient Relationship
Reasonable skill An average degree of skill possessed by his professional brethren of the same standing
Reasonable care Such care and attention for the safety of the patient as their mental and physical condition condition may requiremay requireCommunication
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Too little time for patients Does not listen Does not explain well Shows no sympathy Neither understands the
patient nor his family
Common Patient Common Patient ComplaintsComplaints
Harris Poll, 2000 Roper Center Polls, 2000
Hey, DOC
!
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““Informed” ConsentInformed” Consent
How well do How well do you you
understand understand it?it?
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Informed ConsentInformed Consent
IMPLIES:IMPLIES:
Understanding by the patientUnderstanding by the patient • Natural history of the disease.Natural history of the disease.• Nature of proposed treatment. Nature of proposed treatment. • Anticipated prognosis of the proposed intervention.Anticipated prognosis of the proposed intervention.• Expected side effects.Expected side effects.• Unexpected hazards.Unexpected hazards.• Any alternative and potentially successful treatment.Any alternative and potentially successful treatment.• Consequences of no treatment at allConsequences of no treatment at all..
Bailey and Love’s Short Practice of Surgery, 24th Edition
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Types of consentTypes of consent
Implied : inferred from actions
Express : actively stated
Proxy consent : on behalf of others
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Why is Consent Why is Consent NecessaryNecessary
Willing patient,
better outcome
defense against a charge of assault / battery
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When is Consent When is Consent NecessaryNecessary
Everything in the Doctor - Patient Relationship is CONSENSUAL
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Express Consent is Express Consent is expected..expected..
Surgical/Invasive Procedures
Chemotherapy / Radiotherapy
Radiological / Investigational Procedures
Medical Research
Teaching - intimate examination
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Competence/Capacity in Competence/Capacity in Informed ConsentInformed Consent
Competent Adult ( > 18 yrs )
In case of Minors ( < 12 yrs ) – Parent or legal guardian( Loco Parents ).
Emergency ( the law implies consent ) (Sec.92.I.P.C.)
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Rules Of Consent:Rules Of Consent:
Consent - in the presence of a disinterested third party, e.g., a nurse.
Consent should not be a blanket permission.
In criminal cases the victim/assailant cannot be examined without his/her consent.
Consent given for illegal acts is invalid. When an operation is made compulsory by law, e.g. vaccination, the law provides the consent..
The law of Medical Negligence – Dr. H. L. Chulani, 1996.
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WhyWhy do patients sue? do patients sue? ““Original injury is not enough.”Original injury is not enough.”
Prime concern: perceived lack of caringPrime concern: perceived lack of caring
3 reasons for litigation3 reasons for litigation1)1) Altruism – protect othersAltruism – protect others2)2) Expose the truthExpose the truth3)3) Financial restitution. Financial restitution.
Lack of communication. Lack of communication.
Over 1/3 would have opted out of litigation with Over 1/3 would have opted out of litigation with explanation, apologyexplanation, apology
Vincent, Young, Philips, “Why do people sue doctors?” Lancet, 1994
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How does fear of lawsuits How does fear of lawsuits alter patient care?alter patient care?
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definition
Defensive Medicine – the use of costly diagnostic efforts of medical treatments for the sole purpose of avoiding potential litigation
Litigation has decreased quality of care
More tests than medically needed
More specialist referrals than needed
More invasive procedures than needed
More medicines than needed
Fear of Litigation study, Harris Interactive, Apr 2002
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Fear of the patient !!Fear of the patient !!Altered patient-doctor Altered patient-doctor
relationshiprelationship Potentially adversarial
relationship Each patient a potential
plaintiff Each question a possible
source of angst “Doctors who worry about
being sued probably will be.”
Lown, Bernard, MD, “The Lost Art of Healing: Practicing Compassion in Medicine,” 1999
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IOM - “To Err Is Human”IOM - “To Err Is Human”The American health care system The American health care system is not as safe as you might thinkis not as safe as you might think
#1 – #1 – deaths by medical errordeaths by medical error
#2 – motor vehicle collisions#2 – motor vehicle collisions
#3 – breast cancer#3 – breast cancer
#4 – AIDS#4 – AIDS
44,000 - 98,000 deaths by 44,000 - 98,000 deaths by PREVENTABLEPREVENTABLE medical errors in medical errors in hospitals each yearhospitals each year
Institute of Medicine, “To Err is Human: Building a Safer Health System,” Nov 1999Institute of Medicine, “To Err is Human: Building a Safer Health System,” Nov 1999Harvard School of Public Health, from Testimony of Harvey Rosenfield, FTCR, Feb 2003Harvard School of Public Health, from Testimony of Harvey Rosenfield, FTCR, Feb 2003Jrnl of Health Care Info Management, “A System Approach the Error Reporting,” Vol. 16, No. 1Jrnl of Health Care Info Management, “A System Approach the Error Reporting,” Vol. 16, No. 1
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Types of Deadly Medical Errors in 1997
44%
17%12%
10%
17%
Technical errors DiagnosisFailure to prevent injury DrugsOthers
To err is human : Building a safer health system, IOM, 2000
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ALLEGATIONS THE SURGEON Articles left in patient’s body.
Consent not taken prior to operation.
Operation on wrong side.
Failure in diagnosis or operation.
Not operating in time.
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ANAESTHESIOLOGIST
Excessive anesthesia
Injury to eyes/skin
Injury from mask/mouth gag
Allegations…
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Allegations… RADIOLOGIST
Electrical shock & burns
Injuries to vision
Pigmentation
Loss of hairs
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GYNAECOLOGIST Consent not taken before abortion
Failed tubal ligation
Injury to uterus
Operation causing sterility
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MEASURESPREVENTION AT PREVENTION AT PERSONAL LEVELPERSONAL LEVELQualificationQualificationCommunicationCommunication
INTERPERSONAL LEVELINTERPERSONAL LEVELCourteous and polite if Courteous and polite if any mishapany mishap
ACADEMIC AND TECHNICALACADEMIC AND TECHNICALUP GRADATIONUP GRADATIONAttend CME,Workshops and Conferences
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PREVENTION AT PRACTICEMEDICAL
Reasonable skill and care
SOCIAL
Exhibit skill to patient: body language
LEGAL
Document in legible handwriting
Record of failure
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OTHER MEASURESOTHER MEASURESPEOPLE SUPPORT GROUPSPEOPLE SUPPORT GROUPS
Forum to discuss acts and cases fought Never talk loose of your colleague
MEDICAL ETHICS
Thorough knowledge is a must
PROFESSIONAL INDEMNITYPROFESSIONAL INDEMNITY
Insurance
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DO’S AND DON’TS FOR DO’S AND DON’TS FOR DOCTORSDOCTORS
HISTORY TAKINGDO’S Listen attentively
Maintain privacy
Face patient
Start afresh if distraction
Ask questions intelligently
Give time to the patient
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HISTORY TAKINGDON’TS
Don’t discriminate.
Don’t assume all what patient says as correct
Don’t smoke
Don’t look overconfident
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EXAMINATION OF PATIENTEXAMINATION OF PATIENTDO’SDO’S
Thoroughly examine the pt.
Oblige again if patient considers examination incomplete
Review next day if patient is examined hurriedly
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EXAMINATION OF PATIENTDON’TS
Don't examine if you are: sick exhausted intoxicated
NEVER examine a female patient in the absence of a female nurse or an attendant especially during genital or breast examination
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PRESCRIPTIONPRESCRIPTIONDO’SDO’S
MENTION: Qualification/training/experience/designation
(Indian Medical Degree Act’1916)
Date and timing of the consultation
Age and sex of patient
Precise history of illness/physical finding
Diagnosis under review if unsettled
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PRESCRIPTIONPRESCRIPTIONDO’S(cont..)DO’S(cont..)
MENTION :
Refusal for investigation/administration in local language with proper witness
H/O drug allergy
Names/dosage/route of administration of drugs clearly with precautions like ac/pc.
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PRESCRIPTIONPRESCRIPTIONDO’S(cont..)DO’S(cont..)
MENTION :
If patient is pregnant/lactating
Side effect/interaction of drug
Emergency treatment in chronic illness
Not to stop drug suddenly if tapering required
If a particular drug/equipment unavailable
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PRESCRIPTIONPRESCRIPTIONDO’S(cont..)DO’S(cont..)
MENTION :
Reasons for deviation from standard
care
Prognosis explained
Where patient should contact if you
are unavailable
Review SOS.
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PRESCRIPTIONPRESCRIPTIONDON’ TSDON’ TS
Don’t prescribe : without examination/ banned drugs/ for experimental reasons.
Don’t write : multiple drugs/instructions on separate slip.
Don't allow substitutions.
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INVESTIGATIONSDO’S
Analyse cost benefit ratio
Read reports carefully and interpret results of tests/X-rays properly
Rule out pregnancy before subjecting uterus to X-ray
Consent-invasive invest.
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INVESTIGATIONSINVESTIGATIONSDON’TSDON’TS
Never order an investigation unless result is likely to help direct treatment
Don’t allow modern diagnostic test to substitute your clinical judgment
Don’t inform patient has HIV till confirmatory test is done
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MANAGEMENTDO’S
Update with latest management by attending CME and conferences
Employ qualified assistants Update facilities and equipment
Obtain legally valid consent before any procedure
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MANAGEMENTDO’S(contd..)
In case of MTP/sterilization, follow
guide lines issued by Govt of India
Ensure proper post - operative care
Relieve pain specially in cancer patients
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MANAGEMENTMANAGEMENTDON’TSDON’TS
Don’t perform procedures in agitated patients eg. broken needle can be a cause for law suit
Don’t forget to count swab and instruments when ending operation
Don’t hesitate to take senior’s or colleague help if in trouble
Don’t deny medical care to HIV positive
NEVER AVOID EMERGENCY CALLS
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OTHEROTHERDO’SDO’S
Extend your sympathy to bereaved family
Label a condition as functional only when other causes are ruled out
Issue certificates only when full verification is done
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OTHEROTHERDON’TSDON’TS
Don’t refuse leave against medical advise
Don’t withhold information however harsh and difficult(sensitive communication)
Don’t refuse patient’s right to examine and receive an explanation about your bills
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Outcome: judgment Outcome: judgment and awardsand awards
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Patient injured
Claim filed
Case to trial
Court verdict
Verdict for plaintiff
Award designated
98.5%
1.5%92-87%
8-13%93%
7%81%
19%
Hyatt, et al, “A study of medical injury and med mal: an overview,” NEJM, 1989Hyatt, et al, “A study of medical injury and med mal: an overview,” NEJM, 1989
“Litigation lottery” and frivolous law suits?
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Doctor’s Indemnity
Why do doctors need insurance anyway?
Peace of mindPeace of mind
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Insurance does not coverInsurance does not cover
Any Criminal act
Services rendered while intoxicated
Any procedure under GA outside hospital
Use of miracle drugs
Cosmetic surgery
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Other Problems With InsuranceOther Problems With Insurance
High premiums High premiums
Do not pay whole of the damages Do not pay whole of the damages Lot of running aroundLot of running around Defense lawyer in the insurance co.panel lacksDefense lawyer in the insurance co.panel lacks adequate medico-legal knowledgeadequate medico-legal knowledge Patients are encouraged to go in for litigationPatients are encouraged to go in for litigation
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The Best Insurance PolicyThe Best Insurance Policy
THE 3 C’s:
CARE
CONCERN
CONSIDERATION
Faith is the only currency between a doctor and a patient ( Dr. K. C. Mahajan FRCS)
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