PER SHRI. S.B.DHUMAL - HON’BLE PRESIDENT :
1) In brief present dispute is as under –
The Complainant on payment of premium of Rs.2,087/- to the Opposite Party obtained Mediclaim Policy bearing No.250700/48/05/8500008878 for the period from 25/01/06 to 28/01/07. In the policy the Opposite Party has given sum assured of Rs.1,50,000/- to the Complainant and sum of assured of Rs.1,00,000/- to the wife of the Complainant. Cumulative Bonus of Rs.12,500/- is recorded against the name of Complainant.
2) It is case of the Complainant that in the month of June, 2006, he has suddenly got pain the right side of stomach and was required to admit in the Nakoda Hospital, Nageshwar Park, Devchand Nagar Rd. Bhayander (E), Dist. Thane. The Complainant was admitted in the said hospital on 03/06/06. Doctor conducted various medical tests and it was found that there was stone in the kidney (Multiple Gall Stones with Dm). The Complainant was required to be operated on 10/06/06 and after recovery he was discharged from the hospital on 25/06/2006. The Complainant paid hospital bill dtd.25/06/06 for total Rs.1,24,500/-. Apart from the said amount sum of Rs.22,803/- was incurred for medicines and other medical tests. Thus, the Complainant has incurred total expenses of Rs.1,47,000/- for medical treatment.
3) After discharge from the hospital the Complainant had submitted claim form alongwith medical documents, original bills of the hospital, medicines bills, etc. and claimed reimbursement of Rs.1,47,303/-. However, Opposite Party had sanctioned only Rs.62,136/-. Cheque of the said amount was given to the Complainant. No reason was shown for deduction of large sum from claim amount. The Complainant’s claim of Rs.85,168/- is rejected by the Opposite Party by its letter dtd.23/07/07.
4) After receipt of aforesaid letter alongwith cheque, the Complainant immediately approached Opposite Party and discussed the matter but there was no proper response from the Opposite Party. Officer of the Opposite Party directed the Complainant to deposit the said cheque in the bank. Accordingly the Complainant deposited the said cheque with the bank without prejudice to his rights. Then the Complainant sent notice to the Opposite Party through his advocate on 25/0308 and called upon Opposite Party to pay balance amount. The Opposite Party had send reply to the said notice and advised the Complainant to contact National Insurance Co. Ltd. Thereafter, the Complainant sent letter on 26/07/08 but the Opposite Parties have not made any payment nor sent any reply to the said letter. According to the Complainant, Opposite Party has without any reason deducted huge amount of Rs.85,168/-. So the Complainant has requested to direct Opposite Party to pay an amount of Rs.85,168/- to the Complainant with interest @18% p.a. from the date of filing of this complaint till realization of amount. He has claimed Rs.25,000/- as compensation for mental agony and Rs.15,000/- towards cost of this proceedings. The Complainant has filed his affidavit in support of his complaint and produced copies of the documents alongwith complaint.
5) Opposite Party has filed written statement and thereby denied claim of the Complainant contending that complaint is illegal and filed with malafide intention and therefore, complaint is liable to be dismissed. It is submitted that claim preferred by the Complainant was exorbitant and was not tenable under the terms and conditions of the policy. The Complainant’s claim was bogus. As per terms and conditions of the policy Opposite Party has sanctioned the reasonable amount by cheque which is accepted by the Complainant. Reasonable charges of the hospital were collected by third policy as per the terms and conditions of the policy.
6) It is submitted that cause of action for this complaint took place in the year 2006 and the complaint which is filed in the year 2010 is barred by law of limitation. The Opposite Party has denied allegations made in the complaint and submitted that complaint be dismissed with cost.
7) The Complainant has filed affidavit of evidence and produced copies of the documents alongwith list of documents. The Complainant has filed written notes of documents. Opposite Party has also filed written notes of affidavits. After filing of written argument the Opposite Party has not appeared before this Forum from 28/12/2010. So we heard oral submissions of Ld.Advocate Mr. M.D. Mali for the Complainant.
8) Following points arises for our consideration and our findings thereon are as under -
Point No.1 : Whether complaint is barred by law of limitation ?
Findings : Yes.
Point No.2 : Whether the Complainant is entitled for any reliefs against Opposite Party from this Forum as prayed for ?
Findings : No
Reasons :-
Point No.1 :- It is undisputed that the Complainant obtained Mediclaim Policy for the period from 25/01/06 to 28/01/07. Schedule of Mediclaim Policy is produced by the Complainant alongwith complaint. According to the Complainant, in the month of June, 2006, suddenly he got pain in right side of stomach. So on 03/06/2006, he was admitted in Nakoda Hospital, Nageshwar Park, Devchand Nagar Road, Bhayander (E), District - Thane. After medical examination it was found that there was a stone in the kidney of the Complainant. He was required to be operated. The Complainant was operated on 10/07/2006 and was discharged from the hospital on 25/06/06. The Complainant incurred total medical expenses of Rs.1,47,303/-. After discharge from the hospital the Complainant had submitted his claim form for reimbursement of the amount from the Opposite Party. Thereafter, Opposite Party vide their letter dtd.23/07/07 partly allowed claim of the Complainant to the extent of Rs.62,136/- and cheque of the said amount was sent to the Complainant. The Complainant claim for the balance amount of Rs.85,168/- was rejected by the Opposite Party by its aforesaid letter. The Complainant has produced copy of the aforesaid letter alongwith complaint at Exh. ‘1’. In the said letter it is stated by the Opposite Party that amount claimed for Rs.1,47,303/-, amount sanctioned Rs.62,136/- and claim of amount of Rs.85,168/- was repudiated contending that claim of only reasonable charges is allowed. The Complainant has accepted the cheque of Rs.62,136/- from the Opposite Party.
Ld.Advocate for the Complainant has submitted that the Complainant has encashed the cheque of Rs.62,136/-. The Complainant through his advocate on 25/03/2008 sent notice to Opposite Party and thereby called upon to pay balance amount of Rs.85,168/-. As mentioned above by letter dtd.23/07/2003, the Opposite Party had sent cheque of Rs.62,136/- to the Complainant stating that Complainant’s claim of balance amount of Rs.85,168/- is rejected. In the said letter it is specifically stated that, “Encashment of the Cheque Discharges the Liability of Insurer under the said claim.” Even though, aforesaid cheque was received by the Complainant in the month of July, 2007. The Complainant had sent notice to the Opposite Party through Advocate on 25/03/08. There is no evidence on record to show that prior to 25/03/08, the Complainant approached Opposite Party to claim balance amount. It appears that copy of notice dtd.25/03/08 was sent to E-Meditek Solutions Ltd., 306, Konark Shram, 156, Tardeo Road, Mumbai-34 and E-Meditek Solutions Ltd., 45, Nathupur Road, DLF Phase-III, Gurgaon. According to the Ld.Advocate for the Complainant, Opposite Party has partly repudiated the claim without assigning any reason for the same. Repudiation of the claim of sum of Rs.85,168/- is against the terms and conditions of the policy. Terms & conditions of the policy are not produced on record either by the Complainant or by the Opposite Party. It is submitted by the Ld.Advocate for the Complainant that E-Meditek Solutions Ltd. by letter dtd.24/04/08 informed the Complainant that they have sent Complainant’s original file to National Insurance Co. Ltd. on 30/01/08 and advised the Complainant to contact National Insurance Co. Ltd. It is submitted that in view of the letter dtd.28/04/08 sent by E-Meditek Solutions Ltd. the Complainant’s claim is within limitation.
As mentioned above the Complainant accepted cheque for Rs.62,136/- alongwith letter dtd.23/07/07 and enchased the cheque. It is specifically mentioned in the letter by the Opposite Party that encashment of the cheque discharges the liability of the Insurer. About 8 months thereafter the Complainant sent notice through advocate to the Insurance Company and its copy to E-Meditek Solutions Ltd.. National Insurance Co. Ltd. has not sent reply to the Complainant’s notice. E-Meditek Solutions Ltd. who sent letter dtd.24/04/08 is not joined as a party to this proceeding. We have carefully gone through the contents of letter dtd.24/04/08 sent by E-Meditek Solutions Ltd. It appears from the contents that E-Meditek Solutions Ltd. informed the Complainant’s Adv. that original file of fir No.124485 has been sent to the National Insurance Co. Ltd. DO-7 on 30/01/08 and advised to contact National Insurance Co. Ltd. In the letter dtd.28/04/08 E-Meditek Solutions Ltd. has not admitted liability to pay balance amount. There is no assurance of any kind to pay the balance amount therefore, the letter dtd.28/04/08 will not extend the period of limitation. Cause of action for this complaint took place on 23/07/07 when Complainant’s claim was partly repudiated by the Opposite Party. The Complainant has filed this complaint for recovery of the balance amount on 15/01/2010. The complaint is not filed within period of 2 years from the date of repudiation of part of the claim i.e. from 23/07/2007. The Complainant ought to have filed this complaint on or before 23/07/2009. Delay of about 6 months is caused in filing of this complaint. The Complainant has not filed an application for condonation of delay alongwith complaint. As per the provision of Sec.24(A) of the Consumer Protection Act, 1986, complaint is required to be filed within period of 2 years from the date of cause of action. Present complaint is not filed within 2 years from the date of cause of action, so we hold that complaint is barred by law of limitation. Therefore, we answer point no.1 in the affirmative.
Point No.2 :- As the complaint is barred by law of limitation. The Complainant is not entitled to recover any amount or for any other relief from the Opposite Party. Hence, point no.2 is answer in the negative.
For the reasons discussed above the complaint is liable to be dismissed. Hence, we pass following order -
O R D E R
i.Complaint No.18/2010 is dismissed with no order as to cost.
ii.Certified copies of this order be furnished to the parties.
