The Bill and the Body, India’s Twin Crises of Regulatory Abandonment and Adolescent Criminalisation
On the surface, they are unrelated. One concerns the extortionate pricing of surgical gloves and the creative accounting of hospital administrators. The other concerns the criminalisation of consensual adolescent romance and the state’s refusal to distinguish between a predator and a boyfriend. One is about money; the other is about bodies. One is a scandal of the healthcare market; the other is a scandal of the criminal law.
Yet these two crises, unfolding simultaneously in the India of 2026, are expressions of the same pathology. Both reveal a state that has abdicated its fundamental responsibilities: to protect citizens from exploitation, to ensure that markets serve human welfare rather than human vulnerability, and to calibrate the law’s coercive power to the realities of human development and human relationships. Both expose the gap between law on the books and justice in practice—a gap that is not an unfortunate oversight but a structural feature of governance that privileges the interests of the powerful over the rights of the ordinary.
The private hospital billing scandal, exhaustively documented by The Times of India and summarised in the accompanying commentary, is not a story of isolated misconduct by a few rogue institutions. It is a story of systemic regulatory collapse. Private hospitals, which now handle approximately 80 per cent of India’s medical services, have developed sophisticated, institutionalised mechanisms for extracting excess revenue from patients. They double-count procedures, inflate consumable usage, and maintain a dual pricing system in which out-of-pocket payers are charged up to a third more than insurance companies. They mark up basic supplies—masks, gloves, syringes, IV sets, catheters—by margins as high as 1,737 per cent, according to a 2018 analysis by the National Pharmaceutical Pricing Authority. They refuse to release patients or even the bodies of the deceased until disputed bills are settled, converting medical care into a form of hostage-taking.
And they do all of this with impunity. The Clinical Establishments Act, 2010, which was enacted precisely to address such malpractices, has not even been adopted by Delhi—the national capital, the seat of government, the city where the law is supposed to mean something. The Bureau of Indian Standards introduced billing standards for hospitals last year but made them “voluntary”—an oxymoron that perfectly captures the Indian state’s approach to corporate regulation. The NPPA’s damning analysis of profiteering on consumables, published in 2018, has elicited no discernible follow-up from any government agency. The 2024 investigation into dual pricing has produced no legislation, no prosecutions, and no public accountability.
This is not a failure of enforcement; it is a failure of political will. The state has the legal authority, the institutional capacity, and the empirical evidence to act. It chooses not to. It chooses, instead, to leave patients at the mercy of a for-profit medical model that treats illness as a revenue opportunity and vulnerability as an exploitable asset.
The Romeo-Juliet controversy, which has re-emerged following the government’s emphatic rejection of the Supreme Court’s advice to exempt genuine adolescent relationships from the harshest provisions of the Protection of Children from Sexual Offences (POCSO) Act, is a different kind of regulatory failure—but it is a failure of the same underlying disposition.
POCSO is a necessary and important law. It was enacted to protect children from sexual abuse and exploitation, and it has provided a legal framework for prosecuting predators who prey on the vulnerable. But its provisions, designed with the worst cases in mind, have been applied indiscriminately to consensual relationships between adolescents. Teenagers who fall in love, who explore their sexuality, who make mistakes and learn from them, are being arrested, prosecuted, and incarcerated under a law that was never intended to punish them. Their families are torn apart; their futures are destroyed; their lives are scarred by the very state that claims to protect them.
The Supreme Court, recognising this manifest injustice, urged the government to create a narrow, carefully defined exception for genuine adolescent relationships. It did not propose to weaken the law’s protection against actual abusers; it proposed to calibrate the law’s application to the realities of adolescent development. The government’s response, delivered by Women and Child Development Minister Annapurna Devi in a written reply to a parliamentary question, was a flat, unyielding refusal. Any dilution of POCSO, the minister warned, would “undermine child safety, increase the risk of exploitation, and weaken India’s commitment to the protection of children, especially adolescent girls.”
This is not principled policymaking; it is performative protectionism. It elevates symbolic purity over substantive justice. It refuses to acknowledge that the law, in its current form, is causing immense harm to precisely those it is supposed to protect. It treats all adolescent sexuality as inherently exploitative and all adolescent boys as potential predators. It denies young people the capacity for informed consent and meaningful relationship, infantilising them well into their late teens while simultaneously holding them fully accountable under the criminal law.
The Normalisation of Billing Malpractice: How Regulatory Collapse Became Business Strategy
The private hospital billing scandal is not a recent phenomenon; it is the culmination of decades of regulatory neglect. India’s healthcare system has undergone a profound transformation over the past generation, shifting from a predominantly public sector model to one in which private providers now dominate. This shift was not accompanied by the development of a robust regulatory infrastructure to ensure that private providers serve public purposes. The result is a market in which the profit motive operates with few constraints and accountability is virtually non-existent.
The mechanisms of overcharging are sophisticated and varied. Double-counting—charging a patient twice for the same procedure—is routine. Consumable inflation—billing for masks, gloves, syringes, and other supplies at multiples of their actual cost—is standard practice. The NPPA’s 2018 analysis found markups of up to 1,737 per cent on basic consumables; there is no evidence that these margins have narrowed in the intervening years. Dual pricing—charging out-of-pocket patients significantly more than insurance companies for identical services—is an open secret, documented by multiple investigations and confirmed by industry insiders.
The most egregious practice, and the one that most clearly reveals the power imbalance between hospitals and patients, is the refusal to release patients or bodies until disputed bills are settled. This is not debt collection; it is false imprisonment and abuse of a corpse. It treats the patient not as a person entitled to medical care but as a collateral asset to be held hostage against payment. That this practice continues, unabated and unpunished, is a measure of how completely the regulatory state has abandoned its responsibilities.
The response of governments—central and state—to these documented malpractices has been studied indifference. The Clinical Establishments Act, 2010, which provides a framework for regulating private healthcare providers, has been adopted by only a handful of states. Delhi, the national capital, has not even brought the Act into force. The Bureau of Indian Standards’ billing guidelines, introduced in 2025, are “voluntary”—a designation that, in practice, means they are ignored. The NPPA’s analysis, published with great fanfare, has generated no follow-up action. The 2024 dual pricing investigation has produced no legislation, no prosecutions, and no public hearings.
This is not a failure of information or capacity; it is a failure of political will. The private healthcare sector is wealthy and influential. It employs thousands of doctors, nurses, and administrators. It serves middle-class and upper-class voters who are, in electoral terms, a crucial constituency. Regulating it effectively would require confronting powerful interests, imposing costs on influential actors, and accepting the political risks that such confrontations entail. Successive governments have calculated that the costs of action exceed the benefits—and patients have paid the price.
The Criminalisation of Adolescence: How POCSO Became a Weapon Against Love
The POCSO Act, enacted in 2012 in response to public outrage over horrific cases of child sexual abuse, was a necessary and long-overdue reform. It created a comprehensive legal framework for prosecuting predators, established special courts for speedy trials, and mandated reporting of offences. It has been used to convict thousands of abusers and to send a clear message that the state takes child protection seriously.
But the law’s scope is indiscriminate. It defines a child as any person under the age of 18 and criminalises all sexual activity with such persons, regardless of consent or the proximity in age of the participants. A 17-year-old boy who has consensual sex with his 16-year-old girlfriend is, in the eyes of the law, a child sex offender. Both are victims; both are also perpetrators. The law makes no distinction between predatory abuse and adolescent exploration, between coercion and consent, between a 40-year-old man who grooms a child and a 17-year-old boy who kisses his classmate.
The consequences of this indiscriminate application are devastating. Young people are arrested, jailed, and prosecuted for engaging in behaviour that is a normal part of adolescent development. Their families are subjected to the trauma of criminal proceedings, the stigma of public accusation, and the financial burden of legal defence. Their educational and employment prospects are destroyed by criminal records that follow them into adulthood. The law that was intended to protect children has become a weapon against them.
The Supreme Court has repeatedly urged the government to address this manifest injustice. In multiple judgments and observations, it has pointed out that the automatic application of POCSO to consensual adolescent relationships is contrary to the best interests of children, contrary to the developmental needs of adolescents, and contrary to the legislative intent behind the Act. It has suggested the creation of a “close-in-age” exemption—similar to those that exist in many other jurisdictions—that would decriminalise consensual sexual activity between adolescents whose ages are within a specified range.
The government’s response has been consistently and emphatically negative. The Ministry of Women and Child Development has repeatedly stated that any dilution of POCSO would undermine child protection and send the wrong message to society. Minister Annapurna Devi’s recent parliamentary reply is merely the latest in a long series of rejections, each couched in the language of unwavering commitment to child safety, each refusing to acknowledge the harm that the law in its current form is causing.
This refusal is not evidence of principled commitment; it is evidence of political cowardice. The government fears that any amendment to POCSO, however carefully crafted and narrowly targeted, will be portrayed by its opponents as a weakening of child protection laws. It fears the outrage of moral conservatives and the campaign of religious organisations. It prefers the safe path of symbolic purity, even when that path leads to the destruction of young lives.
The Common Thread: The State That Refuses to Protect
The hospital billing scandal and the POCSO controversy are, despite their apparent differences, manifestations of the same underlying failure: the Indian state’s systematic refusal to exercise its regulatory authority on behalf of ordinary citizens.
In the healthcare context, this refusal is a failure of market regulation. The state has the legal authority to set standards, monitor compliance, and punish violations. It chooses not to exercise this authority because doing so would require confronting powerful corporate interests and accepting the political costs of such confrontation. It prefers the path of least resistance, leaving patients to navigate a market in which they are systematically exploited.
In the POCSO context, this refusal is a failure of legal calibration. The state has the constitutional authority to amend the law, to create exceptions, to tailor its provisions to the realities of adolescent development. It chooses not to exercise this authority because doing so would require confronting powerful moral conservatives and accepting the political costs of such confrontation. It prefers the path of symbolic purity, leaving young people to bear the consequences of a law that treats them as both victims and perpetrators.
In both cases, the state refuses to protect. It refuses to protect patients from predatory pricing. It refuses to protect adolescents from predatory prosecution. It offers, in place of protection, platitudes and performative gestures—press releases about voluntary standards, parliamentary statements about unwavering commitment—that cost nothing and change nothing.
Conclusion: The Accountability Deficit
The two crises documented in the accompanying commentary are not discrete, isolated failures. They are symptoms of a deeper pathology: the systematic erosion of state capacity and state will to regulate powerful interests and protect vulnerable citizens.
This erosion is not inevitable; it is the product of political choices. Every year that the Clinical Establishments Act remains unimplemented is a choice. Every investigation into hospital profiteering that is filed and forgotten is a choice. Every parliamentary reply that rejects the Supreme Court’s advice on POCSO is a choice. These choices are made by identifiable actors, in identifiable institutions, for identifiable reasons. They are not accidents; they are policy.
The question is why these choices are not contested. Why is there no sustained public outrage at hospitals that mark up gloves by 1,700 per cent? Why is there no sustained public campaign to amend a law that criminalises adolescent love? Why do voters not hold their representatives accountable for the systematic failure to protect patients and young people?
Part of the answer lies in the invisibility of the harm. Inflated hospital bills are hidden in complex itemised statements; the victim rarely knows that they have been overcharged. POCSO prosecutions of adolescents are conducted in juvenile courts, away from public view; the young people whose lives are destroyed are invisible to the broader society. The harms are real, but they are not spectacular. They do not generate headlines or mobilise protests. They are suffered silently, individually, without collective response.
Part of the answer also lies in the asymmetry of power. The private hospital industry is wealthy and well-connected; it can deploy formidable resources to resist regulation. The moral conservatives who oppose any amendment to POCSO are organised and vocal; they can mobilise their followers to punish politicians who deviate from their orthodoxy. Patients and adolescents have no comparable power. They are diffuse, unorganised, and politically marginal. They are easy to ignore.
The editorial that accompanies these commentaries is a rare exception to this pattern of invisibility and silence. It names the hospitals, cites the investigations, and documents the regulatory failures. It identifies the government’s rejection of the Supreme Court’s POCSO advice and exposes the hollowness of its justifications. It insists, against the weight of indifference, that these failures matter and that they demand accountability.
Whether this insistence will translate into action is uncertain. The history of such exposés is discouraging; the NPPA’s 2018 analysis produced no discernible change, and the 2024 dual pricing investigation has already been forgotten. The Supreme Court’s repeated observations on POCSO have been met with consistent rejection. The pattern is deeply entrenched, and the forces that sustain it are powerful.
But patterns can be broken, and forces can be opposed. The first step is to see the harm clearly—to recognise that inflated hospital bills and criminalised adolescent relationships are not minor aberrations but fundamental failures of the state to fulfil its most basic responsibilities. The second step is to demand accountability—to insist that those who make the choices that produce these failures be held responsible for their consequences. The third step is to organise—to build the collective power that can challenge the entrenched interests that benefit from the status quo.
These steps are difficult, but they are not impossible. Other societies have successfully regulated private healthcare providers and calibrated child protection laws to distinguish between predatory abuse and adolescent exploration. There is no reason why India cannot do the same—except the absence of political will. That absence is not a fact of nature; it is a product of political choices. And political choices can be changed.
Q&A Section
Q1: What are the principal mechanisms of billing malpractice documented in the private hospital sector, and why have regulatory interventions failed to address them?
A1: The commentary identifies three principal mechanisms. First, double-counting: charging patients twice for the same procedure. Second, consumable inflation: marking up basic supplies (masks, gloves, syringes, IV sets, catheters) by extraordinary margins. A 2018 NPPA analysis found markups as high as 1,737 per cent on consumables. Third, dual pricing: charging out-of-pocket payers significantly more than insurance companies for identical services, with differentials of up to one-third.
Regulatory interventions have failed for multiple reasons. The Clinical Establishments Act, 2010, which provides a framework for regulating private healthcare, has not been adopted by many states, including Delhi. The Bureau of Indian Standards’ billing guidelines, introduced in 2025, were made “voluntary”—rendering them effectively meaningless. The NPPA’s damning 2018 analysis generated no follow-up action. The 2024 TOI investigation into dual pricing produced no legislation or prosecutions. This is not a failure of information or capacity but a failure of political will. The private healthcare sector is wealthy and influential; regulating it effectively would require confronting powerful interests and accepting political risks. Successive governments have calculated that the costs of action exceed the benefits, leaving patients to bear the consequences.
Q2: What is the “dual pricing” system in private hospitals, and why does its continued operation without intervention illustrate regulatory capture?
A2: Dual pricing is the practice of charging different prices for identical medical services based on the patient’s payment method. Patients paying out-of-pocket are charged significantly higher rates—up to a third more—than insurance companies for the same procedures, consultations, and consumables. This is not cost-based pricing; it is price discrimination that exploits the differential bargaining power of individual patients versus corporate insurers.
Its continued operation without intervention illustrates regulatory capture because it demonstrates that the state is more responsive to organised corporate interests than to unorganised citizen-victims. Insurance companies, which have the resources and expertise to negotiate favourable rates, benefit from the system. Individual patients, who lack such resources and expertise, are systematically overcharged. A regulator that was genuinely committed to consumer protection would have prohibited dual pricing long ago. That it has not done so suggests that its priorities are aligned with the industry it is supposed to regulate rather than with the public it is supposed to serve. This is the classic definition of regulatory capture: the regulator becomes the agent of the regulated, not the guardian of the public interest.
Q3: What is the “Romeo-Juliet” controversy in the context of the POCSO Act, and what is the government’s stated rationale for refusing to create exceptions for consensual adolescent relationships?
A3: The “Romeo-Juliet” controversy refers to the indiscriminate application of the POCSO Act to consensual sexual relationships between adolescents. The Act defines a child as any person under 18 and criminalises all sexual activity with such persons, regardless of consent or age proximity. A 17-year-old boy who has consensual sex with his 16-year-old girlfriend is legally a child sex offender. Both are victims; both are also perpetrators. The law makes no distinction between predatory abuse and adolescent exploration.
The Supreme Court has repeatedly urged the government to create a narrow, carefully defined “close-in-age” exemption that would decriminalise consensual relationships between adolescents whose ages are within a specified range. The government’s stated rationale for refusal, articulated by Women and Child Development Minister Annapurna Devi, is that “any dilutions or exceptions would undermine child safety, increase the risk of exploitation, and weaken India’s commitment to the protection of children, especially adolescent girls.”
Critics argue this rationale is performative rather than substantive. It refuses to acknowledge that the law in its current form is causing immense harm to precisely those it is supposed to protect. It treats all adolescent sexuality as inherently exploitative. It denies young people the capacity for informed consent while holding them fully accountable under criminal law. The refusal is not evidence of principled commitment but political cowardice: the government fears that any amendment will be portrayed as weakening child protection, prefers symbolic purity over substantive justice, and is unwilling to confront moral conservatives who oppose any recognition of adolescent sexuality.
Q4: What common underlying pathology does the commentary identify linking the hospital billing scandal and the POCSO controversy?
A4: The commentary argues that both crises are manifestations of the same underlying failure: the Indian state’s systematic refusal to exercise its regulatory authority on behalf of ordinary citizens.
In the healthcare context, this is a failure of market regulation. The state has legal authority, institutional capacity, and empirical evidence to act against predatory pricing. It chooses not to, because regulating powerful corporate interests carries political costs. It prefers the path of least resistance, leaving patients to navigate a market in which they are systematically exploited.
In the POCSO context, this is a failure of legal calibration. The state has constitutional authority to amend the law, create exceptions, tailor its provisions to the realities of adolescent development. It chooses not to, because confronting moral conservatives carries political costs. It prefers the path of symbolic purity, leaving young people to bear the consequences of a law that treats them as both victims and perpetrators.
In both cases, the state refuses to protect. It refuses to protect patients from predatory pricing. It refuses to protect adolescents from predatory prosecution. It offers, in place of protection, platitudes and performative gestures—voluntary standards, parliamentary statements of unwavering commitment—that cost nothing and change nothing. This is not a failure of information or capacity but a failure of political will, driven by the calculation that the costs of action exceed the benefits and that the victims of inaction lack the power to impose consequences.
Q5: What does the commentary mean by describing the harm in both cases as “invisible” and its victims as “easy to ignore,” and why is this diagnosis significant for understanding the persistence of these crises?
A5: The harm is “invisible” in two senses. First, it is hidden from view. Inflated hospital bills are buried in complex, itemised statements; the victim rarely knows they have been overcharged. POCSO prosecutions of adolescents occur in juvenile courts, away from public scrutiny; the young people whose lives are destroyed are invisible to the broader society. Second, it is not spectacular. These are not dramatic, single events that generate headlines and mobilise protests. They are chronic, cumulative, ordinary failures that are suffered silently, individually, without collective response.
The victims are “easy to ignore” because they are diffuse, unorganised, and politically marginal. Hospital patients are not a cohesive constituency; they are 1.4 billion individuals who occasionally require medical care. Adolescents subject to POCSO prosecution are a tiny fraction of the population, each case isolated, each family struggling alone. Neither group has the resources, networks, or organisational capacity to mount sustained advocacy campaigns or impose electoral consequences on politicians who fail to act.
This diagnosis is significant because it explains the persistence of these crises despite abundant documentation and repeated exposure. The NPPA’s 2018 analysis produced no change; the 2024 dual pricing investigation has already been forgotten; the Supreme Court’s repeated observations on POCSO have been met with consistent rejection. The pattern continues not because policymakers are unaware of the problems but because the political incentives to address them are weak and the political costs of addressing them are high. The victims are invisible and unorganised; the beneficiaries of the status quo are visible and powerful. This asymmetry is not accidental; it is the product of the same political choices that produce the harms themselves. Breaking the pattern requires not merely better documentation or more compelling moral appeals but the construction of collective power capable of challenging entrenched interests and imposing accountability on unresponsive institutions.
