Doctor's Absence During Delivery Is Gross Negligence; Insurer Liable To Pay Compensation Under Indemnity Policy: State Consumer Commission - 2025-08-23

Bikaner Consumer Commission Holds Doctor Liable for Patient's Death Due to Absence, Directs Insurer to Pay ₹10 Lakh

Bikaner, November 22, 2024 – The State Consumer Disputes Redressal Commission, Bikaner Circuit Bench, has upheld a finding of gross medical negligence against Dr. Iti Mathur, holding her responsible for the death of a patient from postpartum hemorrhage. The Commission found that the doctor's decision to leave her hospital to attend a camp after admitting a patient for delivery, leaving her in the care of an inexperienced Ayurvedic doctor and a trainee nurse, constituted a severe deficiency in service.

In a significant modification to the District Commission's order, the bench, comprising Presiding Member (Judicial) Mr. Atul Kumar Chatterjee and Member Mr. Sanjay Tak, partially allowed the doctor's appeal by directing her insurer, Oriental Insurance Company Ltd., to pay ₹10,00,000 of the total ₹15,00,000 compensation to the victim's family, under the terms of her Professional Indemnity Policy.

Background of the Case

The complaint was filed by Yakim Ali, whose pregnant wife, Manfool Bano, was admitted to Dr. Iti Mathur's hospital on August 20, 2016, for her fourth delivery. All her previous three children were also delivered at the same hospital. Mr. Ali stated that his wife was healthy and had no pre-existing conditions like blood sugar or blood pressure issues.

Shortly after admitting Manfool Bano, Dr. Mathur left for a camp in Lunkaransar, approximately 70 km away, assuring the family that everything was under control and she had instructed her nursing staff. At around 4:05 PM, Manfool Bano gave birth to a healthy boy via normal delivery. However, family members soon noticed excessive bleeding and deteriorating health. The staff, an Ayurvedic doctor named Dr. Tahira and a trainee nurse, Ms. Tulsi, contacted Dr. Mathur by phone for instructions. As the bleeding worsened, the family was asked to arrange for two units of blood.

By the time Yakim Ali returned with the blood, he was informed that his wife had passed away and her body had already been sent home in an ambulance.

Arguments from Both Sides

• Complainant's Arguments: Yakim Ali argued that Dr. Mathur's absence during a critical medical procedure was a clear case of negligence. He contended that the post-delivery stitching was improperly handled by the inexperienced nurse, leading to a torn uterine membrane and uncontrollable bleeding (postpartum hemorrhage), which ultimately caused his wife's death. He further alleged that the hospital's medical records (Bed Head Ticket) were manipulated to cover up the negligence.

• Doctor's Defense: Dr. Iti Mathur admitted to being away at a camp but claimed she returned to the hospital in time for the delivery. She disputed the timeline presented by the complainant, stating she reached the hospital by 4:00 PM despite her car breaking down. She relied on a police investigation and a medical board report, which she claimed found no evidence of negligence.

• Insurer's Stance: Oriental Insurance Company Ltd. argued that the complainant was not their consumer and had no right to claim directly from them. They stated that their Professional Indemnity Policy was a contract to indemnify the doctor, not to pay third parties directly.

Commission's Findings and Reasoning

The State Commission meticulously analyzed the evidence and dismissed the doctor's defense, affirming the District Commission's findings of gross negligence on several grounds:

• Abandonment of Patient: The Commission found it "sufficient to prove medical negligence" that Dr. Mathur, the sole gynecologist at the hospital, left a patient in labor in the care of an unqualified Ayurvedic doctor and an inexperienced nurse. The judgment noted, "...these circumstances themselves are sufficient to be considered a basis for medical negligence against the appellant/opposite party No. 1, Dr. Iti Mathur."

• Doubtful Timeline: The Commission upheld the District Forum's suspicion regarding Dr. Mathur's claim of returning to the hospital by 4:00 PM, finding it improbable given the distance, traffic, and her reported car trouble.

• Manipulated Records: The Commission noted the existence of two different Bed Head Tickets for the patient, one of which appeared to have been prepared later to create a defense, strengthening the allegation of a cover-up.

• Failure to Refer: The court condemned the hospital's failure to refer the patient to the nearby P.B.M. Government Hospital, a major medical facility, when she started bleeding excessively. Instead, they sent the husband on a futile errand for blood.

• Medical Board Report Criticized: The Commission criticized the medical board's report as "surprising and ridiculous," especially its inability to determine whether the hospital or the family was responsible for arranging blood. It concluded the board did not seriously consider the circumstances.

Ruling on Insurance Company's Liability

While the District Commission had absolved the insurance company, the State Commission overturned this part of the decision. Citing precedents from the National Consumer Disputes Redressal Commission (NCDRC), it ruled that while an insurer may not be a necessary party , it is a proper party in medical negligence cases.

The Commission ordered that making the insurer a party ensures that if the doctor is found liable, the victim can directly receive the benefits of the insurance policy. The judgment stated: "...as the appellant/opposite party No. 1 Dr. Iti Mathur had taken a Professional Indemnity Doctor's Policy for ten lakh rupees from the insurance company... the responsibility to pay up to the policy limit will be that of the respondent No. 2/opposite party No. 2."

Final Order

The State Commission modified the District Commission's order dated February 24, 2020. It directed: 1. Dr. Iti Mathur is liable to pay a total compensation of ₹15,00,000 to Yakim Ali, along with 9% annual interest from the date of the complaint (August 30, 2018) and ₹10,000 in litigation costs. 2. Oriental Insurance Company Ltd. must pay ₹10,00,000 of the awarded amount directly to the complainant, in accordance with the insurance policy limit. 3. Dr. Iti Mathur is liable to pay the remaining amount. 4. The parties were given two months to comply with the order.