Delhi

East Delhi

CC/331/2019

YASH GOYAL - Complainant(s)

Versus

MAX BUPA HEALTH INS. - Opp.Party(s)

03 Dec 2019

ORDER

            DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, EAST, Govt of NCT of Delhi

              CONVENIENT SHOPPING CENTRE, 1^st FLOOR, SAINI ENCLAVE, DELHI 110092  

 

                                                                                                   Consumer complaint no.       331/2019

                                                                                                   Date of Institution               08/11/2019

                                                                                                   Order reserved on               03/12/2019        

                                                                                                   Date of Order                       06/12/2019                                                                                    

In matter of

Mst. Yash Goyal (minor)

Through- Natural Guardian (Father)

Mr Neeraj Goyal    

S-85, Sunder Block, Shakarpur, Delhi 110092….……………...…………….Complainant                             

                                     

                                                                            Vs

1-M/s The Manager,

H.O.-Max Bupa Health Insurance Co. Ltd. 

Max House 1, Dr Jha Marg, Okhla New Delhi 110020

 

2-Mr Ritesh Kumar Upadhyaya

DST Agent for Max Bupa Health Insu. Co.

39, 3^rd floor, Pusa Road

WEA Karol Bagh, Delhi 110005

 

3-The Director, Malik Redix Healthcare Pvt Ltd

C-218, Niman Vihar, Delhi 110092

 

4-Dr Ravi Malik

 Malik Redix Healthcare Pvt Ltd

C-218, Niman Vihar, Delhi 110092

 

5-Dr Amit

c/o- Malik Redix Healthcare Pvt Ltd

C-218, Niman Vihar, Delhi 110092…………………………..…..….…………..Opponents

 

Complainant’s Advocate-             Ms Usha Garg & Asso.

 

Quorum    Sh Sukhdev Singh        President

                   Dr P N Tiwari                Member

                   Mrs Harpreet Kaur      Member                                                                                             

 

Order by Dr P N Tiwari  Member-   

 

Brief Facts of the case –

 This complaint has been filed under Section 12 of the Consumer Protection Act, 1986 by Mr Neeraj Goyal , natural guardian of Mst. Yash Goyal aged about 12 years, with allegation of deficiency of OP1/Max Bupa Health Insurance Co. for repudiation of Cashless authorization and alleged dealing in unfair trade practice.

 

The case came up for arguments on admission-hearing. The counsel for complainant submitted facts as obtained mediclaim policy from OP1 vide policy no. 30766998201800 having tenure from 23/04/2018 to 2204/2019 having sum assured 5 lacs (Ex CW1/1) and the same was received through agent OP2. The son of complainant had sudden giddiness and difficulty in walking due to vertigo so was taken to Matrix Hospital /OP3 where son was admitted on 06/08/2019 and was discharged on 08/08/2019 after investigation and symptomatic treatment. On the date of discharge, OP3 sent a pre requisition letter to OP1 which was denied by OP1on the ground of hospitalization not justified. So, complainant perused his claim with point that cashless repudiation was not justified under the policy terms and conditions. When no response received from OP1, filed this claim and claimed treatment bill Rs 25,000/- with 18% interest per annum with compensation Rs 1,75,000/- for harassment and mental agony.

 

Heard on Admission-

We have heard at length from the Ld counsel on the point of denial of cashless authorization which not passing cashless amount. It was also argued on the point of policy terms and conditions which were on record and further submitted that after cancellation of cashless request to the treating hospital on the ground that Hospitalisation was not justified and all investigations were done and no active line of treatment was given. Counsel of the complainant stated that hospital bill which was initially for Rs 35,500/- was reduced to 25,000/- which was claimed by complainant’s father, but this amount was also not considered by OP1. Hence it is a gross deficiency in services of OP1 and amounts to unfair trade practice.   

 

It is settled law that mere denial of cashless does not give rise any cause of action by which it could be said that OP did deficiency in services or dealt in unfair trade practice. Here in this case no cause of action arisen for which complainant can seek redressal for his grievances by proving cause of action in cashless denial.

 

This complaint has no merit and that being so this complaint cannot be admitted.

Copy of this order be sent to the party’s counsel and party as per the Sec. 18(6) of the Consumer Protection Regulation, 2005 and file be consigned to Record Room Sec. 20(1).   

 

(Dr) P N Tiwari  Member                                                                         Mrs  Harpreet Kaur  Member                                                                                                                       

 

                                                  Sukhdev Singh  President