Consumer court relief to Max Hospital New Delhi, holds no medical negligence by doctors in minor's treatment
No Medical Negligence
New Delhi: The District Consumer Disputes Redressal Commission, South Delhi, recently exonerated Max Smart Super Speciality Hospital, Saket, New Delhi, from the charges of medical negligence during the treatment of a minor, who had been suffering from recurrent abdominal pain.
Even though the patient's father alleged that the doctors of the hospital started the treatment without an appropriate diagnosis and kept treating her on assumptions and presumptions, the District Consumer Court held that there was no evidence to establish negligence or deficiency in service.
"Thus without any cogent evidence or expert opinion the doctors of OP-1 (hospital) cannot be held negligent. Complainant has failed to establish any deficiency or negligence of the doctors, para-medic staff therefore no liability is fixed on OP-1 for the same," held the Consumer Court.
However, the DCDRC held United India Insurance Company liable for deficiency in service after noting that the Insurance Company failed to furnish a formal repudiation letter containing valid reasons to the complainant within a reasonable time.
The history of the case goes back to 2017, when the complainant's 14-year-old daughter was admitted to Max Smart Super Speciality Hospital as she had been suffering from recurrent abdominal pain for about one and a half months and had a past history of typhoid.
A Paediatric Gastroenterologist and a Paediatric Surgeon examined and treated the patient first and later she was referred to the Psychiatry Department. The patient was duly evaluated and was diagnosed with Anxiety and Stress with Somatic Symptoms and she was discharged on 30.10.2017.
The complainant's grievances were against the hospital and also against the insurance company. He had obtained a mediclaim policy from United India Insurance Co. Ltd. with coverage extending to himself and his family members, including his wife, son, and daughter, for the period from 10-06-2017 to 09-06-2018.
Even though the Insurer initially sanctioned an amount of Rs 15,000 towards treatment, the said amount was withdrawn at the time of discharge. As a result, the complainant had to pay the entire hospital bill of Rs. 97,446.46 from his own pocket. When the complainant submitted a claim for reimbursement, it was rejected
Although OP No.3 had initially sanctioned an amount of Rs. 15,000 towards the treatment, the said amount was withdrawn at the time of discharge, compelling the complainant to pay the entire hospital on the grounds of Exclusion Clause 4.9 of the policy, which excludes coverage for psychiatric and psychosomatic disorders.
Against the insurer, the complainant's grievance was that allegedly, no proper repudiation letter containing valid reasons was furnished to him promptly.
Meanwhile, against Max Hospital, the complainant alleged that in spite of treatment at the Gastrology Department, his daughter did not get any relief. He alleged that the doctors at the hospital started the treatment without an appropriate diagnosis and kept treating her based on assumptions and presumptions. He also claimed that his daughter was referred to the Psychology Department in an attempt to get money from the patient's family in an illegal manner. According to the complaint, the patient was discharged without any satisfaction and therefore, the hospital was deficient in service.
On the other hand, the hospital argued that the dispute arose solely due to the repudiation of the insurance claim and therefore, the complaint suffers from misjoinder of parties. Further, the hospital submitted that there was no negligence in the treatment of the patient, and the treatment resulted in recovery.
The hospital submitted that to investigate and diagnose the patient was also referred to and seen by other medical specialists including Paediatric Gastroenterologist, Paediatric Surgeon as well as a Psychiatrist. The patient was discharged on 30.10.2017 after she improved and showed no fresh complaints.
Meanwhile, the Insurance Company argued that the diagnosis relating to stress and psychiatric issues clearly fell within the Exclusion Clause 4.9 of the policy, which excludes coverage for psychiatric disorders. It was also argued that the claim was not maintainable under the policy terms and that the repudiation was lawful and in accordance with the conditions of the policy.
Observations by Consumer Court:
After examining the medical records, the Commission noted that after being treated for her physical ailments, the daughter of the complainant was ultimately diagnosed with "Anxiety and Stress with Somatic Symptoms".
Accordingly, it held, "We are of the view that Complainant’s claim was repudiated as per Clause 4.9 of the terms and conditions of the policy which clearly states that the treatment related to Psychiatry and psychosomatic disorders are excluded . Hence complainant is not entitled for the reimbursement of the claim as the same is rejected as per the terms and conditions of the policy."
However, the Commission observed that the insurer had failed to furnish a formal repudiation letter containing valid reasons to the complainant within a reasonable time. It also noted that the letter was produced only at a much later stage during the proceedings.
Addressing the claim of medical negligence, the Commission noted that there was no evidence to support the allegations by the complainant. "Complainant has failed to substantiate and evidence the fact that complainant’s daughter was still unwell when she was discharged from the hospital of OP-1. Complainant has filed the OPD slip and prescriptions of Madan Mohan Malviya Hospital and Safdarjung Hospital which are seen to be prescribed after almost one year from the discharge of complainant’s daughter from the hospital of OP-1. Thus without any cogent evidence or expert opinion the doctors of OP-1 cannot be held negligent. Complainant has failed to establish any deficiency or negligence of the doctors, para-medic staff therefore no liability is fixed onOP-1 for the same," it noted.
Accordingly, the Commission exonerated the Hospital and directed the Insurance Company to pay Rs 25,000 for deficiency in service. The Consumer Court ordered, "In light of the discussion above, OP-3 is directed to pay Rs.25,000/- towards deficient service of not providing repudiation letter to the complainant stating valid reasons for rejecting the claim amount. OP-3 is directed to pay the said amount within three months failing which OP-3 shall pay the said amount with interest @6% per annum till realization."
To view the order, click on the link below:
https://medicaldialogues.in/pdf_upload/2026/04/11/south-delhi-dcdrc-max-hospital-341086.pdf
