Doctors with Sharp Scalpels Beware!
30 September 2013
Harold Tan explains the Singapore Court’s decision in Lim Mey Lee Susan v Singapore Medical Council.
The key question that arose in Lim Mey Lee Susan v Singapore Medical Council [2013] SGHC 122 was whether doctors who practice medicine in Singapore are under an ethical obligation to charge a fair and reasonable fee for their services. This question was answered in the affirmative by the High Court of Singapore that comprised a panel of three judges.
THE FACTUAL BACKGROUND
The Appellant in the case, Dr. Susan Lim, is a registered medical practitioner in Singapore whose primary area of practice is general surgery. In or around 2001, the Appellant began treating a member of the royal family of Brunei (“Patient”) for breast cancer. The Appellant was the Patient’s principal physician and was responsible for the Patient’s overall care until the Patient’s demise on 19 August 2007.
The arrangement between the parties with regard to the Patient’s medical fees was that such fees would be paid for by the Government of Brunei. For her services and the services rendered by other doctors from January to June 2007, the Appellant issued 94 invoices. The total quantum of the fees charged in those invoices covered 110 treatment days and amounted to approximately S$24 million.
The Bruneian authorities were dissatisfied with the invoices which they considered excessive and lodged a complaint with the Ministry of Health of Singapore. A series of discussions ensued, which ultimately led to the Respondent in this case, the Singapore Medical Council, issuing to the Appellant in July 2009 a notice of inquiry containing 94 charges of professional misconduct under section 45(1)(d) of the Medical Registration Act (Cap 174, 2004 Rev Ed).
THE CHARGES AGAINST THE APPELLANT
The Disciplinary Committee (“DC”) appointed by the Respondent to conduct a hearing on the charges, convicted the Appellant on all 94 charges of professional misconduct proffered against her. The DC, in its decision, grouped the 94 charges into 2 broad categories:
- The first 83 charges were for allegedly invoicing the Patient medical fees that were far in excess of and disproportionate to the services rendered by the Appellant and her medical team.
- The remaining 11 charges were for allegedly invoicing the Patient medical fees that were far in excess of and disproportionate to the services rendered as well as falsely representing that such fees had been invoiced by and/or would be payable to certain named doctors, when the Appellant knew, or ought to have known, that such representation was not true in so far as she had added a significant and undisclosed markup to the actual fees charged by those doctors.
On finding the Appellant guilty of all 94 charges, the DC ordered that the Appellant:
- be suspended from practice for a period of 3 years;
- pay the maximum financial penalty of S$10,000;
- be censured in writing;
- undertake, on her return to practice, not to charge her patients more than a fair and reasonable fee for her services; and
- pay the costs of the disciplinary proceedings.
APPEAL TO THE SINGAPORE HIGH COURT
Dissatisfied with the decision of the DC, the Appellant appealed against her conviction to the Singapore High Court. The Appellant’s appeal was unanimously dismissed by the three judges who comprised the panel.
In coming to its decision, the court dealt with five principal issues in its written judgment of over 150 pages, the findings of which are summarised below.
- The court began by answering the key question as to the meaning of a “profession”. In the context of the medical profession, the court found that given a doctor’s specialised knowledge and training, and his corresponding duty to utilise these skills with conscience and dignity in the patient’s best interest, a doctor is under an ethical obligation not to take advantage of his patients (whether monetarily or otherwise). This ethical obligation includes an obligation to charge a fair and reasonable fee for services rendered, and excessive overcharging would constitute a breach of this obligation. In the court’s opinion, this ethical obligation operates over and above contractual and market forces, and is not superseded by a valid fee agreement between the parties.
- The court went on to hold that a doctor’s ethical obligation to charge a fair and reasonable fee for services rendered is an inherent one and would bind a doctor even if such obligations had not been published in any legislation or ethical code at the material time.
- After reviewing the findings of the DC in respect of each and every charge brought against the Appellant, the court concluded that there was sufficient evidence to make out all the 94 charges of professional misconduct in the form of overcharging. The Court held on the facts of the case that the fees charged by the Appellant were grossly excessive and that many invoices raised by the Appellant were issued in an unsystematic, arbitrary and, ultimately, opportunistic manner. By way of an example, the evidence revealed that the Appellant had in one instance invoiced the Patient for S$211,000 for an “urgent intravenous therapy for tumour of spine” when the treatment had been carried out by another doctor who only charged S$400 for that treatment.
- The court also held that there was sufficient evidence to make out the 11 charges alleging (in addition to overcharging) false misrepresentation on the part of the Appellant in having falsely represented to the Patient and/or the Patient’s representatives that the 11 impugned invoices represented fees due to third party doctors. In each of these 11 cases, the Appellant issued invoices which read “Professional Fees for Dr …”. In none of these invoices was there any express or implied reference to any input by the Appellant herself, and yet the Appellant had added a significant undisclosed mark-up of fees in the invoices. The court nevertheless found the Appellant not to have deliberately falsified the invoices.
- Finally, the court held that the sentence meted out by the DC on the Appellant commensurate with the gravity of the professional misconduct in the case. The court agreed with the DC’s view that it did not think it appropriate to remove the Appellant’s name from the register of medical practice given the fact that the Appellant:
- did not, in the context of the 11 invoices for fees payable to third party doctors, deliberately falsify any of those invoices;
- had displayed exceptional care to the Patient; and
- is an exceptionally skilled doctor who has brought credit to Singapore.
CONCLUSION
The decision of the High Court of Singapore is final under Section 55(10) of the Medical Registration Act (Cap 174, 2004 Rev Ed) and is not subject to further appeal.
This case is significant as it is the first reported case in Singapore of a doctor having been found guilty of professional misconduct for overcharging a patient excessively for medical services rendered. There are no similar cases reported in Malaysia.
The finding by the Singapore courts that a medical practitioner, as a professional, is bound by an inherent ethical obligation to inter alia charge fair and reasonable fees for services rendered, and that the ethical obligation overrides the doctor’s commercial obligations and interest, may bring forth interesting implications to other professions, such as architects, engineers and lawyers.
Editor’s Note: The disciplinary proceedings in this case were commenced against the Appellant under the Medical Registration Act (Cap. 174, 2004 Rev. Ed). The Act has since been amended pursuant to Medical Registration (Amendment) 2010 Act. If proceedings had been commenced after the Amendment Act came into operation, the maximum financial penalty that may be imposed against a medical practitioner would be S$100,000 instead of S$10,000.