The hungarian system of the legal relaitonships which determine the civil responsibility of the healthcare service providers

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THE HUNGARIAN SYSTEM OF THE LEGAL RELATIONSHIPS WHICH DETERMINE THE CIVIL RESPONSIBILITY OF THE HEALTHCARE SERVICE PROVIDERS

Dr. Judit Zakany,

PhD, Research Fellow, Civil Procedure Department of the Faculty of Law of the University of Debrecen

The purpose of the article is to demonstrate the legal relationships that are essential in Hungary in terms of the civil liability of healthcare providers. The paper provides two examples of legal relationships: the legal relationship between the healthcare provider and the healthcare provider and the legal relationship between the healthcare provider and the insurer.

If a patient has suffered a negative outcome as a result of receiving medical care and wishes to exercise his or her right to damages, he or she is entitled to bring a civil action. The defendant in such a claim will always be the healthcare provider. Direct liability for damages to health care providers who have participated in the provision of medical services is excluded. If the court establishes liability for damages for the health care provider, the provider has the right to shift the liability for a specified proportion of the compensation for the loss to the health care provider, depending on the legal relations involved in the provision of health care services. The paper analyzes the typical legal relations of medical services with an emphasis on the problems of transferring responsibility of the amount of compensation.

The article also discloses the legal relationship between a health care provider and an insurer that performs insurance in the event of loss. In accordance with the provisions of the Act CLIV of 1997 on Healthcare, in order for a health care provider to be licensed for health care, its liability must necessarily be insured to finance the losses that may result from the provision of these services. If the court recognizes the guilt as a healthcare provider, the policyholder will be held liable. The liability insurance contract is designed to guarantee legal and property security for both the healthcare provider and the patient in the event of loss of health care services. At first, the system worked properly, but recently there are problems that are covered in the article, so the author tries to find their solution.

Key words: claim for damages in the field of medicine, legal civil responsibility, healthcare service provider, medical liability insurance, medical employee.

СИСТЕМА ПРАВОВИХ ВІДНОСИН УГОРЩИНИ, ЯКІ РЕГУЛЮЮТЬ ЦИВІЛЬНО-ПРАВОВУ ВІДПОВІДАЛЬНІСТЬ ПОСТАЧАЛЬНИКІВ МЕДИЧНИХ ПОСЛУГ

Мета статті полягає в тому, щоб продемонструвати юридичні відносини, які є основними в Угорщині з позиції цивільно-правової відповідальності постачальників медичних послуг. У роботі наводяться два приклади юридичних відносин: правові відносини між постачальником медичних послуг і медичним працівником та правові відносини між постачальником медичних послуг та страховиком.

Якщо пацієнт постраждав через негативні наслідки в результаті отримання ним медичних послуг і хоче скористатися своїм правом на відшкодування збитків, він має право на подання позову до цивільного суду. Відповідачем у такому позові завжди буде постачальник медичних послуг Безпосередня відповідальність за відшкодування збитків медичними працівниками, які брали участь у наданні медичних послуг, виключається. Якщо суд встановлює відповідальність за збитки за постачальником медичних послуг, постачальник має право перекласти відповідальність за визначену частку відшкодованих коштів за збитки на медичного працівника залежно від того, у межах яких правових відносин той брав участь у наданні медичних послуг. У роботі аналізуються типові правові відносини надання медичних послуг із наголошенням на проблемах перекладення відповідальності суми компенсації.

Також у статті розкрито правові відносини між постачальником медичних послуг та страховиком, який здійснює страхову діяльність у разі виникнення збитків. Відповідно до норм Закону Угорщини про охорону здоров'я 1997 р. для того, щоб постачальник медичних послуг отримав ліцензію на медичну діяльність, його відповідальність обов'язково повинна бути застрахованою задля фінансування збитків, які можуть виникнути в результаті надання цих послуг. Якщо суд визнає провину за постачальником медичних послуг, настає цивільно-правова відповідальність страхувальника. Договір страхування відповідальності призначений гарантувати правову та майнову безпеку як постачальника медичних послуг, так і пацієнта у випадках виникнення збитків під час надання медичних послуг. Спочатку система працювала належним чином, однак останнім часом виникли проблеми, які й висвітлюються у статті, тому автор прагне знайти їх вирішення. legal medical right hungary

Ключові слова: позов на відшкодування збитків у сфері медицини, правова цивільна відповідальність, постачальник медичних послуг, страхування медичної відповідальності в разі виникнення збитків, медичний працівник.

Problems in general

An expressly strict legal practice has been evolved in the area of the civil liability of the healthcare service providers in Hungary. It is quite common that the healthcare institutions are condemned to pay, furthermore the amounts of the adjudicated compensations have also increased. However, every healthcare service provider is obliged to conclude a liability insurance contract, so that the damages can be financed from this insurance. Because of the exclusions, that are defined in the contract, the insurer tend not to pay in many cases at all. If the insurer complies, the occasional insurance limit, which is approximately 3-5 million HUF (9 000-15 000 €), usually does not cover the adjudicated compensation, so unfortunately the healthcare institution is forced to pay it from the operational budget. In such circumstances the institution might claim to devolve either the total amount, or only one part of the amount of the compensation to that medical employee who actually caused the damages, depending on the form of the employment. The article deals with scrutinizing the questions coming from these basic problems.

Researches and publications in this topic

The studies dealing with this topic, especially with the employment forms of the medical employees and their liabilities, are very infrequent. Tamas Simon [3], Agnes Dozsa [5] and Zsombor Kovacsy [7] are certainly worth mentioning as researchers of this topic.

The purpose of the article is to demonstrate the legal relations which are fundamentally important in Hungary in the view of the civil responsibility of the healthcare service providers. I want to analyze two legal relationships, first to demonstrate the legal relationship between the healthcare service provider and the liability insurer, which is important because of the financing of the amount of the compensation. The liability insurance contract is destined to guarantee the legal and the wealth safety both to the healthcare service provider and the patient in cases of the culpable tort arosing during the healthcare service. Sadly, because of the existing problems - which will be also demonstrated - in many cases the amount of the compensation is on the budget of the hospital.

The second legal relationship is the legal relationship between the healthcare service provider and the medical employee, which influences many factors. This is fundamentally important in this topic, because it determines who has the direct obligation for the damage arosing during the healthcare service and it determines the possibilities to fend on the amount of the compensation. In the end the - by the analysis of the legal relationships - the reader will become acquainted with that who and in what form is responsible if the healthcare service provider is condemned.

The main research material. If the harmed patient, or his relative sues for damages, the action must be started against the healthcare service provider. In point of the extent of the financial liability of the healthcare service provider, the contract with the liability insurer and its elements are fundamental, so I will analyse them hereafter.

In the phrasing of the Civil Code of Hungary (hereafter: Ptk.), an insured party is entitled, on the basis of a liability insurance contract, to request the insurer to exempt him, up to the limit specified in the contract, from paying for damages for which he is legally liable (Ptk. 6:470. § 1). The charasteristic of the liability insurance that it makes a special legal relation with three subjectives by linking an insurance and a damage obligation legal relation [1, p. 374]. The insurance contract is made between the insurer and the insured. The insured is also a subjective of the damage obligation, he is responsible for the damage, but he is not every time the tortfeasor. For example, when the health institution makes the liability insurance, claims will be against this institution, the liability is its, but the real tortfeasor is the doctor who is in a legal relation with the institution.

The other subjective of the damage obligation is the harmed party, whose damage is compensated - fully or partly - by the insurer, instead of the insured one. So, the liability insurance is the security of the satisfaction of the damage obligation, an establishment of the obligated part, which makes it possible - maintaning the original obligatory situation and without changing the subjectives - for the insurer to comply instead of the obligated [2, p. 12].

In 1989 the pursuance of private medical practice and healthcare enterprises was authorized. The provisions of law on licensing first required mandatory liability insurance in the abovementioned two areas. Despite the fact that in this period there was no mandatory liability insurance for state-run healthcare institutions, almost all of them have purchased coverage by 1992. In the initial period, insurers also enthusiastically embraced the opportunities inherent in the new market and competed for satisfying the needs of hospitals with a diversity of offers. The 2nd Subsection of 108th Section of Act CLIV of 1997 on Healthcare (Health Act) extended the obligation of purchasing liability coverage to all healthcare service providers. Initially the system worked well, and it meant real safety for the service providers, assurance for the patients that the damages would be paid and, also a new source of income for the insurers. Changes of the ideal condition as described above and the decline of our medical liability insurance system can be primarily traced back to the change in the practice that can be observed in the lawsuits against the healthcare service providers. This was the circumstance disrupting the identity of interests that had previously existed between insurers and service providers. It was only in the interest of profit-oriented insurers to provide the service as long as it generated a profit for them. However, between 1997 and 1999, the proportion of the income from the insurance premiums relative to the insurance amounts paid began to gradually deteriorate. Due to the increase in the number of lawsuits and the amounts paid, this line of business was no longer profitable, and insurers recognized that it was no longer in their interest to provide insurance services in this market segment. This was the so-called first insurance crisis [3, p. 15].

In the following, I would like to highlight three factors that were, in my opinion, the genesis of all other problems. Firstly, the dwindling of the supply side of the insurance market. Currently there are a few insurance company that offers its service to all healthcare providers, which means that there is practically a monopoly on the market. Furthermore, there is an unilateral obligation to contract, since the healthcare service provider is required to take out liability insurance as a condition of its operating permit, but the insurer will only conclude a contract with a healthcare provider if and when it is worth it for them. Finally the relevant authorization has been declared for more than a decade, the Hungarian Government still has not issued the decree concerning the minimum conditions of professional liability insurances for healthcare service providers. The closing provisions of the Health Act originally only gave an authorization to the Minister of Health to draw up the detailed rules of the liability insurance of healthcare service providers. This provision of the Health Act was amended in 2002. The Government has since had the authority to create the relevant decree (Section 247(1), point “f” of the Health Act); however, this decree has not been adopted since.

As a result, nothing else determines the detailed rules of operation of this special type of liability insurances than the business policy, i.e. the general terms and conditions of the insurance company. These general terms and conditions, on the other hand, include numerous elements that are unfavorable for the institution and that do away with the essence of the liability insurance and disregard the original aim of this legal institution.

In the following, I will mention some problematic contractual provisions set forth by the insurers. Insurance premiums have increased significantly in recent years [4, p. 36]. The level of the services provided by the insurer, however, did not increase. The insurance limits are still at the level they were 15 years ago, generally 5 million HUF per insurance event in exception cases, 8 or 10 million HUF, with a maximum of 50 million HUF per year. By way of comparison: in case of automobile liability insurance, the limit is 500 million HUF per insurance event for damage to property and 1 250 million HUF per insurance event for personal injury. Damages above this limit are paid by the hospital from their own budget, i. e. the amount earmarked for running costs, or the maintaining entity fulfills the payment obligation.

Insurers interpret the concept of insurance event in an increasingly narrow way, and risk factors causing large amounts of damage are excluded from those covered, thereby practically dissipating the essence of liability insurance. The problem is that these exclusions are discussed on the basis of the general terms and conditions published by the insurance companies are beginning to take irrational proportions, and insurers are now excluding entire medical fields (e. g. plastic surgery), diagnostic methods (e. g. CT, MRI, X-ray) from the coverage they provide. In addition insurers exclude claims based on the failure or insufficiency of information, despite the fact that this is the legal grounds most frequently identified by patients [5, p. 24]. Among the exclusions there also appeared damages caused in connection with obstetrical and gynaecological activities, from the onset of labour until midnight of the fifth day after delivery.

Several strong reasons can be enumerated to support the importance of restoring the operability of the system as early as possible. The most urgent problem is that in the current situation there is no adequate solution for the financing of insurance events occurring in the course of providing healthcare services. As mentioned above, the approximately 5 million HUF limit offered by insurers is far less than the tens or hundreds of millions claimed. We could say that the proportions of payment have almost been reversed in such a way that the insurer pays the amount corresponding to a deductible, and the healthcare institution has to pay the amounts above that. The essence of a deductible is that the insured is to bear a certain part of the full insurance amount, as defined in the insurance policy. The extent of the deductible is typically 10% per insurance event. The deductible must only be paid if the insurance amount remains within the limit of the insurer per insurance event, and therefore, its main point is that the healthcare service provider cannot escape the payment obligation, not even if the damages awarded are lower than the insurance limit.

The other issue that I would like to emphasise is that the solution must also be found because of our obligation to harmonize with the laws of the European Union. In case the Directive on cross-border healthcare is adopted, there will be pressure from the EU on the member states, including on Hungary, to institute an efficient liability insurance system or other guarantees for the financing of insurance events occurring in the course of the healthcare services.

In point of the liability insurance of the state healthcare service providers there is an actual fact, that the National Healthcare Services Center (hereafter: AEEK) has the competence to conduct public procurement procedures contractedly in case of the health institutions which are under its direction. On behalf of the 27/2015 (II. 25) government decree 5. Section l) point, the AEEK and the health institutions have made an agreement on conducting the public procurement procedure. The AEEK by the licence and in the name of the health institutions as prospective constractors conducted an explicit public procurement procedure in 2016 to procure an insurance service. As a result of this the prospective constractors have made their contracts one by one with the insurer [6, p. 1]. Unfortunately, this procedure has not changed much in connection with the contractual terms, so it has not given a solution.

If the patient or his relative sues for damages successfully against the healthcare service provider, in the view of shifting off the payed amount it is significant that which legal form is used to occupy the medical employees who have had part of the service of the injured patient. The legal form of the healthcare service provider is also significant, and if the healthcare service provider has contractual connection with other healthcare service provider this also can affect to shifting off the damage.

The possible forms of the healthcare activities are determined by the LXXXIV Act of 2003 (hereafter: Eьtev.), which can be various. According to this, everyone who has appropriate skill has the possilbility that as a professional, or medical contractor, or a member of a joint business, member of an individual firm, ecclesiastic, volunteer he can do medical activity in labour relation, public servant relation, government serving relation, state serving relation, serving relation. A person can do medical activity in more legal relation even at the same provider, but it is important that the medical activity can not be more than 60 hours a week, on average 12 hours a day - within a month. In point of duty work, only the term of the actual medical activity must be taken notice of.

In the following sectors I will mention some legal forms which have important role in practice, in the middle there will be the liability rules in connection with these legal relations. The stress is on compensating the damages caused to a third, outside party in connection with the legal relation. First, I chose the legal possibilities, to which the operational permit of the healthcare administrative organization is not necessary. In these cases the activity is done in the name of a healthcare service provider which has operational permit and in a contractual legal relation with it. In this case I will analyse the labour relation, the public servant legal relation and the professional legal relation.

The common employment form of the Hungarian medical employees is the public servant legal relation, and the medical activity which is done in a labour relation. The 3rd Subsection of the 2nd Section of XXX Act of 1992 on the public servants (hereafter: Kjt.) orders that for the other, unregulated questions the I. Act of 2012 on the Labour Code (hereafter: Mt.) should be applied. Subjectives of the public servant legal relation are the employer and the public servant, labour relation is made between the employer and the employee. For doing medical activity by public servant, or the employee, the appropriate qualification is necessary. Public servant legal relation can be made by competition, the legal relation is born by nomination and its acceptance. The labour ralation is made by signing the labour contract which testifies the mutual and concurrent manifestation of will of the parties. The liability rules of the two form are connected strictly, so they will be demonstrated side by side. In accordance with the 14/A Section of Eьtev. if the employee or the public servant causes damage to a third party in connection with the labour relation or the public servant relation, the employer is liable for the injured party directly. In the case of obligation to fulfill his commitment, the provider has the chance to devolve a part of the damage to the employee - in consideration of the form of the medical activity. According to the 3rd Subsection of 197 Section of the Mt., the employee and the public servant is responsible fully in the case of willful and recklessly careless tort too, in other cases he is responsible with his 4 months absence fee maximum. This rule would make significantly harder even the position of the most protected medical employee in labour relation and public servant relation in regard to the wilder liability of the healthcare service providers, the increase of the fees for damages and the explanation from the liability getting harder. The legislator has got wise to this fact and the necessity of the special regualtion for the healthcare services. With the 15/C. Section of the Eutev. he has overwritten the mentioned rule of the Mt., but not generally, only in point of the damages caused for the patients with the medical activity. Although the orientation is favourable, I think that the rule must be modified not only in relation to the damages caused to the patients, because in sues for damages the claims from the relatives are frequent and mean large amounts. So the rule must be applied to these, which says that in the case of careless tort the amount of the compensation is maximum 4 months absence fee of the employee.

The main point of the professional legal relation is that the medical employee engages to do a medical activity - to which he has the competence - in a mandate contract. A special mandate contract is born between the parties with the elements determined by the Eutev [7, p. 241]. The factual terms are secured - essentially - by the healthcare service provider, which pays a fee - determined in the contract - for the professional activity. The professional legal relation is an appropriate solution if the employee wants to take part of an activity of a bigger, or private healthcare service provider on some occasions weekly for some hours, wants to take part of duty activities, but he does not want to work as a healthcare contractor, or he does not have the personal and objective terms which are necessary for the operational permit [8, p. 17]. If the professional causes damages to the patient or to his relative during the healthcare service or correlating with it, the liability is based on that if he is a legal relation with a healthcare public service provider or healthcare private provider [9, p. 23]. In the prior case according to the 19/A Section of Eutev. the healthcare service provider - which gives the public service - honors obligations directly towards the injured party, which can sue the tortfeasor professional by the rules of the civil law. There is not any special protocol for the healthcare service providers who service private service, for them the rules on the mandate contracts from the Ptk. must be applied. According to these, if the mandated - in his position - causes damages for a third party, he has joint and several liability with the principal. The principal can be excused if he can prove that he has acted as it has been reasonable under the circumstances with choosing, instructing and supervising the supervising the mandated. If there is a permanent mandate betweent the healthcare service provider and the professional, the rules on the healthcare public service providers must be applied. But, if the mandated has caused the damage willfully, he has has joint and several liability with the principal (6:542. Section and 6:540. Section of Ptk.).

Hereinafter I will deal with the legal possibilities, when the medical activity can be done only with operational permit. The subjectives who have operational permit are healthcare service providers, so they give medical services in their own names. According to the law 96/2003 (VII. 15) government decree, private healthcare enterprise, private firm, and joint enterprise must require operational permit (from the Chief Medical Officer or the township office - depending on the feature of its activity) to work as a healthcare service provider. For this, it must complete the personal and objective terms from the Vth Chapter of Eutv. and must make liability insurance.

Operational permit can be given to private healthcare enterprise from the administrative healthcare organization if it has qualification, it is in the operational register of the medical employees, it proves its health competence, and the planned medical activity is not limited by the law, or the law does not name a specific healthcare service provider to this planned activity. The condition to start the work is to report the activity to the Central Office for Administrative and Electronic Public Services which making the register of the private enterprises, this report is free. The benefit to work as private enterprise that there is not a boss, but the terms to get the operational permit must be made, and this means costs. As to the liability for damages, the private healthcare enterprise is liable with its whole private wealth for the damages caused in connection with the medical activity, and it is can be limited only by the mandatory liability insurance. If the enterprise has an employee, and he causes damage in connection with the healthcare activity to the patient or his relative, the healthcare enterprise will be responsible in front of the injured party, but in the case of will- full tort the enterprise can avoid the whole amount, in the case of negligent tort the enterprise can avoid maximum 4 months absence fee to the employee.

The private firm - acting as a healthcare service provider - is strictly connected with the prior legal form, because this form - without legal personality - can be founded only by a private enterprise. This possibility is favourable for everyone who wants to act not in their own name, but under a corporate name, and a private firm can turn into other business association [10, p. 26]. The private firm is born with the registration to the register of companies, and at the same time, the status of the private enterprise ends. To ban the unlimited liability, the member of the private firm can not be - at the same time - private enterprise, general partner of a limited partnership, or member of other private firm. A private firm can have only one member, but the firm can have employee in employment relationship. As to the liability, if there is a loss during the healthcare activity, the private firm will be liable towards the injured party directly. For the debts which are not covered by the wealth of the firm (to found the firm the law does not require a minimum subscribed capital) the founding member will be liable fully, with his whole private wealth. In the case of the tort caused by the employee, the mentioned rules on the employees of the private enterprise are applied.

Business association can do healthcare activity too, the work can be done as a member of a joint enterprise. It is indispensable to found a business association to draw up the instrument of constitution in a notarial document, or in a private document countersigned by a lawyer, which have to be signed by all of the founders. The administrative healthcare organization with competence can give operational permit to the association, if the planned medical activity is not limited by the law, or the law does not name a specific healthcare service provider to this planned activity. And because the medical activity is connected to qualification, it is necessary that the enterprise has at least one member who constracts personal cooperation, or has at least one person who is in employment relationship or civil law contractual relationship with the association, and who suits the qualification requirements, who is in the operational registration of the medical employees and proves his competence (96/2003 (VII. 15) government decree 11. § 2). This legal possibility is practical in the case whent more medical employees want to cooperate permanently, it has the advantage that they can prove the necessary terms - to the service - more easier together, they can partake from the common gain and have the chance to make an uniform image [11, p. 21]. In Hungary there is form pressure for the business associations, they can be founded only in the forms determined by the law. In Hungary joint enterprises operate mostly as limited partnerships or limited liability partnerships. In the prior case the costs of the foundation are more favourable, because the law does not require a minimum subscribed capital for the limited partnership. For the obligations of the healthcare service provider - in the form of a limited partnersip - so for the case if its member or employee causes damage during the medical activity for the patient, principally, the association will be liable with its whole wealth. But, for the debts which are not covered by the wealth of the association, at least one general partner is liable with his private wealth vicariously and unlimitedly. The foundation of the limited liability partnership is more expensive, because it needs minimum 3 million Ft subscribed capital, but the financial liability of the members - fundamentally - reach only to the paid primary stake, so they are in a more protected legal status in the case of an action for damages.

The healthcare service providers can act in their own names and liabilities - as it was mentioned earlier - but there is the legal possibility to cooperate in other activities which are in an operational permit of other healthcare service provider. The collaborate contracts are very common, especially in connection with inspection activities, and they are used in connection with specialist consultations too, so it is important to mention them. For example - according to the data from - in 2013 more than 7 200 collaborate contracts were in force. The collaborate contract is a special mandate contract, both of its subjectives are healthcare service providers. The point is that the collaborator personally or with his medical employees gives medical service in the name of the other healthcare service provider and for the latter one's patient, secures the necessary objective and personal terms, and the other healthcare service provider pays for the service. It is important that the subject of the collaborate contract can be only a medical service to which both healthcare service providers have operational permit [12, p. 24].

Conclusions

In point of the measure of the financial liability of the healthcare service providers the contract with the liablility insurer is determinative important, its system of terms, so we dealt with them first. There are problems with financing the amounts of the compensations, because of the “vacating” of the compulsory professional liability insurance these amounts are mostly covered by the budget for the function of the healthcare service providers. In the beginning, the compulsory professional liability insurance was a legal institution which has given real legal protection, security for patients and providers too and has worked according to the legislator's will. But the increase of the borders of the liability of the healthcare service providers has disrupted the compatibility between the providers and the insurance companies. Because of the closed character of the supplying part of the healthcare professional liability insurance market, the unilateral contracting obligation for the healthcare service providers, the lack of the regulation on determining minimum conditions of the healthcare liability insurance, the contractual conditions determined by the insurance companies “are vacating” the legal institution. Without real legal protection this legal institution is a fetter for service providers, and the financing of the amounts of the compensation is not solved yet.

Secondly, we examined the legal possibilities which are usually used during medical activities. It can be said the there are many variable possibilities. I dealt preferentially with the liability rules of the legal relations, which are important and actual because of the tendencies, concerning the liability for damages of the healthcare service providers and make this liability more malevolent, and because of the explanation which is getting harder. Because of the wider liability there is the possible chance that the damage amount, or its part can be avoided to the employees who do the medical activities. The measure of this depends on the legal form in which the medical activity is being done. Not only a person with qualification can be in legal relation with the healthcare service provider, but - in favour of complete the personal and objective resources - the healthcare service providers can make contracts with each other. This means collaborate contracts which are significant in the area of the medical services. The term of starting the services, the costs and the liability are mainly diverge from each other in the legal relations. This is beneficial because the qualified medical person can find the form which is the most sufficient for his prioriries and possibilities. Ha can operate in contractual relation at a healthcare service provider, or independently, or - in the form of a joint enterprise - he can operate a healthcare service provider. But there is the disadvantage that the possibilities are hardly seen clearly because of the many legal relations and the fragmented regulation.

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