Consumer Court relief to Max hospital, cardiologist accused of recommending unnecessary tests including angiography, coercion into cardiac procedures

The bench of Justice Daya Chaudhary, President and Simarjot Kaur, Member issued the order while considering an appeal filed by Max Super Speciality Hospital, Mohali against the order dated 05.05.2022 issued by the District Consumer Disputes Redressal Commission, SAS Nagar (Mohali), challenging the decision to allow the complaint filed by Nishan Singh Kahlon.

According to the complaint, the patient applied for immigration/PR with the Canadian Embassy, requiring a medical fitness certificate. The patient visited Max Hospital, an empanelled hospital for the Canadian Embassy, for the required medical examination. He deposited Rs 6,300/- on 21.09.2020 as prescribed by Canadian Authorities. Dr Khetarpal at Max Hospital examined him and declared him fit. However, the complainant alleged that he was unnecessarily referred to Dr Singh for a Cardiology opinion.

It was claimed that despite normal test reports for ECG, ECHO, and TMT, the cardiologist insisted on a Stress Thallium Test, for which the complainant paid Rs 13,725/-. The subsequent report indicated a mild problem, leading to a recommendation for Coronary Angiography. Kahlon sought a second opinion from Fortis Hospital, where it was stated that no further cardiac evaluation was required. Kahlon submitted these reports to Max Hospital, but they were not sent to the Canadian Embassy.

The complainant alleged unnecessary tests, charging extra amounts, and forcing him into procedures like Coronary Angioplasty or Bypass Surgery. The complaint termed these actions as 'unfair trade practices' and sought a refund of Rs 26,526/-, compensation of Rs 10,00,000/- for negligence, and reimbursement of Rs 1,240/- paid to other hospitals.

Upon receiving notice of the complaint, the appellants, Max Super Speciality Hospital (OP No.1) and OPs No.2&3 (referring to the doctors), filed a joint written statement raising preliminary objections. They argued that the complainant had no cause of action, and there was no evidence of medical negligence or malpractice. They claimed that the complaint was false, baseless, and filed for publicity and monetary gain. The treating doctor had followed medical protocol and used their best skills, advising necessary tests based on the complainant's health history.

The complainant had approached the hospital for immigration medical checkup and cardiac evaluation, considering a long-term perspective. Due to the complainant's diabetes and past history of coronary artery disease, the doctors advised ECG, Echocardiography, and Stress Thallium Test to rule out potential cardiac complications. The Stress Thallium Test showed positive results for Inducible Ischemia, necessitating Coronary Angiography. The complainant, however, refused the procedure.

Subsequent tests, including a Stress Nuclear Test, were conducted to verify the results, and Coronary Angiography became imperative. The Punjab Medical Council found the complainant's allegations baseless, and the doctors argued that they were not obligated to send opinions of other doctors to the Canadian Embassy. The District Commission, after considering the arguments, allowed the complaint on May 5, 2022, stating that the opposite parties had engaged in unfair trade practices, providing false reports and causing physical discomfort and mental harassment to the complainant. A consolidated compensation of Rs 5.00 lakhs was awarded.

However, Max Hospital filed an appeal with the State Commission, challenging the order issued by the District Commission.

During the arguments before the State Commission, Yoginder Nagpal, the advocate representing the appellant Hospital, argued that the District Commission failed to consider crucial aspects of the case. He emphasized that the doctor at Fortis Hospital had recorded on the prescription slip that the complainant had cardiac stress and needed medication to control blood pressure and blood thickening. Nagpal contested the District Commission's view on the observation from Rajindra Hospital, Patiala, arguing that it wrongly concluded that cardiologist's line of treatment was incorrect.

The hospital's counsel asserted that the tests recommended by the cardiologist were necessary given the complainant's medical history, including diabetes, hypertension, and a prior coronary artery disease with angioplasty and stenting. The appellant(s) were not obligated to send references to other authorities without the recommendation of the Canadian Embassy, as the complainant had initially approached them voluntarily for the medical certificate required for immigration purposes.

Nagpal contended that the tests were not conducted solely for obtaining a medical certificate but also to identify the complainant's general medical problems. He argued against the District Commission's claim that these tests were advised to extract more money from the complainant, asserting that the findings of none of the tests conducted were found to be wrong, and no other doctor provided a contradictory opinion.

On the other hand, the counsel for the complainant argued that the District Commission rightly concluded that the appellant/opposite parties engaged in unfair trade practices, unnecessarily pushing the complainant into Coronary Angiography. The complainant's tests were normal, and the cardiologist's intention was to extract a substantial amount by forcing unnecessary procedures. The District Commission's order detailing malpractices and factual positions was defended, and the counsel requested the dismissal of the appeal with costs.

The State Commission considered arguments from the appellant (Max Hospital), respondent No.1 (Complainant), and respondent No.3 (Cardiologist), along with reviewing relevant documents and the District Commission's order. It summarized the undisputed facts of the case and noted that the complainant had sought a medical fitness certificate for immigration to Canada from the appellant Hospital. Events unfolded as the complainant, on 21.09.2020, visited the hospital, informed Dr Khetarpal about past medical history, leading to a referral to Cardiologist Dr Singh. The subsequent tests showed positive results for Inducible Ischemia, prompting advice for Coronary Angiography. The complainant, dissatisfied, complained to the M.D., sought a second opinion from Fortis Hospital, and shared Fortis Hospital's opinion with Max Hospital. Rajindra Hospital on 28.09.2020 observed no further cardiac evaluation was needed, and the Canadian Embassy subsequently cleared the complainant's medical examination.

Thereafter, the Commission focused on the issues to be considered in the case as;

a) Whether advising Angiography by a Specialist of the empaneled Hospital of the Canadian Embassy/Immigration Services, after evaluating the test reports, constitutes 'unfair trade practice/deficiency in service/medical negligence'?

b) Should the concerned Hospital have forwarded a factual report regarding the complainant's refusal to undergo further investigation into his Cardiovascular Health?

c) Is there any deficiency in service on the part of the appellant in not sending the reports of Fortis/Rajindra Hospital procured by the complainant from the concerned quarters?

d) Can the complainant, who is not a medical professional, assert that he was not required to undergo further medical investigation after being found positive for Mild Ischemia in TMT/Stress Thallium Test?

e) On what basis did the Canadian Embassy/Immigration Department clear the complainant's medical exam for PR/Immigration to Canada?

Before addressing these issues, the Commission found it is crucial to understand Ischemia. As per "Dorland’s Illustrated Medical Dictionary," 'Ischemia' refers to the deficiency of blood in a part, usually due to functional constriction or actual obstruction of a blood vessel. The complainant was diagnosed with Ischemia of the heart, having undergone Angioplasty in 2003 at Fortis Hospital.

The Cardiologist at Max Hospital diagnosed Inducible Ischemia based on TMT and Stress Thallium Test. Inducible Ischemia implies that the heart, under stress, demands more oxygen than it receives at rest. The doctor at Fortis Hospital confirmed a similar issue. The complainant sought a third opinion from Rajindra Hospital, Patiala, which concluded that no further Cardiac evaluating investigation was required as the patient was stable on treatment.

Despite these findings, the complainant sent a complaint to the Canadian High Commission, alleging malpractices by Cardiologist Dr T P Singh. The Embassy accepted the reports and cleared the medical exams.

The appellant's arguments revolved around the fact that the Doctor's advice for Angiography was based on thorough evaluation and did not constitute unfair trade practice. They assert that no deficiency in service or medical negligence occurred. The Commission explained;

"As per these observations of the Doctor as mentioned in the prescription slip Ex. C-5, it clearly emerges that it was an exhaustive/thorough evaluation of his health condition. It is apparent from the said evaluation of the Doctor that the complainant was a known case of Cardiac History and Cardiac issues were there even at the time of TMT and Stress Thallium Test. Regarding the allegation of cutting on the previous prescription slip i.e. Ex. C-3 allegations of an unfair practice does not hold correct as it was the foremost duty of the Doctor to give the factual report of the health condition of the patient (complainant) as required by the Canadian Embassy/Immigration Department. Moreover the Doctor had checked the complainant to the best of his ability and skill while following the Standard Medical Procedure and condition of safety of the complainant. He had taken all possible due care and caution while giving his opinion for angiography. Since the complainant had applied for PR to Canada, the medical check-up was required to cover a period of at least 10-15 years/ longer period and it was his bounden duty to ascertain any long term health implications. Regarding the allegation of the complainant that his ECG and ECHO were found fine and accordingly, he did not wish to go ahead for further investigation. We cannot comment anything upon this aspect, whether he was having heart problem (illness) being asymptomatic at that time. The Doctor wanted to probe it further. As per the standard medical procedure, the complainant had to go through TMT wherein the report of the complainant was found “positive”. To further assess his condition and to rule out any complications, the Doctor asked him to undergo Stress Thallium Test keeping in view the reason that the TMT test sometimes can show up to 30% false positivity. Moreover the duty of the Doctor was not only to give clearance for medical exam for immigration purpose but to give the proper report by considering his general health whereby he could help him to lead a qualitative life. The complainant/respondent No.1 had also sent two emails to M.D., Max Healthcare Mohali in which a lot of allegations/accusations had been made but nowhere in the documents the complainant had been able to prove that Dr.... Singh had forced him to undergo angiography/angioplasty. Dr. ..Singh had only advised him for Coronary Angiography. The complainant had mentioned in email (Ex. C-8) that he was forced to undergo angioplasty/bye-pass surgery by Dr... Singh due to which he would have incurred an expense of Rs.4-5 lacs. However, nowhere in the documents/prescription slips, there is mention of angioplasty by Dr...Singh. It clearly shows that the patient being the layman did not know the difference between Angiography and Angioplasty. "

In context of unfair trade practice, the Commission observed that;

"Two out of three opinions of his Cardiac evaluation had indicated his heart condition of Ischemia. In one case after the evaluation, angiography was advised while in the other case the medicines were prescribed. The further investigation of angiography was advised just to rule out any heart related complication. Therefore, the said act of the Doctor, which is based upon medical condition/tests of the complainant, is by no mean fall into the category of ‘unfair trade practice’ especially with respect to making any statement, whether orally or in writing or by any visible representation including by means of electronic record, as the Doctor had advised a factual follow up investigation, based on his cardiac medical tests, which could save him from any complications in future. Therefore, we do not find any unfair trade practice on the part of the appellant/Dr.Singh (Respondent No.3)."

The Commission further clarified that;

"The Doctor would have failed in his duty if he had not advised the complainant for further investigation into his cardiac issues as his TMT and Stress Thallium Test report was positive. Then in that scenario it would have been a case of negligence or breach on his part in his duty leading to medical negligence."

The Commission also explained that sending a factual report to Canadian Authorities based on the complainant's test results and information that the complainant refused angiography is deemed not negligent. This action did not result in any loss for the complainant obtaining Permanent Residency (PR) as the complainant was granted PR by the Canadian Embassy. The doctor fulfilled his medical responsibility, and the allegation of deficiency in service against the appellant, Dr. Singh, is deemed incorrect, and the contention is not accepted.

It further noted that despite the complainant making serious allegations of unfair trade practice and deficiency in service against Cardiologist Dr. Singh, who is a specialist in the field, the complainant himself described his condition as fit. However, the cardiologist's reports indicated that the complainant's heart condition was not normal. The sensitivity and accuracy of electronically/computerized conducted tests like TMT/Stress Thallium Test make it improbable for doctors to fabricate false reports. According to established law, the doctor did not engage in unfair trade practices, nor was he deficient in service or medically negligent. The complainant's self-assessment of being medically fit cannot override the evaluation and diagnosis of a specialist doctor.

The Commission elaborated that the complainant, in arguing medical negligence and unfair trade practices against Dr Singh and the appellant hospital, questioned how he was granted Permanent Residency (PR) in Canada despite his alleged medical issues. The document reveals that the Canadian Authorities hold the discretion to process PR/Immigration cases, and the complainant's successful visa approval does not provide conclusive evidence against Dr Singh. The lack of communication from Canadian Authorities regarding reasons for medical exam acceptance or rejection, coupled with the absence of any action against the appellant, indicates a lack of evidence supporting the complainant's claims of unfair practices. The document concludes that the complainant failed to substantiate allegations of medical negligence, deficiency of service, or unfair trade practices. The successful PR acquisition and the absence of tangible harm from Dr Singh's report further weaken the complainant's case.

Subsequently, the Commission noted;

"The observation of the District Commission that Dr Singh had advised various tests to the complainant to earn huge amount and had tempered on his own initial recommendation on the prescription slip was a case of deficiency in service, unfair trade practice and negligence on the part of the appellant, is against the documents and circumstances as mentioned above. Whereas no case is made out of deficiency in service, unfair trade practice or even medical negligence on the part of the appellant or Dr Singh as the said over writing or cutting was done only due to Cardiac Test reports."

Subsequently, the Commission set aside the District Commission's order, dismissing the complaint and finding no evidence of medical negligence, deficiency in service, or unfair trade practice. It held;

"Keeping in view the detailed discussion and reasons and the documents available on the file and also the judgment of the Hon’ble Apex Court as cited above, we find force in the arguments First Appeal No.798 of 2022 30 raised by the counsel for the appellant that the Doctor had advised further tests/management on the basis of previous medical history of the complainant as well as current reports, which were found to be positive. As such, we deem it appropriate to set-aside the impugned order dated 05.05.2022 passed by the District Commission."

"Accordingly, the present appeal is allowed and the impugned order dated 05.05.2022 passed by the District Commission is set-aside. Consequently, the complaint filed by the complainant is dismissed for the reasons as referred above. No order as to costs. Since the main case has been disposed of, so all the pending Miscellaneous Applications, if any, are accordingly disposed of. The appellant had deposited a sum of Rs.2,50,000/- at the time of filing of the appeal. The said amount, along with interest which has accrued thereon, if any, shall be remitted by the Registry to the appellant, after the expiry of period of appeal/revision before the Higher Court/Commission."

To view the original order, click on the link below: