When one examines the disputes involving healthcare professionals, including doctors of all categories and specialties, and healthcare practitioners against insurance companies before the Disputes Resolution and Violations Committees, particularly when medical claims arise from some patients and the insurance companies refuse to cover those medical errors, it becomes apparent that most of the reasons insurance companies give for their refusals generally fall within one of the following categories: the doctor’s failure to disclose certain required data in the application form for obtaining the insurance policy, questioning the validity of the information provided, the occurrence of the medical error after the insurance coverage period has ended, the doctor’s failure to promptly notify the insurance company of the existence of a claim, or the assertion that the doctor exceeded their scope of practice in treating the patient.
A review of the judgments issued by the Dispute Resolution and Violations Committees shows that these committees base their rulings on the legal principle that “Contracts are binding on the parties.” The contract, in this case, is represented by the insurance policy established between the doctor or healthcare practitioner and the insurance company, which governs their relationship, and the extent to which both parties adhere to the terms and conditions of the relevant insurance policy. It is indeed true that the insurance policy for medical errors sets the legal framework for the limits of the obligations and rights of the parties involved and the extent of the insurance coverage. Therefore, if either party fails to fulfill their obligations under the insurance relationship, it can significantly impact the exclusion of the doctor’s claim from medical coverage sought by the patient. Reality has shown that many doctors do not recognize the importance of carefully reading the terms and conditions of the policy, which is essential for them to understand their rights and obligations, allowing them to counter any rejection of claims filed against them by patients and the consequent denial of coverage by the insurance company.
However, a thorough reading of such disputes reveals that there are other key factors that play an important role in these types of cases before specialized committees and affect the ability of doctors and healthcare practitioners to win their cases against insurance companies. Firstly, insurance companies exploit the fact that doctors are preoccupied with their profession and are keen to protect their medical reputation, which is a sensitive aspect that plays a crucial role in the doctor’s attempts to settle disputes discreetly with patients to avoid the presence of lawsuits impacting their professional careers. This has led to the emergence of many frivolous lawsuits against doctors, allowing insurance companies to take advantage of this factor to reject claims submitted by doctors for insurance coverage based on unjustified reasons, knowing that a significant number of doctors and healthcare practitioners are reluctant to go to court and face judicial committees to avoid harming their professional careers.
On the other hand, it has become clear that there is another fundamental reason many doctors and healthcare practitioners lose their cases against insurance companies: many of them rely on their personal abilities to file the lawsuit themselves without hiring a competent lawyer or assign a lawyer who is not specialized in insurance matters. This, in itself, is just as detrimental to the doctor and healthcare practitioner as the previously mentioned reasons, because filing the lawsuit, defending, arguing, objecting, and providing evidence are governed by numerous regulations, such as the Code of Civil Procedure, the Evidence Law, and other systems and regulations that doctors often do not fully understand and appreciate. The same adverse effect occurs when a doctor or healthcare practitioner hires a lawyer who is not professionally specialized in this type of case; this lawyer may actually cause the client to lose their case due to their lack of expertise in insurance regulations, which include various statutes such as the Insurance Companies Control Law, its Executive Regulations, and Codes of Conduct for insurers, among others, along with the need for thorough knowledge and experience in interpreting medical malpractice insurance policies and understanding how to connect their provisions and rules.
Therefore, one of the primary goals and starting points of the platform is to provide high-quality legal protection for doctors and healthcare practitioners, delivered by specialized consultants solely focused on this type of litigation, at a minimal financial cost that does not burden this elite group of physicians and healthcare practitioners.
لا تعليق