The Italian Supreme Court, with judgment no. 25568/11, deals with the question of what evidentiary value can be attached to information contained in medical records.
The case at hand concerns four mammary cist and breast reduction operations carried out by a clinic.
The first question dealt with by the Court was the defense raised by the Insurance Company summoned as a third party by the defendant clinic.
Such parties had, in fact, taken out an insurance policy in which the Insurance Company undertook to hold the clinic harmless for liability arising out of cosmetic surgery and not for operations carried out in arrangement with the Italian National Health Service (as was the case at hand).
On this point, the Italian Supreme Court effectively upheld the rulings handed down in first and second instance, holding that the aforementioned operations did not have any aesthetic purpose.
The Court held, therefore, that such operations were to be deemed to have been carried out in arrangement with the Italian National Health Service and that, as such, the Insurance Company’s defense was grounded.
The second part of the judgment seemed, however, to be more interesting insofar as it dealt with the evidentiary value to be attached to medical records.
The Supreme Court judges upheld the ruling that medical records drawn up by a public hospital or by a hospital having an arrangement with the Italian National Health Service are – in the absence of a complaint for forgery – to be deemed genuine as regards the records concerning the activities carried out during the course of therapy or an operation, with the exclusion of assessments, diagnoses or statements of fact or opinion contained therein (cfr. Italian Supreme Court judgment nos. 7201/03 and 10695/99).
The above concerns only the validity of medical records for public sector medical liability and does not concern those torts that are committed in private medical facilities.
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