The Insurance Department at Belzuz Abogados, S.L.P. provides a detailed analysis of a recent and important Supreme Court ruling that addresses fundamental issues in the field of healthcare liability and insurance law. The ruling puts an end to a complex litigation arising from the sequelae and subsequent death of a patient following surgery at the Nuestra Señora de la Salud Hospital in Granada.
The case, initially heard in the criminal courts for five years and concluded with an acquittal, gave way to a civil lawsuit filed against several physicians, the hospital and their insurers, claiming compensation for alleged malpractice. The lawsuit was dismissed in the first instance, but the Provincial Court partially overturned the ruling, ordering the defendants to jointly pay €991,712.27, recognising the limits of coverage for insurers and the obligation to pay default interest in accordance with Article 20 of the Insurance Contract Act (LCS). Finally, the Supreme Court dismissed the appeals, consolidating key jurisprudential criteria in this area.
Theory of Disproportionate Damage
The ruling delves into the doctrine of disproportionate damage in the field of medical civil liability. This concept applies when there is a significant discrepancy between the nature of the intervention and the harmful result, requiring the medical team to reasonably justify the origin and cause of the damage. It does not constitute an automatic presumption of fault, but it does ease the burden of proof on the patient, given the difficulty of proving negligence in the healthcare environment.
The Supreme Court specifies that the doctrine of disproportionate damage is not applicable when the result constitutes a typical and foreseeable risk of the intervention, unless malpractice is proven. In the case analysed, although the complication was foreseeable, a chain of negligence (lack of suturing, poor care in the ICU) was proven, which justified the conviction.
Burden of Proof and Ease of Proof
The Chamber reiterates that it is up to the claimant to prove the breach of lex artis and the existence of a causal link. However, it allows for the modulation of the burden of proof in favour of the patient, applying the principle of ease and availability of evidence pursuant to Article 217.7 of the Civil Procedure Act (LEC), especially when the damage is disproportionate and access to the evidence is in the hands of healthcare professionals.
Assessment of Evidence
The Supreme Court dismisses the grounds for procedural infringement relating to the assessment of documentary and expert evidence, recalling that the joint and rational assessment of evidence is the responsibility of the court of first instance, and that only clear factual errors may be reviewed on appeal.
Liability of the Hospital
The judgment examines the hospital’s liability both from the perspective of functional dependence (Art. 1903 CC) and from the perspective of the hospitalisation contract and consumer and user regulations (Art. 26 LGDCU). It concludes that the absence of a surgeon on duty constituted a significant organisational deficiency, causally related to the damage suffered by the patient, which justifies the hospital’s conviction.
In this case, the surgeon responsible did not have an employment or dependency relationship with the hospital, but provided his services to the subcontracted company providing the ICU service. The Chamber concludes that the hospital and its insurer cannot be exonerated from their liability on the grounds that the healthcare personnel have a commercial relationship, without prejudice to their right of recourse against the directly responsible parties.
Insurance Compensation Limits
The ruling analyses the validity and enforceability of limiting clauses in insurance policies. The Supreme Court determines that sub-limits per victim do not constitute clauses limiting the insured risk, but rather clauses limiting the rights of the insured, and as such, must comply with the formal and substantive requirements set forth in Article 3 of the Insurance Contract Law (LCS) in order to be enforceable against the injured parties, which in this case is not proven, rendering them unenforceable. This resolves a doctrinal dispute, expressly determining the nature of these sub-limits and reinforcing the special protection for the injured party.
The sum insured per claim is a clause limiting the insured risk and is fully enforceable; the sub-limit per victim, on the other hand, is a limiting clause.
The ruling does not state whether or not the policy in question was high risk. If so, would the conclusion reached by the Chamber have been the same? What role would the autonomy of will play in the drafting of the policy?
Default Interest under Article 20 of the Insurance Contract Law
The ruling reiterates the restrictive interpretation of the justified causes for exemption from the payment of default interest. The mere judicialisation of the claim is not sufficient cause; only the existence of well-founded reasonable doubt regarding the obligation to compensate can justify exemption from the payment of default interest. In this case, neither the previous criminal proceedings nor the civil judgment dismissing the case at first instance were considered valid grounds for opposition.
Noteworthy is the presumption made by the Chamber regarding the insurer’s knowledge of the accident, bordering on probatio diabólica: in accidents of particular relevance, it is not plausible that the insured did not report the accident to their insurer, with the burden of proof of lack of knowledge falling on the Company.
Conclusion and Practical Relevance
This ruling consolidates jurisprudential criteria on medical malpractice, burden of proof, application of disproportionate damage and liability of healthcare centres and their insurers. It highlights the importance of hospital organisation and diligence in the provision of services, as well as the protection of the rights of patients and consumers.
At the Insurance Department of Belzuz Abogados, S.L.P., as specialists in Medical Liability and Insurance Law, we consider this ruling to be of particular relevance to solicitors, insurers, healthcare professionals and hospital managers. It is a warning regarding the risk of joint and several liability in cases involving commercial relationships, the importance of policy wording, proactivity in claims management and the relevance of hospital organisation in generating direct liability and insurance coverage.
Ignacio Montero Pujante
Departamento de Seguros
España
BELZUZ ABOGADOS SLP, Insuralex´s Exclusive Member in Spain and Portugal
