ORDER

PARAMJIT SINGH, PRESIDENT

1. Brief facts of the present complaint are that complainant hired the services of opposite party for way of taking an overseas Mediclaim Policy No.2008/401111/48/08/0570000052 Ex.C1 before traveling to USA to visit her grandson settled there. The policy was valid for the period from 4.11.2008 to 3.3.2009 and paid a premium of Rs14,562/-. Unfortunately on 20.11.2008, the complainant insured tripped in backyard of the house of her grandson and

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landed on left hand resulting wrist fracture on her left hand and mouth injury leading to teeth fracture. She was immediately taken to near by hospital namely CAPE FEAR VALLEY, Health System, 1638 Oven Drive, Fayetteville, N. 28303 USA. She under vent basic treatment in the emergency and thereafter advised to follow up in clinic with Orthopedic Physician on all for continued care which happened to the Doctor Denial Mebrayer of Fayetteville Orthopedics and Sports Medicines, located at 3308 Metrose Rd. Fayetteville N 29304. The complainant was further advised to follow up with any local dentist for treatment of fractured teeth.

2. That when a son of the complainant herein India came to know regarding non-settling of the medical bills by the franchise of the opposite party and due to that his mother i.e. complainant was unable to get the treatment of her fractured teeth. He wrote a letter dated 13.1.2009 and opposite party vide reply dated 14.1.2009 assured the complainant to settle the complaint but nothing was done by the opposite party. After exchange of lot of correspondence, she received a letter dated 22.7.2009 along with a cheque of Rs.30,000/-only Ex.O10 in her favour as full and final settlement of the claim from the side of the opposite party. The settling of the claim of the complainant on lesser side than the actual claim is deficiency in service on the part of the opposite party. Hence the present complaint.

3. Notice of the complaint was issued to the opposite party who appeared through counsel and filed written statement raising as many as six preliminary objections by refuting all the allegations

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made in the complaint. It is admitted that complainant obtained the policy and met with accident and subsequently he lodged a claim with the opposite party. It is also admitted by the opposite party that correspondence was exchanged between the party It is submitted that after pursuing the bills and payment receipt submitted by the complainant, she was found entitled to the reimbursement of Rs.30,000/- only as her overseas claims had already been settled and paid to the complainant. So there is no deficiency in service on the part of opposite party.

4. The counsel for the complainant has tendered into evidence affidavit of complainant along with documents Ex.C1 to Ex.C31 and closed the evidence.

5. On the other hand the opposite party tendered into evidence affidavit Ex.OA along with document Ex.O1 to Ex.O11 and closed the evidence.

6. We have heard learned counsel for both the party. In this case, the complainant hired the services of opposite party by taking an overseas medical policy before traveling to U.S.A. to visit her grand son who is settled there and she had paid Rs.14,562/- as the premium of the policy. On 20.11.2008 when this policy was in force, complainant slipped in the backyard of the house of her son and her wrist of left hand was fractured and was also sustained mouth injury leading to teeth fracture. She took the basic treatment in U.S.A. and the complainant filed her claim to the opposite party National Insurance Company Limited informed Shri Rakesh Kumar son of the complainant vide letter Ex.C11 that they have taken up the matter

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with their authorized representative at Mumbai and on receipt of their reply, the same will be communicated to you at the earliest.

7. Heritage Health TPA Pvt Ltd. informed the complainant that her two bills are outstanding for payment and the payment will be made to the service provider. One bill is for USD 268 and second bill is 2970.80 USD Ex.C3. It is also mentioned in this, letter Ex.C15 that it has also come to their knowledge that the complainant has paid an amount of USD 1364 to FAY Ortho and Sport MED. Vide this letter, the complainant was also informed that her claim has been approved for payment The opposite party also relied upon this letter and they have exhibited this document as Ex.O6. Vide letter Ex.O2, the opposite party informed that they have received payment, details of Coriss Miami of the above mentioned claim which is as under-

Dental

In this letter, the opposite party informed that they have paid on 23.11.09, a sum of USD 1364.99 Cheque # 29303, a bill of USD 268 through Cheque # 29302 on 23.11.09 and bill USD 2970.85 Cheque # 29034 on 23.11.09 vide Ex.O2 and after receiving this information, Anand Kishore Branch Manager of the opposite party at Kapurthala vide an affidavit Ex.OA in which he has mentioned that the payment has been duly made and the claim of the complainant has been fully discharged. The payment has been made as under-

CHART

When the complainant reached India, he took the treatment for her fractured teeth from Bhola Surgical Clinic and Bhola Dental Clinic. It

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is mentioned in this certificate that the complainant came to the Dental Clinic on 16.9.2009 with fractured 12345 and she needs root canal treatment for her fractured teeth and the Bhola Dental Clinic received Rs.17500/- on 20.2.2009 and again Rs.17500/- on 28.2.2009. So total bill of Bhola Dental Clinic was Rs.35000/- which was also submitted by the complainant for payment to the opposite party and the opposite party wrote a letter to the complainant Ex.C27 in which they informed the complainant they are enclosing Cheque No. 006212 dated 22.7.2009 for Rs.30,000/- drawn on ICICI Bank, Mumbai towards the full and final settlement of your claim and it is also mentioned in this letter please note the amount arrived at after applying deduction USD 100 under Section "A" for the above policy. The opposite party also exhibited this letter Ex.O9. The complainant received this Cheque No. 006212 placed photostat copy of the cheque on the file Ex.C28 and the opposite party also exhibited copy of this cheque Ex.O10. We have also perused the insurance policy Ex.C1. There is also a provision of deducting USD 100 from the claim of the complainant. So the claim of the complainant regarding the treatment of her fractured teeth has been settled by the opposite party.

Chart

So the complainant has filed three overseas claims First USD 2970.85 Ex.C3, Second USD 1364.99 Ex.C5 and the third USD for 268.00 Ex.C7.

8. Apart from this three overseas bills, the complainant also submitted two bills Ex.C19 and Ex.C20 issued by Bhola Dental

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Clinic, Kapurthala dated 20.2.2009 and 28.2.2009 of Rs.17,500/- each and the total amount of bills Ex.C19 and Ex.20 is Rs.35,000/-. After receiving these two bills of Rs.17,500/- each, the opposite party wrote a letter to the complainant Ex.C27 in which they informed the complainant that they are including cheque No. 0061212 dated 22.7.2009 for Rs.30,000/- drawn on ICICI Bank, Mumbai towards full and final payment of your claim of Rs.35000/- and it is also mentioned in this letter that please note that the amount arrived at after applying deduction of USD100 under Section "A" of the above said policy Ex.C1 where it is mentioned that USD100 is deductible on each claim. This clause is mentioned in page-I of Ex.C1. For this purpose, the counsel for the opposite party has relied upon a case decided by the Apex Court titled as Grasim Industries Ltd & Anr. Vs. Agarwal Steel 2009 (4) Civil Court Cases page 598 wherein it is held that :-

"Evidence Act, 1872, S.114-Signature-A person

signing a document is presumed to have signed

after reading and understanding the document

properly unless there is proof of force or fraud."

9. The counsel for the complainant argues that Nand Kishore Branch Manager of the opposite party has filed a false affidavit Ex.OA in this Forum, but on the other hand, the counsel for the opposite party argues that the Branch Manager has filed this affidavit on the basis of facts and figure supplied to him by the insurance company and by their overseas franchises and nothing has been added of his own. On 22.4.2010, the counsel for the complainant moved an

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application leading additional evidence and the opposite party filed the reply to the said application. There is a dispute regarding the payment of USD 2970-85 by the overseas branch of the opposite party and the counsel for the opposite party has filed a document along with the reply to the application. This document is filed by CAPE FEAR VALLEY MED CT dated 2.2.2010. Vide this document payment of USD 2079.60 was made to this hospital as full and final payment and the original bill of CAPE FEAR VALLEY MED CT was USD 2970-85 and CAPE FEAR VALLEY MED CT and voluntarily accept this payment of USD 2079.60 from the overseas branches of the opposite party as full and final payment and issued this receipt dated 2.2.2010. At the time of conclusion of argument, the counsel for the opposite party submits that opposite party had paid three overseas claims First USD 268.00, Second USD 1364.99 and the third for USD 2970.85 Ex.C3, Ex.C5 and Ex.C7 and even in India, the opposite party had paid the two bills submitted through Ex.C19 and Ex.C20 for a total amount of Rs.35000/- and there is no deficiency in service on the part of the opposite party, but on the other hand, the counsel for the complainant argued that the opposite party paid their bills after a long delay and even the complainant was compelled to cut short her journey for the proper treatment of her fractured teeth and there is deficiency in service on the part of the opposite parties

In view of the above discussion, we accept the complaint and direct the opposite parties to pay Rs.5000/- to the complainant for the treatment of root canal treatment for her fractured teeth

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and mental tension besides Rs.3000/- as costs of the complaint payable by the opposite party within one month from the receipt of copy of this order.

Copy of the order be sent to the parties through registered post free of costs. File be consigned to the record room.

Dated: Gulshan Prashar Paramjit Singh

12.05.2010 Member President