In a significant ruling, the District Consumer Disputes Redressal Commission South Delhi has exonerated Max Smart Super Speciality Hospital from allegations of medical negligence in the treatment of a minor patient suffering from recurrent abdominal pain. However, the Commission held United India Insurance Company liable for deficiency in service.
No Evidence of Medical Negligence: Court
The Consumer Court observed that the complainant failed to provide any expert opinion or substantial evidence to prove negligence by the hospital or its medical staff. It ruled that treatment was carried out following due medical procedures and consultations with specialists.
“Without any cogent evidence or expert opinion, the doctors cannot be held negligent,” the Commission stated, dismissing allegations against the hospital.
Case Background: Minor Treated for Abdominal Pain
The case dates back to 2017, when a 14-year-old girl was admitted to Max Hospital with complaints of prolonged abdominal pain and a prior history of typhoid. She was examined by pediatric specialists and later referred to psychiatry, where she was diagnosed with “Anxiety and Stress with Somatic Symptoms.”
The patient was discharged on October 30, 2017, after showing improvement and no fresh complaints.
Insurance Claim Rejected Under Policy Clause
The complainant had a mediclaim policy with United India Insurance Company covering his family. Although an initial approval of ₹15,000 was granted, it was later withdrawn at discharge, forcing the family to pay ₹97,446.46 out of pocket.
The insurer rejected the reimbursement claim citing Exclusion Clause 4.9, which excludes psychiatric and psychosomatic disorders from coverage.
The Commission upheld the insurer’s right to reject the claim under policy terms, stating that the diagnosis fell within the excluded category.
Insurer Penalised for Lack of Proper Communication
Despite validating the claim rejection, the court found fault with the insurer for failing to provide a formal repudiation letter with valid reasons in a timely manner. The letter was only produced later during proceedings.
Calling this a deficiency in service, the Commission directed the insurer to pay ₹25,000 to the complainant within three months. Failure to comply will attract an interest of 6% per annum until payment is made.
Allegations Against Hospital Rejected
The complainant had accused the hospital of starting treatment without proper diagnosis and unnecessarily referring the patient to psychiatry for financial gain. However, the hospital maintained that the patient was treated by multiple specialists and discharged only after improvement.
The Commission noted that follow-up prescriptions from other hospitals were dated nearly a year after discharge, weakening the claim of continued illness.
Key Takeaway
The ruling reinforces that medical negligence must be supported by strong evidence and expert opinion. While hospitals may be protected against unsubstantiated claims, insurers are still accountable for transparent and timely communication with policyholders.
