South Delhi Consumer Commission Dismisses Medical Negligence Claim Against Max Hospital; Holds Insurer Liable For Deficiency Over Failure To Provide Repudiation Letter

The South Delhi District Consumer Disputes Redressal Commission, comprising Monika A. Srivastava (President) and Kiran Kaushal (Member), dismissed the complaint against Max Smart Super Speciality Hospital in relation to the allegation of medical negligence. The Commission, however, held United India Insurance Company liable for deficiency in service on account of its failure to furnish a formal repudiation letter containing valid reasons to the complainant within a reasonable time. Brief Facts The complainant, Pankaj Kumar Sharma, had obtained a mediclaim policy from United India Insurance Co. Ltd. (OP No.3), 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. On 21-10-2017, the complainant's 14-year-old daughter was admitted to Max Smart Super Speciality Hospital (OP No.1). She had been suffering from recurrent abdominal pain for about one and a half months and had a past history of typhoid. During her hospitalization, she was examined and treated by a Paediatric Gastroenterologist and a Paediatric Surgeon. She was then referred to the Psychiatry Department. After evaluation, she was diagnosed with Anxiety and Stress with Somatic Symptoms and was discharged on 30-10-2017. Although OP No.3 had initially sanctioned an amount of Rs. 15,000 towards the treatment, the said amount was withdrawn at the time of discharge, compelling the complainant to pay the entire hospital bill of Rs. 97,446.46 from his own pocket. When the complainant submitted a claim for reimbursement to Vipul Medi Corp Insurance TPA Private Ltd. (OP No. 2), it was rejected on the grounds of Exclusion Clause 4.9 of the policy, which excludes coverage for psychiatric and psychosomatic disorders. However, the complainant alleged that no proper repudiation letter containing valid reasons was furnished to him in a timely manner. Aggrieved by these actions, the complainant approached the Consumer Commission. Contentions by the Opposite Parties The Max Smart Hospital (OP No.1) contended that the complaint suffers from mis-joinder of parties, as the dispute arose solely due to the repudiation of the insurance claim. It submitted that no negligence was committed on its part and that the admission and treatment of the patient were medically justified. It was further stated that the treatment resulted in recovery, and therefore, the allegations made against the hospital are unwarranted and misleading. The United India Insurance (OP No.3) argued that the diagnosis relating to stress and psychiatric issues clearly falls within Exclusion Clause 4.9 of the policy, which excludes coverage for psychiatric disorders. It was further contended 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 the Commission The Commission, upon examining the medical records, noted that the complainant's daughter was ultimately diagnosed with “Anxiety and Stress with Somatic Symptoms” after being treated for her physical ailments. In view of this diagnosis, it held that the repudiation of the claim was justified under Exclusion Clause 4.9 of the policy, which excludes coverage for psychiatric and psychosomatic disorders, and consequently, the complainant was not entitled to reimbursement of the hospital expenses. The Commission, while dealing with the claim of medical negligence against the treating hospital, found that the complainant had failed to place on record any substantive evidence to establish that his daughter continued to suffer from any ailment at the time of discharge. It further observed that the prescriptions and OPD slips from other hospitals relied upon by the complainant were dated nearly one year after discharge from OP No.1 and were therefore insufficient to establish any negligence on the part of the treating doctors. Accordingly, no deficiency in service was found on the part of the hospital. However, the Commission observed that the insurer, OP No.3, had failed to furnish a formal repudiation letter containing valid reasons to the complainant within a reasonable time. The Commission noted that such a letter was produced only at a much later stage during the proceedings. Accordingly, the Commission found OP No.3 liable for deficiency of service for failing to furnish a formal repudiation letter to the complainant within a reasonable time. Concluding, the Commission partly allowed the complaint and directed OP No.3 to pay a sum of Rs. 25,000 to the complainant as compensation for deficiency in service. Case Title: Pankaj Kumar Sharma vs Max Smart Super Speciality Hospital CC NO. DC/83/CC/299/2018 Click Here To Read/Download Order

South Delhi Consumer Commission Dismisses Medical Negligence Claim Against Max Hospital; Holds Insurer Liable For Deficiency Over Failure To Provide Repudiation Letter

Muhammed Razik

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