Delhi

North East

CC/106/2019

Sh. Ravindra Panchal - Complainant(s)

Versus

M/s Max Bupa Health Insurance Co. Ltd. - Opp.Party(s)

03 Jul 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

Complaint Case No. 106/2019

 

 

In the matter of:

 

 

	Sh. Ravindra Panchal S/o Lt. Sh. Jai Bhagwan R/o C-5, Ramo Devi Building, Indira Niketan, North Chajjupur, Delhi-110094	Complainant
	Versus
1.                     2.	Niva Bupa Health Insurance Co. Ltd. (Formerly known as Max Bupa Health Insurance Co. Ltd.) Servicing Branch: 39, 3rd Floor, WEA, Karol Bagh, New Delhi-110005 (Through its Principal Officer/ Branch Manager)   Also at:- Regd. Office: Max House 1, Dr. Jha Marg, Okhla New Delhi-110020   M/s C M Patel Hospital ( Proforma Party) E-7, West Jyoti Nagar Extension 100 Feet Road, Shahdara, Delhi-110064	Opposite Parties

 

DATE OF INSTITUTION:        JUDGMENT RESERVED ON:                           DATE OF ORDER:

27.11.2019 03.03.2023 03.07.2023

 

CORAM:

Surinder Kumar Sharma, President

Anil Kumar Bamba, Member

Ms. Adarsh Nain, Member

 

 

 

ORDER

 Anil Kumar Bamba, Member

The Complainant has filed the present complaint under Section 35 of the Consumer protection Act, 2019.

Case of the Complainant

1. The case of the Complainant as revealed from the record is that Complainant availed a cashless health insurance policy bearing no. 30614495201600 for the period 26.12.16 to 25.12.17 from Opposite Party No.1 by paying Rs. 23,277/-. The said policy was renewed by Complainant year to year and the same was in force upto 25.12.19. The Complainant stated that on 18.05.19 the wife of Complainant got admitted in Opposite Party No.2 hospital with complaint of abdomen pain, loose motion and fever and general problems. Since abovesaid policy was cashless policy, the said hospital (Opposite Party No.2) had admitted the patient only after getting a prior approval from Opposite Party No.1 for the treatment. The patient remained in hospital from 18.05.19 to 22.05.19 and total medical expenses occurred Rs. 43,051/-. The Complainant stated that at the time of discharge Opposite Party No.2 demanded the said amount from Complainant and told that the prior approval has been cancelled by Opposite Party No.1 as per their ‘Denial of Authorization’ dated 22.05.19. The Complainant stated that according to the ‘Denial of Authorization’ issued by Opposite Party No.1 on the last moment of discharge, Opposite Party No.1 allegedly requested the hospital to settle the bill directly from the Complainant and also allegedly requested the said hospital to send them the documents for processing of claim reimbursement. The Complainant stated that being the policy in question cashless the Opposite Party No.1 denied the claim of Complainant and Complainant was unable to pay a huge amount of Rs. 43,051/- to the Opposite Party No.2 hospital the Complainant had requested the hospital to charge the said amount from Opposite Party No.1 and accordingly requested to discharge the patient without charging any payment. On request of Complainant, Opposite Party No.2 discharged the patient without collecting any payment from Complainant. The Complainant sent a legal notice dated 22.10.19 to Opposite Party No.1 to settle the dues of Opposite Party No.2 hospital. On 11.09.19 the Complainant again visited Opposite Party No.2 hospital for treatment of his minor daughter but Opposite Party No.2 denied to provide the treatment on the ground of non-payment of dues of Rs. 43,051/-. On 17.11.19 Complainant again visited Opposite Party No.2 hospital to render treatment to his wife in OPD but same was refused for non-payment of aforesaid dues. Hence, this shows deficiency on the part of Opposite Parties. Complainant prayed to issue directions to Opposite Party No.1 to settle the entire claim of Opposite Party No.2 hospital relating to treatment in question and he further prayed for Rs. 1,00,000/- for mental harassment. He also prayed for Rs. 33,000/- towards litigation expenses.  
2. None has appeared on behalf of Opposite Party No.2 to contest the case neither any written statement has been filed on its behalf. Therefore, Opposite Party No.2 was proceeded against Ex-parte vide order dated 09.05.2022.

Case of the Opposite Party No.1

3. The Opposite Party No.1 contested the case and filed written statement. Opposite Party No.1 stated that the Complainant had taken a policy on 26.12.16 which was renewed year on year. The health companion policy had a base sum insured of Rs. 10,00,000/- and insurance coverage was provided to the Complainant, his wife and two kids.
4. That wife of the Complainant got admitted in CM Hospital on 18.05.2019 with provisional diagnosis of gastroenteritis and fever. From the details mentioned in the preauthorization from request ID 241192, the liability could not be ascertained and Complainant was asked to file the reimbursement claim after completion of the treatment, which he did not file and directly approached the court. Hence, complaint is not maintainable as the claim for reimbursement       (as per the applicable terms and conditions of the policy) is not denied by the answering Opposite Party rather the Complainant has not filed the claim.
5.  It is further stated that prima facie no cause has arisen in favour of the Complainant to file the present complaint. Complainant has no reason to file any complaint against Insurance Company since he has not filed a claim for reimbursement and is only making false allegations post denial of cashless facility. The Opposite Party company received non satisfactory response from the Hospital and hence cashless authorization was denied with request to the Complainant to complete the treatment and then get back to the insurance company for reimbursement of the claim by submitting all the documents. Complainant has not submitted the claim for reimbursement and has filed this complaint. Hence the complaint is premature and deserves dismissal with direction to the Complainant to file the claim for reimbursement in the office of the answering insurance company.
6. The Opposite Party insurance company has never confirmed or admitted to the Complainant that the bills of treatment would be paid to Opposite Party No.2, even after denial of cashless facility. The contest of the denial of authorization is pasted here for ready reference: 
7. “The details submitted along with the preauthorization request and other documents suggest that liability cannot be established as request hospital to settle all the bills directly with the customer & request the patient to go for reimbursement with all medical records on receipt of which the claim shall be processed on merit i.e. depending upon medical admissibility and policy terms & conditions.  Therefore send us the documents for reimbursement claim processing.”
7. That the claim referred by the Complainant in present complaint was closed only after denial of cashless facility/ pre-authorization request. However, the Complainant was having option to file the claim for reimbursement, which he did not made.
8. That further, the Opposite Party No.1 precisely mentioned in the cashless facility denial Letter that denial of cashless could not be considered as denial of the claim/treatment itself. As per the terms and conditions, the insured can always filed a claim for reimbursement in case there is a denial of Preauthorisation Request. It is only at the reimbursement stage the in-depth investigation is conducted and Bills/Receipts/Discharge Summary etc. are checked. It is pertinent to mention that subsequently, the Complainant did not lodge any claim for reimbursement of the Bills with the Opposite Party No.1.

Rejoinder to the written statement of Opposite Party No.1

9. The Complainant filed rejoinder to the written statement of Opposite Party No.1 wherein the Complainant has denied the pleas raised by the Opposite Party No.1 and has reiterated the assertion made in the complaint.

Evidence of the Complainant

10. The Complainant in support of his complaint filed his affidavit wherein he has supported the averments made in the complaint.

 

 

Evidence of the Opposite Party No.1

11. In order to prove its case, Opposite Party No.1 has filed affidavit of   Sh. Bhuwan Bhashker, Employee of Opposite Party No.1, wherein the averments made in the written statement of Opposite Party No.1 have been supported.

Arguments & Conclusion

12. We have heard the Ld. Counsels for the Complainant and Opposite Party No.1 and we have also perused the file. The case of the Complainant is that he is having a cashless health insurance policy from Opposite Party for the period 26.12.16 to 25.12.17 from Opposite Party No.1 which was renewed year to year and the same was in force upto 25.12.19.  It is stated by Complainant that his wife was admitted in Opposite Party No.2 hospital since she was covered under cashless policy issued by Opposite Party No.1, Opposite Party No.2 admitted the patient only after getting prior approval from Opposite Party No.1 for the treatment. The wife of the Complainant remained in hospital from 18.05.19 to 22.05.19 and total medical expenses occurred         Rs. 43,051/-. It is further stated by the Complainant stated that at the time of discharge Opposite Party No.2 demanded the said amount from Complainant and told that the prior approval has been cancelled by Opposite Party No.1 as per their ‘Denial of Authorization’ dated 22.05.19. According to the ‘Denial of Authorization’ issued to Opposite Party No.2 at the time of discharge, Opposite Party No.1 requested the hospital to settle the bill directly from the Complainant and requested the said hospital to send them the documents for processing the reimbursement of claim. On the request of the Complainant, Opposite Party No.2 discharged the patient without charging any payment. It is further stated by the Complainant that on 11.09.19 and 17.11.19 he approached for treatment of his minor daughter and wife respectively and same was refused by Opposite Party No.2 on the ground of non-payment of earlier bill by the Opposite Party No.1. Hence, this shows deficiency on the part of Opposite Parties.
13.  It is admitted by the Opposite Party No.1 that Complainant is having a valid policy at the time of treatment of the wife of the Complainant and they did not deny regarding preauthorization of treatment given to the Opposite Party No.2. It is stated by the Opposite Party No.1 that wife of the Complainant got admitted in CM Hospital on 18.05.2019 with provisional diagnosis of gastroenteritis and fever. From the details mentioned in the preauthorization from request ID 241192, the liability could not be ascertained and Complainant was asked to file the reimbursement claim after completion of the treatment, which he did not file and directly approached the court. Hence, complaint is not maintainable as the claim for reimbursement (as per the applicable terms and conditions of the policy) is not denied by the answering Opposite Party rather the Complainant has not filed the claim.
14. It is further stated by Opposite Party that in the cashless facility denial letter, the denial of cashless could not be considered as denial of claim/treatment itself. As per terms and conditions, the insured can always filed a claim for reimbursement in case there is a denial of preauthorization request. It is only at the reimbursement stage the in-depth investigation is conducted and Bills/Receipts/Discharge Summary etc. are checked. It is pertinent to mention that subsequently, the Complainant did not lodge any claim for reimbursement of the Bills with the Opposite Party No.1.
15.  It is clear from the above, Opposite Party No.1 ready to settle the bill if the Complainant has filed the claim for reimbursement which was not filed in this case. It is also admitted by the Complainant he did not pay any amount to Opposite Party No.2 for the treatment. Enough opportunities were given to the Opposite Party No.2 to appear before the Commission to present their case for reimbursement of hospital expenses which they failed to avail. Complainant also failed to provide any evidence regarding taking his daughter and wife in another hospital after denial of Opposite Party No.2 for treatment of them on refusal of Opposite Party No.2 on the ground of non-payment of dues.
16.  In view of the above discussion, we are of the considered opinion that there is no deficiency of service on the part of the Opposite Parties. Therefore, the complaint of the Complainant is dismissed.
17.  Order announced on 03.07.2023.

Copy of this order be given to the parties free of cost.

File be consigned to Record Room.

( Anil Kumar Bamba)        Member

(Adarsh Nain)   Member

(Surinder Kumar Sharma) President