A Doctor’s Professional Indemnity Insurance (PI) protects the insured against breach of duty or negligence. It saves the legal cost incurred while fighting liability claims. Thus, doctors need to scrutinize the scope of the coverage offered and understand the exclusions carefully. S0, let’s see what Claims are not covered in a doctor’s professional indemnity.
Key Takeaways
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The “Grey Zone” of Specialty: In 2026, Cosmetic and Bariatric (weight loss) surgeries are considered high-risk categories. If you are a general surgeon who occasionally performs these, you are not covered unless you explicitly declare this and pay the specialized premium.
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The “Retroactive” Cut-off: Your insurance is not a time machine. If an incident occurred before your Retroactive Date (the first day you started continuous insurance), even if the patient sues you today, the claim will be rejected.
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Criminal vs. Civil: As demonstrated in the AR Hospitals case study, insurers will not touch a case involving a criminal offense (like sex determination). However, a unique 2026 provision allows for conditional reimbursement: if the court later clears you of criminal charges, the insurer may then pay for your legal costs.
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Ethics and Documentation: Issuing false medical certificates or misrepresenting clinical records is classified as “Fraudulent Misrepresentation.” This not only leads to claim rejection but can also lead to the insurer blacklisting the practitioner.
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The Intoxication Absolute: There is zero tolerance for practicing under the influence. If a patient alleges negligence and a medical report shows the doctor was intoxicated, the insurer will immediately step out of the legal defense.
Following claims not covered in a doctor’s professional indemnity :
Willful misconduct
The Doctor’s Professional Indemnity Policy does not cover intentional negligence or malpractices like the insured doctor issuing false certificates.
Moreover, the policy does not apply to instances where the insured has provided misinformation about clinical records for deceiving the insurer. It also does not protect someone who provides professional services without valid certification or registration.
Weight reduction procedures (Bariatric Surgery)
This insurance does not cover weight reduction surgeries like gastric bypass surgery. However, if you inform the insurer upfront that you conduct these surgeries you have a possibility of being covered.
Practicing under influence of alcohol or narcotics
Consultation provided or operations done under the influence of drugs or intoxicants will not be covered under this insurance.
Cosmetic procedures
The policy does not cover claims related to cosmetic or plastic surgery, hair transplants, or cosmesis. However, cosmetic surgeons can declare before buying the insurance and get coverage. Many insurers do not insure this specialty or will charge a high premium as cosmetic surgery is considered the riskiest of specialties.
Unlawful practices
The policy will not cover violations of legal compliances, for instance, prenatal sex determination. Besides, if the information in the proposal form doesn’t match the doctor’s actual practice there are high chances the claim will be rejected. Coverage will not be provided for criminal offenses like illegal abortion, organ trade, or prescription of prohibited drugs.
Existing issues
The insurer will investigate if the doctor became aware of an issue before the policy was bought or the retroactive date. Hence, while buying the policy the insurer must be informed of all known issues.
Prior period exclusions
Claims for incidents that have taken place before the retroactive date (policy issue date) will be rejected.
Summary: Major Exclusions in DPI Insurance
Case Study
AR Hospitals Pvt Ltd filed a professional indemnity insurance claim. The hospital’s doctors and staffers were accused of conducting prenatal sex determination. Although the hospital denied the accusation, the insurer rejected the claim. There appeared to be compelling evidence that sex determination was being conducted. The insurer denied the coverage as it is a criminal offense and is excluded under the policy. However, the insurer did state that if the courts were to absolve AR Hospitals, they would pay the claim.
Frequently Asked Questions (FAQs)
Q1: If I am falsely accused of a criminal act, will my insurer pay for my lawyer?
A) Initially, no. Most insurers will reject the claim if the FIR or summons is for a criminal offense. However, you can negotiate a clause where the insurer reimburses your legal fees if you are ultimately acquitted (found innocent) by the court.
Q2: I am a Plastic Surgeon; does that mean I have no insurance?
A) No, it simply means you need a Specialized Cosmetic PI Policy. Because cosmetic surgery has a higher rate of “patient dissatisfaction” lawsuits, the premium is higher and the policy wording is more specific than a general physician’s plan.
Q3: What happens if my medical registration expires mid-policy?
A) Your coverage is contingent upon you being a “Qualified Medical Practitioner” as per the law. If your license is suspended or expires, the policy effectively ceases to cover you for any acts performed during that period of non-registration.
Q4: Can I get coverage for a “Known Issue” if I haven’t been sued yet?
A) No. Professional indemnity is for “unforeseen” events. If you are already aware that a patient is unhappy or has sent a legal notice before you bought the policy, that is a “known circumstance” and will be excluded.
Q5: Is “Gross Negligence” the same as “Willful Misconduct”?
A) In 2026, courts and insurers distinguish between the two. Gross Negligence is still an “accident” (albeit a severe one) and is usually covered. Willful Misconduct implies you intended to cause harm or knowingly broke the law, which is never covered.
About The Author
Saloni Mishra
MBA Insurance Management
With an illustrious career in the insurance sector, Saloni is a distinguished writer specializing in articles concerning doctor professional indemnity policies for SecureNow. Leveraging 12 years of hands-on experience, she understands the intricate nuances of professional indemnity insurance tailored specifically for medical professionals. Her articles offer invaluable insights into the significance of doctor professional indemnity coverage, addressing the unique risks and challenges healthcare practitioners face. Renowned for their expertise and attention to detail, Saloni is committed to providing readers with informative and actionable content that empowers them to make informed decisions regarding their insurance needs.
