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Dr Mary Davin-Power, Senior Clinical Risk Advisor at Medisec, outlines why GPs should give PMA reports sufficient care and attention.
At any given time, most GPs will have one or two letters from insurance companies on their desk requesting completion of a private medical attendant (PMA) report. These are generally a request for information only and often do not request a full examination.
They can take some time to complete and one might be tempted to move them to the ‘do later’ pile. While initially they may feel like a simple questionnaire to be completed, in fact the PMA form requires careful and prompt attention for the reasons explored below.
The doctor must confirm full, valid, up-to-date, and informed consent from the patient before disclosing any clinical details to the insurance company. Often one sees a faint photocopied signature of consent from some time past that is attached to the request from the insurance company, and the date the consent was signed may be illegible.
It is essential that the doctor confirms that the patient consents to completion of the insurance form with details of their medical history, perhaps going back many years and including sensitive information that they had totally forgotten about. The doctor must satisfy themselves that the patient is also fully aware of the extent of the disclosure requested and submitted, including sensitive issues, such as sexual health details, pregnancy or termination of pregnancy details, or mental health crises in the past.
No signature policies
Some companies offer a ‘no signature’ policy, where an agent or employee of the insurance company takes a verbal consent from the applicant, and reports it to the doctor as consent having been given.
The doctor completing the PMA form has a responsibility to the patient to ensure that fully informed consent has been given by the patient to disclosure of their medical history to the company involved, and as a result, the doctor may need to contact the patient directly to satisfy themselves.
As a practical step it is advisable to request that the patient read the PMA form as part of the consent process. It must, however, be clarified that the patient cannot dictate what goes into the report, as discussed below.
Managing patient expectations
It is important that the patient understands the doctor’s obligation to the insurance company to provide accurate and truthful information. Should the patient be reluctant to allow the doctor disclose certain details, then they should be reminded that any non-disclosure of relevant information or disclosure of incomplete or misleading information on the form could lead to the rejection of a claim in the future, and that the doctor has a legal and ethical duty to ensure their reports are factual and not misleading.
The Medical Council Guide to Ethics for Registered Medical Practitioners (‘the Guide’) states:
40.5 If you are asked to conduct an examination and give the results to a third party such as an insurance company, employer or legal representative, you should explain to the patient that you have a duty to the third party as well as to the patient, and that you cannot keep relevant information out of the report. You should be satisfied that the patient understands the scope and purpose of the examination, and has given their consent to the examination and the preparation of the report. You should apply the same standard of professionalism to conducting these examinations and preparing these reports as you apply to the care and treatment of patients. [Emphasis added]
Refusal of consent
If the patient does object to necessary or relevant information being provided, they are effectively withdrawing consent and the doctor should decline to submit the report in this circumstance. Any related discussions should be carefully recorded in the patient file.
Remember that to delay so far as to disadvantage the patient (eg, losing approval for a mortgage, bank loan etc) could trigger a complaint and/or claim from the patient. The Medical Council Guide states:
40.3 You should provide reports promptly so that the patient does not suffer any disadvantage.
As an example, it would certainly disadvantage a patient if they miss out on buying a house because the PMA report was delayed and mortgage approval lost.
Under the Disability Act 2005 and according to the Code of Practice on Data Protection for the Insurance Sector, an insurance company cannot take results of genetic screening, whether positive or negative, into account when considering an insurance policy application. Should the results be inadvertently included in the report the company must disregard this information.
However, if a patient is actually suffering from the effects of a genetic condition, then this information should be disclosed. An example might be where a patient had genetic screening for haemochromatosis. If the genetic screening indicated that the patient had positive genes for haemochromatosis, but was not yet suffering from the effects of this, then this need not be disclosed. If on the other hand they had a history of iron overload with high ferritin and transferrin saturation, and needed routine venesection, then this should be disclosed.
This part of the PMA form can often cause a dilemma for the doctor. Information on family history is often gathered through hearsay from the patient, may be factually unreliable, and the doctor does not have consent from this potentially identifiable family member to disclose their medical detail. Even if the doctor has access to the medical records of family members, they most likely have no consent from those family members to disclose their clinical information.
Family history can be completed if the family member is not identifiable, so any reference to ‘father’, ‘mother’, etc, should be omitted. There is usually an option on the patient application part of the PMA form where the patient themselves can enter any such detail. The doctor can then strike through their part of the form stating ‘refer to patient’ or ‘family history may be obtained directly from the patient’.
Medical records and PMA reports
Copies of PMA reports should be kept on the patient file. If there is a request for disclosure of a patient’s records (either under Freedom of Information Act, Data Protection Acts or through the discovery process through the Courts) PMA reports should be disclosed as part of the patient’s records.
The PMA report should be treated by the doctor as requiring as much accuracy in its completion as the patient’s clinical notes. A failure to do so, or treating the forms as separate and distinct from the clinical records, could possibly expose a doctor to criticism if they were to be subject to a claim or Medical Council complaint.
Requests for patient records from insurance companies
Sometimes an insurance company will request copies of patient records, instead of requesting a PMA or medical report. When a request comes from the insurance company on behalf of the patient, just like the PMA report, where the doctor agrees to forward the records, they must ensure that (a) the patient understands the extent of the disclosure, the dates involved and what level of detail is included in the records, and (b) gives express consent, preferably in writing, to the release of the records.
In many cases, as stated above, it is advisable to request that the patient reads the records to be released in advance of disclosing them to the insurance company as part of the consent process. This also gives an opportunity for both parties to identify any errors or inaccurate information inadvertently included in the report or records. It is important to ensure that if records are being released, they are released only according to the limitations of the request – for instance if the insurance company requested records from a certain date and consent is given in respect of that request, ensure that earlier records are not then disclosed.
Requests for records after a patient’s death
Sometimes, in exploring a claim after a patient has died, the insurance company may contact the doctor, requesting copies of clinical records. The patient, now deceased, may well have signed a consent for disclosure to the company while alive, and there could even be a clause stating that the authority remains after death. It is prudent in these circumstances to contact the patient’s legal personal representative (usually the executor, do not rely on ‘next-of-kin’ who have no legal role in confirming consent on the patient’s behalf) to inform them of the request and confirm consent to disclose.
All of these scenarios can be complex, and where there is any doubt regarding release of records, or other uncertainties relating to any aspect of PMA reports, do consider contacting your indemnity company for robust and up-to-date guidance and support.
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