AC-2025-LON-000160 - [2025] EWHC 3006 (Admin)

This concerned Patients C and D. The claims for the treatment in question for those patients were, as was admitted by Mr Mobasseri, inappropriate because the treatment claimed for did not take place. Each of Patients C and D had had treatment, for which an appropriate claim was made, and in each case there followed a further claim replicating (or similar to) the first claim (but with different dates) when there had been no such second course of treatment. The details for each were as follows:

The PCC noted that Mr Mobasseri had not been able to explain how the second, false, claim had come to be made in each case, although he had suggested that it might have been the result of administrative error by the practice staff who might have inadvertently submitted the claim in both SoE and in R4 during the changeover in software. However, it rejected the suggestion these were duplicate claims, due to the inconsistent dates. The PCC noted that the false claim for Patient C was opened and closed on 4 March 2019 using Mr Mobasseri’s log-in details. The PCC found that it made no sense for this to have happened except for the purpose of attempting to claim twice for the same treatment, for which Mr Mobasseri would have been the only person to benefit. It also said this about the administrative staff in relation to the Patient C claim (and something similar in relation to the Patient D claim):

“There would have been no reason for the administrative staff at the Practice to have opened and closed the second course of treatment and submitted it for payment except if acting under your direction. The administrative staff would not have known the date on which treatment is complete, as this is a clinical matter for the treating dentist or other clinician to decide. There was also no evidence before the Committee that the claim could be opened and submitted in this way as a result of computer error.”

The PCC also recorded (in respect of the Patient C claim) that:

“You stated in evidence that you knew in the event of a duplicate claim being submitted to the NHS for the same course of treatment it would not have been paid. However, this was not a duplicate claim: the dates had been manipulated so that what was claimed would appear as a separate course of treatment.”

It said something similar in relation to the Patient D claim, noting also that in respect of Patient D “the type of denture had been changed, meaning it would appear as a different course of treatment.”

The PCC also noted that these patients were both exempt from payment of NHS charges, which meant that a second claim was less likely to have been challenged by the patient, as the practice would not have been asking them to pay any additional charges.

In respect of the second claims for both Patients C and D, the PCC came to the same conclusion:

“Having regard to the totality of the evidence the Committee determined that it is more likely than not that you deliberately changed the dates in order to claim twice for the same course of treatment. Such conduct would clearly be regarded as dishonest by the standards of ordinary decent people.”

The first point here, as with the previous set of patients, is whether the PCC reversed the burden of proof in relation to the question of dishonesty. The way in which it approached its reasoning in terms of structure for Patient C and D does not suggest, in the same way as with Patients B, F and K, that it applied the wrong burden of proof. It is right to say that some of the language used in the PCC’s reasoning suggests an assumption of deliberate conduct (rather than a second claim being submitted in error), in particular in saying that the dates had been “manipulated” for Patient C (and, though less obviously, that the dates and type of denture had been “changed” for Patient D). That on it own does not, however, seem to me to show that an incorrect burden of proof had been applied.

However, there is another problem with the PCC’s reasoning for these patients. The PCC held (in respect of both Patients C and D) that it made no sense for the false claim to have been made except for the purpose of attempting to claim twice for the same treatment, for which Mr Mobasseri would have been the only person to benefit. However, Mr Mobasseri had given evidence, which the PCC did not refer to or deal with, that he understood that the NHS rules meant that the Camden Practice would not be paid for the second claim in these sorts of circumstances. In other words, in his mind, there was no financial advantage to be gained by submitted a second “false” claim in these circumstances:

The PCC’s reasoning on the issue of dishonesty in respect of Patients C and D was, essentially, that the only explanation which made sense was the dishonest one it arrived at, namely that Mr Mobasseri had deliberately made the second claim in each case in order to claim twice, as he would have been the only person to benefit from doing so. However, in light of Mr Mobasseri’s evidence as to his state of mind – that he would not benefit from doing so – I do not see how that can stand.

It must also be recalled that the articulation the PCC gave of what it was looking for in order to find dishonesty under charge 5 was submission of the inappropriate claims “in the knowledge that they were dishonestly inappropriate and submitted for financial gain …”. That is how the case was argued before the PCC and determined by it. Given Mr Mobasseri’s evidence that I have referred to, it cannot be said that these claims were submitted by Mr Mobasseri for the purpose of financial gain.

The rest of the PCC’s reasoning for these patients consisted of rejection of other explanations, including whether the administrative staff might have opened and closed the second course of treatment, which the PCC found they would not have done, except if acting under Mr Mobasseri’s direction. It is not entirely clear whether, in doing so, the PCC took into account all of the evidence given by Mr Mobasseri relating to the changeover from R4 to SoE, which he had suggested was the likely reason for the second set of claims going in. That in itself does not appear to me, however, to be a particularly compelling explanation – it might explain genuinely duplicate claims (with the same dates) which had, by mistake, been entered and then closed and sent on both systems, but it is difficult to see how it explains the situation here, where the second claim has different dates (and, in the case of Patient D, a different material for the mouthguard). However, it is not clear that the PCC really considered the possibility of the making of an error being behind the second claims for treatment, as opposed to it being a deliberate act, including where, by use of terms such as dates being “manipulated”, the PCC appears to have been focused on it being deliberate.

Whilst there was, therefore, no particularly persuasive factual account as to how the second set of claims had come to be made by way of administrative error, that could not in itself prove dishonesty on Mr Mobasseri’s part, still less in circumstances where the PCC made it clear that what it was looking for in order to find dishonesty was that the claims “were dishonestly inappropriate and submitted for financial gain”. Mr Mobasseri’s evidence, which the PCC did not reject, or deal with at all, stands in the way of the suggestion that, however the second claims came about, it was done by Mr Mobasseri for financial gain.

Moreover, on this appeal, the GDC did not suggest (either in its written or oral submissions) that I should take my own view of Mr Mobasseri’s evidence on this issue (his understanding of how the NHS regulations worked in this respect and what he would normally get paid for) and reject it, or explain why it should be rejected.

In the circumstances, the PCC’s conclusion that the claims in respect of Patients C and D were dishonestly made by Mr Mobasseri has to be set aside.