Thursday, 16 November 2017: A new take on medical professional indemnity (PI) protection for doctors is turning the traditional, controversial indemnity insurance model on its head.

EthiQal, a new medical professional indemnity (PI) solution underwritten by Constantia Insurance Company Limited (CICL), was introduced to the market just a year ago and is already changing the way doctors approach and practice medicine – to the protection and benefit of both healthcare professionals and patients.

Says Volker von Widdern, Group Chief Executive Officer of CICL: “South Africa has a critical shortage of medical professionals. According to an Econex survey commissioned by the Hospital Association of South Africa (HASA) in 2015, there were just 60 doctors per 100 000 people in 2013; and the world average is 152. The emigration of healthcare professionals adds to South Africa’s doctor shortage – a situation which is placing the country’s entire healthcare system at considerable risk. While it is uncertain how many doctors have emigrated, Econex reported that between 2004 and 2009, 17% of doctors who had qualified did not report for community service. It is estimated that there are currently only 7 000 medical specialists practicing in South Africa.”

Prohibitive medical PI premiums impacting on doctor numbers

One of the factors contributing to the declining number of doctors in South Africa is the prohibitive cost of monthly medical PI premiums. The issue around premium costs is a very real consideration for doctors currently in practice and those looking to start a career in medicine. In some cases, medical PI costs are driving high-risk specialists such as obstetricians and gynaecologists (ob-gyns) from their professions.

Doctors are a national asset and should be protected

“Doctors are an indispensable national asset and should be protected,” says Von Widdern. Alarmed by the seriousness of the ‘doctor drain’, in November 2016, CICL launched EthiQal, a medical PI solution. As the company celebrates its first birthday this November, Von Widdern says several strides have been made in support of doctors and, ultimately, their patients.

“Before the introduction of EthiQal, few local insurers provided affordable cover for doctors. Many were forced to turn to overseas-based insurers and international organisations for protection. Through EthiQal, we offer both occurrence-based PI liability and claims-based cover to the medical profession. Our focus is on providing doctors with peace of mind and a sense of security that they’ve not had in the past, while also significantly reducing the cost of medical PI cover.”

Medical PI premiums and impact on obs-gynae practices

Highlighting the crisis of confidence in the industry, Von Widdern says the spiralling costs of medical PI cover have had an adverse impact, particularly on high-risk specialists such as ob-gyns, threatening the financial viability of some specialist practices. Over the last 15 years, for example, premiums have reportedly doubled every five years with doctors being given little if any data that supports the reasons behind premium hikes.

“It’s simply not sustainable. When it comes to newly qualified specialists who have taken up to 15 years to qualify, they can’t afford to set up a practice as they don’t have the revenue stream to provide for medical PI insurance cover.”

Fixed, lower premiums now a reality

“Many of these professionals have felt trapped by spiking medical PI premiums, hindering their retirement plans and leaving them feeling they have little control over their destinies,” says Von Widdern. EthiQal has addressed these concerns by basing its medical PI solution on a fixed premium, one which the company hopes to further reduce in time to come. “We believe up to 90% of South Africa’s doctors are good quality risks. And the way we approach our business makes for a realistic and sustainable pricing of premiums”.

Stable group backing

Backed by CICL, a stable group with over 60 years’ experience in the insurance industry, EthiQal is currently the only other provider of occurrence cover in South Africa with a long-term outlook. “More and more doctors are being attracted to what is a credible alternative to what they have had access to in the past; one that offers peace of mind thanks to a solid medico-legal team that understands the particular needs of medical professionals and the medical PI issues they face,” says Von Widdern.

Proactive approach to risk management and litigation

Litigation for alleged negligence by healthcare institutions is claiming increasing proportions of health spend, he says, pointing to the fact that over the last ten years, settlements have shot up from below R15 million to some that reach R40 million.

“To stabilise the South African medico-legal landscape, we advocate alternative dispute resolution as a preferred method of defence in medical negligence claims,” says Von Widdern. “Litigation may be necessary in some cases, but most disputes would be served better by a conciliatory process or mediation, which allow for quick and just conflict resolution. For patients, this has the advantage of ensuring they receive the settlement due to them without having to undergo up to ten years of court proceedings.”

EthiQal has also demonstrated its commitment to providing the most appropriate clinical expertise for purposes of fair dispute resolution, and is actively engaging with professional societies and associations to facilitate unbiased and trusted expert opinion.

To help reduce clinical risk, EthiQal supports initiatives by professional societies and associations that are aimed at designing, implementing and promoting doctor-driven risk mitigation strategies.

“Examples of these include processes to improve informed consent, defining clinical protocols and clinical practice guidelines, establishing peer review and support mechanisms, as well as the development of clinical data collection platforms,” says Von Widdern. “We are also committed to sharing knowledge about clinical practice risks as identified by ourselves, together with the industry. Our drive to collect South African-specific data and pair that with analytic capabilities will provide transparency to South African doctors regarding their specialities, as well as country-specific risk profiles.”
“EthiQal pioneered insurer-sponsored peer support programmes, and has recently initiated early intervention programs that are designed to maintain contact and guidance with higher risk patients.”

In addition to sponsoring many continuing professional development (CPD) meetings and presentations during the course of its first year, EthiQal also participated in debates on medico-legal issues at the annual conference of the Neurosurgery Society, and the Paediatric Management Group.
“The success of our inaugural EthiQal For All conferences at the CSIR Convention Centre in Pretoria and the ICC in Cape Town can be attributed to prominent speakers and their topics,” Von Widdern adds. “These included Judge Hlophe’s dissection of the pros and cons of ‘Mediation versus Litigation’; Advocate Stephen Farrell’s keynote address, ‘The litigation journey: a health care professional’s guide’; and Professor Willem Landman’s presentation on the sensitive subject matter of ‘Assisted Euthanasia,’ which was particularly well received.”

EthiQal also hosted an industry conference in conjunction with the Department of Health, focusing on the advancement of law reform in the field of medico-legal litigation. The meeting aimed at proposing legislative reform and identifying practical solutions to the medico-legal crisis with the intention of reducing medical malpractice litigation and safeguarding the sustainability of the healthcare system. Based on the discussions at the conference, EthiQal has submitted a report to the ANC NEC Subcommittee for Health and Education outlining its recommendations.

Subsequent to this, the South African Law Reform Commission (SALRC) was appointed by the Department of Health and the Department of Justice and Correctional Services to investigate the feasibility of legislative reform in this area. Their work resulted in the publication of a comprehensive summary of their investigations into medico-legal claims in South Africa, including the scope of the problem, expenditure on litigation in relation to spending on health, as well as case law. Legal principles underlying medico-legal claims were furthermore delineated, as were issues relating to payment of compensation. Thoughts for stakeholder consideration were outlined.

“In our quest to contribute to the development of a more sustainable healthcare system, we are motivated by the fact that we are attracting a growing number of doctors who view EthiQal as an alternative that will provide them with peace of mind, and stem the flow of medical professionals from the country, while ensuring that patients are protected. Importantly, we have proposed legislative reform and identified practical solutions to the medico-legal crisis with the intention of reducing litigation and safeguarding the sustainability of the system” says Von Widdern.


  1. In a 2014 edition of SA Medical Journal, doctors warned the health system could collapse as medical negligence lawsuits were driving up the cost of private insurance for doctors, making practising certain specialities of medicine too expensive and risky. (South African Medical Journal, Volume 104, 11, 2014)
  2. The number of claims against healthcare professionals in SA rose by 35% between 2011 and 2016, and the value of the claims during this period had increased 121%. (Medical Protection Casebook, August 2017)
  3. Complaints to the Health Professions Council of SA have risen by 100% to 2 500 a year against doctors, dentists and other healthcare professionals. (Medical Protection Casebook, August 2017)
  4. Malpractice claims have become more complex and frequently involve multiple experts. Wrongful life claims, wrongful birth claims, cerebral palsy, Down syndrome, and birth defect claims are examples of new types of claims. (Medical Protection Casebook, August 2017)
  5. South African Association of Obstetricians and Gynaecologists president, Dr Johannes van Waart says in 2013, insurance against potential malpractice suits cost R250 000 a year; it is R850 000 in 2017 and expected to be R1m within a year. (Ethics under scrutiny as medical malpractice claims soar, Business Day, 26 September 2017)
  6. According to the Health Minister, Aaron Motsoaledi, from the 2014/15 financial year to the 2016/17 financial year, more than R2.3 billion has been paid to cover medical negligence claims – with the state’s contingent liability for the claims sitting at R56 billion. (Taxpayers fork out over R2.3 billion for medical negligence at state hospitals, BusinessTech, 31 October 2017)
  7. Motsoaledi says 360 claims have been lodged in the current (2017/18) financial year so far, amounting to R241 million. Although some of the claims are legitimate, many of them are excessive and unjustified. (Taxpayers fork out over R2.3 billion for medical negligence at state hospitals, BusinessTech, 31 October 2017)
  8. Rising medical PI insurance costs are also having an impact on doctors’ and hospitals’ costs. The rising cost of funding malpractice insurance is having a serious impact on obstetricians, often forcing doctors to charge a co-payment for their services. (Obstetrics in a State of Crisis, IOL News, 4 September 2016)
  9. Doctors are the backbone of hospitals. SA’s three biggest private hospital groups make a significant contribution to the economy, generating R55.5 billion, or 1.3% of gross domestic product (GDP), in 2016, according to research by Econex. (Private hospitals’ contribution to the South African economy 2016/2017, Econex, September 2017)
  10. Econex reports that for every person directly employed by private hospital groups, almost five additional formal and informal jobs are supported in the South African economy, and for every R10 million of capital investment, private hospital groups create 20 jobs. (Private hospitals’ contribution to the South African economy 2016/2017, Econex, September 2017)
  • Medical professional indemnity (PI) covers both doctors and their patients if something goes wrong during medical care and the patient is harmed. It indemnifies the insured for bodily injury or mental injury, illness, disease, or death of any patient caused or alleged by malpractice.
  • It covers doctors for both legal costs and the costs of awarded compensation if they are found to have caused harm by committing an error, omission or negligent act.
  • It’s important because it protects the doctor’s business against claims of malpractice or professional misconduct.


At EthiQal, we are changing medical professional indemnity (PI). Our dedicated, highly experienced and knowledgeable team is working together with doctors, their associations and societies, the legal profession and representatives from Government to ensure trusted outcomes between doctors and patients – in sickness, adversity and health. We believe that together we can positively change the risk landscape for South Africa’s doctors – now and into the future.