The District Consumer Disputes Redressal Commission in South Delhi has exonerated Max Smart Super Speciality Hospital from allegations of medical negligence in the treatment of a minor patient, while holding the insurer accountable for procedural lapses in handling the claim.
No evidence of medical negligence
The case dates back to 2017, when a 14-year-old girl was admitted to the hospital with recurring abdominal pain and a history of typhoid. She was examined by specialists, including paediatric gastroenterologists and surgeons, and was later referred to psychiatry. Doctors diagnosed her with anxiety and stress accompanied by somatic symptoms before discharging her after improvement.
The complainant alleged that the hospital began treatment without a proper diagnosis and acted on assumptions. However, the Commission found no supporting evidence or expert opinion to substantiate these claims. It was observed that the patient had improved at the time of discharge and that subsequent prescriptions from other hospitals were issued nearly a year later.
The court concluded that there was no deficiency in service or negligence on the part of the hospital or its medical staff.
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Insurance claim dispute at centre
The complaint also involved United India Insurance Company, with the patient’s father alleging wrongful rejection of a mediclaim reimbursement.
Although the insurer initially approved ₹15,000 for treatment, the amount was later withdrawn. The claim was eventually rejected under an exclusion clause that does not cover psychiatric or psychosomatic disorders.
The Commission upheld the insurer’s right to reject the claim under the policy terms, noting that the diagnosis fell within the excluded category.
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Insurer penalised for procedural lapse
Despite validating the rejection, the court found fault with the insurer’s conduct. It noted that the company failed to provide a formal repudiation letter with valid reasons within a reasonable time, producing it only later during proceedings.
Calling this a deficiency in service, the Commission directed the insurer to pay ₹25,000 as compensation to the complainant. It also ordered that the amount be paid within three months, failing which interest at 6% per annum would apply.
The ruling highlights the importance of documented evidence in medical negligence claims and reinforces the requirement that insurers follow due process when rejecting claims. While hospitals may be protected in the absence of proof, insurers remain accountable for transparency and timely communication with policyholders.
