Delhi

North West

CC/121/2024

RAKESH KUMAR - Complainant(s)

Versus

ADITYA BIRLA HEALTH INS.CO.LTD. - Opp.Party(s)

S.K.SENGAR

07 Mar 2024

ORDER

DISTRICT CONSUMER DISPUTE REDRESSAL COMMISSION-V, NORTH-WEST GOVT. OF NCT OF DELHI
CSC-BLOCK-C, POCKET-C, SHALIMAR BAGH, DELHI-110088.
 
Complaint Case No. CC/121/2024
( Date of Filing : 15 Feb 2024 )
 
1. RAKESH KUMAR
S/O SH.DEVKI NANDAN R/O RZ-447,KARAN VIHAR PART-I,KIRARI EXTN., KIRARI SULEMAN NAGAR,DELHI-110086
...........Complainant(s)
Versus
1. ADITYA BIRLA HEALTH INS.CO.LTD.
HB TWIN TOWERS-I,OFFICE 3/104,1ST FLOOR,ABOVE STARBUCKS COFFEE,NETAJI SUBHASH PLACE,PITAMPURA,DELHI-110034
............Opp.Party(s)
 
BEFORE: 
 
PRESENT:
 
Dated : 07 Mar 2024
Final Order / Judgement

MS. NIPUR CHANDNA, MEMBER

 

ORDER

07.03.2024

1.       A complaint under Section 35 of Consumer Protection Act filed. In brief the facts are that complainant was having the mediclaim policy vide policy bearing no. GHI-HB-22-2057450-004 for himself and his family w.e.f. 26.08.2023 to 25.08.2024 for a sum insured of Rs. 10 Lakh.

2.       On 10.01.2024, complainant fell ill and approached Max Health Care Hospital, Shalimar Bagh, Delhi in emergency. After complete check up and investigation the treating doctor diagnose the complainant suffering from “Seizure disorder of cervical spondylosis” for which he was admitted in the hospital from 10.01.2024 to 14.01.2024.

3.       The intimation of the admission was provided to OP Ins. Co. by the hospital and initially OP-1 gave the approval of Rs. 60,000/- vide pre authorization reference no.1212485004851, but at the time of discharge i.e. on 14.01.2024 arbitrarily withdraw the authorization under the pretext that the admission was only for investigation and evaluation purpose, hence, not payable, as such complainant was compelled to pay  a sum of Rs. 1,35,427/- to the Hospital from his own pocket. It is further alleged by the complainant that after discharge from the hospital he approached OP on its helpline number 180027070000 and narrate his whole grievances but no satisfactory reply received from OP. It is further alleged that despite repeated request and follow up OP failed to settle the claim. Being aggrieved by the conduct of the OP, complainant approached this Commission for redressal of his grievance.

4.       Present complaint case is on admission stage. We have heard complainant on the issue of maintainability of the complaint and have perused the record.

5.       The complainant has placed on record copy of the policy documents, copy of treatment record as well as the medical bills, copy of certificate of treating doctor.  Copy of preauthorization denial letter dated 14.01.2024 in support of his contention.

6.       Admittedly, in the present complaint case OP had denied the preauthorization/approval earlier given vide letter dated 11.01.2024. Thereafter, the complainant never approached OP Ins. Co. for reimbursement of his claim. We have carefully gone through letter dated 14.01.2024 vide which  the earlier approval was withdrawn by OP. The contents of which are reproduced as under:-

         

Document 3_page-0001.jpg

          The aforesaid letter contained a note in respect to the process of dealing with the claim in case of denial of pre authorization. The bare perusal of the aforesaid note clearly establish  that denial of preauthorization does not imply repudiation of the treatment. It does not prevent insured for reimbursement.

7.       Admittedly, in the present complaint after denial of preauthorization complainant had not approached OP Ins. Co. for reimbursement of his claim, and OP Insurance Co. has not denied the claim of the complainant,  hence, no substantive cause of action arose in favor of complainant and against OP for filing the present complaint case. The present complaint case is a premature one, hence dismissed being having no cause of action against OP.  

8.       With the above observation present complaint stands dismissed. File be consigned to record room.

Copy of the order be given to the parties free of cost as per order dated 04.04.2022 of Hon’ble State Commission after receiving the application from the parties in the registry. Order be uploaded on www.confonet.nic.in.

Announced in open Commission on   07.03.2024.

 

 

Sanjay Kumar                                         Nipur Chandna                     

               President                                                         Member     

 

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