(November 4th, 2024) A patient can request a free copy of their complete treatment documents from their treating doctor, be it a clinic doctor or a doctor in private practice Art. 15 General Data Protection Regulation (GDPR). The one that says otherwise § 630 g paragraph 2 sentence 2 BGB is ineffective. The patient does not have to justify his request for a copy of the treatment file to be sent, nor does he have to specify the legal basis for his request (Dresden Higher Regional Court, judgment of October 1, 2024, ref.: 4 U 425/24).
The case: The patient first paid for copies and then demanded a refund
A patient was admitted to a clinic for treatment. There were arguments between the clinic and the patient and the patient was expelled from the clinic. She later asserted a claim for damages against the clinic and requested that copies of her treatment documents be sent. The clinic charged her around EUR 40 for these copies, which the patient paid.
In a lawsuit, she demanded not only compensation for alleged mishandling but also reimbursement of the copying costs.
The decision: The patient is entitled to a free copy of the file under the General Data Protection Regulation
The plaintiff is entitled to receive copies of her patient file § 630 g BGB as well as Art. 15 Para. 1 and 3 GDPR to. So far § 630 g paragraph 2 sentence 2 BGB imposes on patients the obligation to reimburse the treating physicians for the costs of the copies, this regulation violates the provisions of the General Data Protection Regulation and is not applicable. According to the case law of the European Court of Justice (judgment of October 26, 2023 – C-307/22 – juris), the controller must provide the person concerned with a first copy of his or her personal data that is the subject of processing, free of charge, even if the request in question is based on a request other than that set out in the first sentence of recital 63 of the the purposes stated in the regulation.
However, the claim does not require that the patient has already exercised her right to inspect her medical records Art. 15 GDPR supports. It is not necessary to justify the right to information or inspection (for Art. 15 GDPR cf. ECJ, judgment of October 26, 2023 – C- 307/22Rn 38 – juris) and a norm from which the claim should be derived.
The fact that she based her claim on the basis of damages does not conflict with the patient’s claim, because it concerns the same facts of life and is not obliged to name a specific norm on which she bases her claim.
After all this, the clinic had to pay the copying costs of around EUR 40 back to the patient.
Practical note: Request a free copy with reference to this case law!
The payment of the copying costs for the photocopying of the treatment documents (and their correct calculation) is a long-standing controversial issue. Since many clinics and doctor’s practices now keep digital files and can simply send a digital copy, the dispute has eased somewhat recently. However, it often happens that practitioners who still make copies charge for this (sometimes up to 50 cents per copy). The patient can now also use the higher court case law of the Dresden Higher Regional Court against these practitioners. Incidentally, the case law must be agreed with – the GDPR simply takes precedence over the rules of the German Civil Code (BGB).
If the treatment site is not willing to release the copies without an advance payment, the patient can inform the respective data protection officer by email. Since failure to comply with the information requirements under the GDPR can result in severe GDPR fines, this usually results in the requested copies being sent quickly.
Abstract:
(November 4, 2024) A patient can request a free copy of his complete treatment records from his treating physician, be it a hospital doctor or a practicing physician, in accordance with Article 15 of the General Data Protection Regulation (DSGVO). The contrary provisions of Paragraph 630 g, Section 2, Sentence 2 of the German Civil Code (BGB) are ineffective. The patient does not have to justify his request to receive a copy of the treatment file, nor does he have to name the legal basis for his request (Dresden Higher Regional Court, judgment of October 1, 2024, case number: 4 U 425/24).
