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Can I withhold information from a medical report?

A GP is uneasy when asked to omit information from a patient's medical report

A GP is uneasy when asked to omit information from a patient's medical report

A GP received a letter from an insurance company asking her to complete a medical report on a patient who had recently taken out holiday insurance.

The patient had had a transient ischemic attack (TIA) two years ago but had been well since.

The patient went on holiday and was admitted to hospital with a myocardial infarction.

The patient's husband contacted the surgery from abroad to ask the GP to withhold the information about the TIA in the report.

He confessed that his wife had not declared it to the insurance company as she had feared it might have compromised her application for insurance.

Rang for advice

The GP was uncomfortable with omitting the information and rang the MDU for advice.

The MDU advised that the patient's consent should be sought in the preparation of the report.

The patient might have consented to the GP disclosing information when she applied for the policy and the GP should check if this was the case.

The patient should be made to understand the purpose of the report and the extent of the information to be disclosed.

Also that the GP has a duty to complete the report fully and truthfully and would not be able to withhold relevant details of her past medical history, even though the TIA happened two years ago.

Under section 5 of the Access to Medical Reports Act 1988, if a patient has been given access to a report by their doctor, the report cannot be supplied to the insurer without the patient's consent.

If the patient felt that any part of the report was misleading or incorrect, then the GP could agree to amend the report accordingly.

However, if the GP did not agree to amend the report, the patient could attach a statement with her own comments.

If the patient did not agree to the report being sent, it could not be disclosed, and the insurance company would need to be informed that the patient had withheld consent.

Learning points

• You must have express patient consent to provide a report to an insurance company.

• The GMC's Good Medical Practice (2006) points out that you must be honest when writing reports and that you must not deliberately leave out relevant information (paragraphs 63, 65 and 66).

• The Association of British Insurers advises GPs to use the General Practitioner's Report Form to send reports to insurers, rather than sending printouts of patient's records. Sending printouts runs the risk of irrelevant information being released, for which the patient has not given consent.

• The GMC advises doctors to show insurance reports to patients before sending them, as patients may not recall the exact details of their medical records and it is necessary for the patient to be fully aware of the contents of the report, in order to provide fully informed consent for the report to be sent. (FAQ 13 of Confidentiality: Protecting and Providing Information (2004).)

The case mentioned is fictitious, but based on cases from the MDU's files. Doctors with specific concerns are advised to contact their medical defence organisation for advice.

© copyright MDU 2008

Dr Yvonne McCombie is a medico-legal adviser with the MDU

Can I withold information from a medical report for an insurance company?

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