With telemedicine, there’s no place like home

Here’s a puzzle for you.

A telemedicine company in Singapore engages a local GP to provide medical consultations via video link.  A local subscriber to the telemedicine service goes on holiday to Queensland, Australia, and while there requests a teleconsultation due to a painful swelling that has developed on one of his fingers.  The GP examines the finger on her video screen and concludes that it is an insect bite.  As she is unable to prescribe medicines in Australia, the GP instructs the patient to visit a local pharmacy and obtain an over-the-counter antihistamine cream such as Benadryl to help ease pain and itching at the site.

So, in which country did this consultation take place?

The answer is that telemedicine is too new in Asia for the laws governing it to have been decided.  In the USA, opinion is leaning toward the view that the patient’s location is the deciding factor.  The language that is used in relation to medical treatment supports this – doctors provide medical treatment to their patients, and so the location of the patient must be where the treatment occurs.

Why does any of this matter? Well, from the perspective of the GP in our scenario there is one important reason:

Medical Malpractice Insurance often only covers claims related to treatment provided in Singapore.

Let’s return to our scenario.  The Singaporean patient in Australia follows the advice provided by the GP and applies antihistamine cream to the bite.  Later that evening, the patient falls seriously ill and is rushed to hospital where it is determined that he has been stung by a box jellyfish.

Happily, the patient makes a full recovery and is eventually discharged from the hospital. 

A month later, however, our GP finds herself caught up in three different actions:

1. The patient brings a legal claim in Singapore’s courts alleging that the failure to correctly diagnose the jellyfish sting amounted to malpractice.
2. The SMC, acting on a complaint brought by the Medical Board of Australia, begins investigating whether the GP has practised medicine in Australia whilst unregistered.
3. The Australian Health Practitioners Registration Agency launches a criminal action against the GP in Australia, charging her with practising whilst unregistered.

The first action, the legal claim by the patient, is a straightforward example of a medical malpractice claim and would in other circumstances almost certainly be covered.  However, let’s assume that the GP’s policy has a condition limiting cover to claims arising from treatment rendered in Singapore.  While this is a claim being brought by a Singaporean patient against a Singaporean GP in Singapore’s courts, there is at least some doubt as to whether the medical care was rendered in Singapore or Australia.

The second action, the investigation by the SMC, is also a straightforward example of an event that would normally be covered.  The costs of obtaining legal advice to assist in responding to an SMC investigation are routinely covered under most Medical Malpractice Insurance policies.  Again, however, the nature of the allegation will create a degree of doubt as to whether the policy will respond.

The third action, the criminal case brought by the Australian Health Practitioners Registration Agency, is perhaps the most problematic of all.  The GP cannot ignore the proceedings, as judgments in Commonwealth countries (including Singapore and Australia) are subject to reciprocal enforcement agreements.  From an insurance perspective, most Medical Malpractice Insurance policies issued in Singapore only provide cover for claims brought in Singapore’s legal jurisdiction.  A claim brought in by the Australian courts would likely be subject to a specific exclusion, and no cover would be available. 

Telemedicine is currently on the rise in Singapore, actively supported by the Ministry of Health who

see it as a cost-effective means of providing certain types of primary care and freeing up resources at hospital walk-in clinics and emergency rooms.  The MOH has even created a regulatory “sandbox”, working with eleven different telemedicine providers in establishing regulations for governing the fledgling industry.

For doctors who sign up for telemedicine services, it will not always be apparent that there are additional malpractice risks to consider.   The good news is that most insurers are capable of expanding coverage beyond the territory and jurisdiction of Singapore.  With a few straightforward amendments, the GP’s policy could be expanded to provide cover for claims wherever the treatment is provided, and in whichever legal jurisdiction the claim is brought.

The trick, as is always the case with insurance, is that doctors need to make the request and obtain the cover before the problem arises.