CONSUMER DISPUTES REDRESSAL FORUM – X
GOVERNMENT OF N.C.T. OF DELHI
Udyog Sadan, C – 22 & 23, Institutional Area
(Behind Qutub Hotel)
New Delhi – 110 016
Case No.392/2013
SH. SYED SAMAR ABBAS
FLAT NO.B-106,
C-58/13, SNEH KUNJ APARTMENT,
SECTOR-62,
NEAR FORTIS HOSPITAL,
NOIDA(UP)
…………. COMPLAINANT
Vs.
- M/S NEW INDIA AUSSURANCE CO. LTD.
MR. S.L. KOLI,
SR. DM, BAJAJ HOUSE, 97, NEHRU PLACE,
NEW DELHI-110019
- RAKSHA TPA PTV. LTD.
C/O ESCORTS CORPORATE CENTER,
15/5 MATHURA ROAD,
FARIDABAD, HARYANA-121003
…………..RESPONDENT
Date of Order:08.04.2016
O R D E R
A.S. Yadav- President
This is regarding medical insurance claim. The case of complainant is that he has taken medical insurance policy and his wife was admitted in the hospital as she was suffering from heart disease. Complainant applied for cashless scheme however the same was denied by Raksha TPA of OP. The wife of complainant underwent a surgery in the hospital and the total expenses was approximately Rs.1.17 lakhs. Complainant was entitled for Rs.1.05 lakhs but instead of giving him the aforesaid amount, OP paid only Rs.31,399/-. So far as deduction of Rs.2700/- towards room charges is concerned, that was justified however the deduction of amount of Rs.70,901/- was unjustified. It is prayed that OP be directed to pay a sum of Rs.70,901/- unauthorizedly deducted by OP and also to pay Rs.2 lakhs for compensation.
OP in reply took the plea that the amount has already been paid to complainant as per the terms and conditions of policy and there was no deficiency in service on the part of OP. OP vide letter dated 13.8.12 informed complainant about denial of cashless facility as per the instructions received from GIPSA. It is prayed that there is no cause of action in favour of complainant hence the complaint be dismissed.
We have gone through the written submissions of the parties and carefully perused the record.
OP has placed on record the letter dated 11.10.13 of Raksh TPA whereby it was informed that the claim amount to Rs.11641 was settled for Rs.31,399/-. In this letter the deductions which have been made are detailed and the same were as per the terms and conditions of policy. It is not in dispute that complainant has received settled amount of Rs.31,399/-. In fact the claim voucher dated 15.10.12 which is duly addressed to complainant wherein the amount of Rs.31,399/- has been sent to complainant vide cheque No.484073 dated 11.10.12. It is not in dispute that the aforesaid cheque was accepted by complainant. Once the amount as per the settlement has been accepted by complainant then complaint is not maintainable.
It is useful to refer to case of Bhagwati Prasad Pawan Kumar Vs Union of India (2006) 5 SCC 311 – In that case a cheque was sent to complainant with the condition that if the same is not acceptable to him then the cheque be returned. Complainant got the cheque encashed. It has held by Hon’ble Apex Court that the encashment of the cheques amounted to acceptance of the amount in full and final settlement of the claim. It was further laid down by the Hon’ble Apex Court that the protest and non-acceptance must be conveyed before the cheques were encashed and if the cheques were encashed without protest, then it must be held that the acceptance was voluntary.
Keeping in view the above facts, the complaint is dismissed.
Copy of order be sent to the parties, free of cost, and thereafter file be consigned to record room.
(D.R. TAMTA) (A.S. YADAV)
MEMBER PRESIDENT
