Order No. -10                                                                                                       Dt.-28/07/2015

        Shri Prabin Chettri, Member

        Complainant’s case in brief is that he purchased a Mediclaim Insurance Policy from O.P.1(Star Health and Allied Insurance Co.Ltd.), whose yearly premium was Rs.9500/- and the commencement of the policy was 23/09/2012 to 22/09/2013 bearing policy no. P/190000/01/2013/005177, thereafter Insurance Policy was renewed from 27/09/2013 to 29/09/2014, bearing policy no. P/191124/01/2014/001050, by paying premium amount of Rs.9500/-.

          On 15^th August 2014 the petitioner/ Complainant suddenly became senseless and admitted in Marina Nursing Home , Jalpaiguri, under the treatment of Dr.Sumanta Mukherjee. Dr.Sumanta Mukherjee  advised the petitioner/ Complainant for implantation of permanent pacemaker. Accordingly the petitoner consulted with Dr.Indranil Dutta (Cardio) of R.N. Tagore International Institute of Cardiac Sciences and admitted in that hospital on 24/08/2014 and permanent pacemaker implantation (VVIR) was done on 25/08/2014 (Class II) indication and released on 27/08/2014, with an opinion, pacemaker implied due to bifascular Block not for minor coronary disease.

          The petiitoner informed the matter to the O.P. for making payment of medical expenses under Medi-claim policy and the total expenditure for Implantation of permanent pacemeker , pre-hospitalization expenses and post hospitalization was Rs.1,42,000/-, but the O.P.paid only 44,754/- by a cheque being no. 983692 dt.24/12/2014 in the bank of UCO Bank. And thereby the O.P. has adopted Unfair Trade Practice and the O.P. is also liable for deficiency in service. The complainant’s claim further is Rs.97246/- + 2000/- i.e. Rs.99246/- in total against the O.Ps. Hence the complainant has filed this case before this DCDRF, Jalpaiguri on 27/01/2015.

           The O.P. contested the case by filing Written Version. O.P.2 didn’t appear before this Forum after service of notice to contest this case. So the case is heard ex-parte. Against O.P.2.

           O.P.1 have denied and disputed the claim of the petitioner . They have admitted that the complainant have a Mediclaim Insurance Policy, issued by Star Health and allied Insurance Co.Ltd. the policy known as Star Senior Citizen’s Red Carpet Insurance Policy covering the petiitoner for the sum of Rs.2,00,000/- vide policy nos. P/190000/01/2013/005177 from 23/09/2012 to 22/09/2013 and P/191124/01/20140015050 from 27/09/2013 to 26/09/2014. The complainant’s claim was in the 2^nd year of policy. The O.P.1 on receipt of pre-authorization request from the complainant and the treatment hospital for cashless benefit, has scrutinised the claim records and observed that, the patient is a known case of Coronary Artery Disease (CAD) since 2011 which was prior to inception of the policy. Hence the cashless authorization was denied and the same was communicated to the treatinghospital and the insuredvide letter dt.25/08/2014. However, the Insurance Company O.P.1 sent claim form to the insured to approach for reimbursement of claim as admissible as stated in paragraph no.8 of their Written Version. The complainant also submitted all original medical documents to the O.P. at the time of the claim as per instructions of the O.Ps. as stated in their petition of complaint in paragraph no.8.

       The O.P. Insurance Company perused the case records seeking reimbursement of medical expenses for the treatment and considered the claim for settlement and paid Rs.44,754/- against the bill submitted for Rs.1,17,426/- and the deduction was Rs.43,736/- as per terms and conditions of the policy, as per O.Ps. statement in paragraph no.9 of their Written Version. The Insurance Company in their Written Version in paragraph no.10 states that after settlement of the claim with the petitioner the settlement amount was Rs.44,754/- and accordingly a cheque of Rs.44,754/- was received by the petiitoner as full and final settlement. Thus the payment of Rs.44,754/- was for full and final settlement of the claim and the cheque was received by the petiitoner without protest. The O.P. also submits that the cheque amount of Rs.44,754/- received by the claimant and he got the cheque encashed without protest, so there is no deficiency in service or Unfair Trade Practice on the part of the O.P. ,so the present case is liable to be dismissed.

POINTS FOR CONSIDERATION

1) Is the case/ application maintainable?

2) Is the complainant a consumer under the Consumer Protection act 1986?

3) Are O.Ps. guilty for deficiency in service and for Unfair Trade Practice as alleged?

4) Is the complainant entitled to get the reliefs as prayed for?  

DECISION WITH REASONS

                   All four points are taken up together for consideration and decision.

                   Seen and perused the pleadings of the parties, documents filed by the parties and the written argument filed by the complainant.

                   Now after due consideration of arguments of Ld. Lawyers of both sides and the material on record we find that the complainant has gone under treatment for implantation of permanent pacemaker(VVIR) at R.N Tagore International Institute of Cardiac Science under the advise of Dr.Indranil Dutta(Cardio) and was done on 25/08/2014 and released on 27/08/2014. After recovery/discharge complainant made his claim to the O.P. as he was a policy holder (Mediclaim policy) of O.P. (Star Health and Allied Insurance Co.Ltd.) for reimbursement of medical expenses which he incurred during his treatment which amounts to Rs.1,42,000/-

                  The O.P. considered the claim of the complainant as per terms and conditions of the policy and paid Rs.44,754 by cheque being no. 983692 dt. 24/12/2014 . The complainant accepted the cheque and also encashed the same, without protest.

                 In the decision reported in 2015(I) CPR 135(NC) the  Hon’ble  National Commission has held that “Once complainant had accepted cheque in respect of her claim as full and final settlement, she cannot reopen her claim”.  In view of that decision of Hon’ble National Commission and the facts and the circumstances of this case we can safely come to the conclusion that as the complianant has received the cheque for Rs.44,754/- being no.983692 dated 24/12/2014 from the Insurance Company (O.P.1) without protest and encashed the same towards full and final settlement of his claim as claimed by the O.P. So this case is not maintainable. Therefore question of deficiency in serviec by O.P. as alleged by the complainant doesn’t arise.

                    So, the complainant is not entitled to get any relief as prayed for although he is a consumer of O.P.( Star Health and Allied Insurance Co.Ltd.).

                      All points are disposed of accordingly.

                      In the result the case / application fails.

                      Hence, it is

O R D E R E D

                    that the case/ application u/s 12 of the Consumer Protection Act 1986 stands dismissed on contest against O.P.1 and ex-parte against O.P.2 without cost being not maintainable.

                     Let a plain copy of this order be supplied to the parties free of cost forthwith as per sec 5(10) of West Bengal Consumer Protection Rules,1987.