Anil Gupta complainant has filed the present complaint against the titled opposite parties U/S 12 of the Consumer Protection Act, 1986 (hereinafter for short, the C.P.Act.) in which he has prayed that the opposite parties be directed to make the reimbursement amount of Rs.2,45,300/- with interest @ 18% Per Annum from the date of due till its actual realization in his favour alongwith compensation and litigation expenses, in the interest of justice.   

2.       The case of the complainant in brief is that he alongwith his family members have got themselves insured with the opposite parties under the Group Medi Claim Insurance Cover from 30.11.2013 to 29.11.2014 for which a premium of Rs.17,412/- including Service Tax of Rs.2152/- i.e. total amount of Rs.19,564/- was paid. He is taking the said Policy since the year 2009 regularly. Under this policy, the insurance company undertook to reimburse medical expenses incurred in respect of the medical treatment which insurers may have to undergo during the validity of the policy. His sum insured was Rs.3,00,000/- + Rs.30,000/- as CB amount. He has further pleaded that on 14.12.2013 he suffered with chest pain and then he contacted Shri Ram Cardiac Centre, Joshi Hospital, Jalandhar and after investigation the concerned Doctor advised Coronary Angiography which he underwent on 24.12.2013 at Jalandhar, that revealed Double Vessel Disease. He was admitted in Fortis Hospital, Mohali where he underwent PTCA +Stunt to LAD on 27.12.2013. He discharged from the abovesaid hospital on 29.12.2013 and he spent Rs.3,88,317/- for his treatment in the abovesaid hospital. Thereafter, he completed all the requisite formalities and relevant medical bills submitted to the opposite parties for the settlement of the claim as per the Policy on 1.1.2014 and then the opposite parties started that reimbursement of medical bills would be made within two/three weeks but after about more than 2 months i.e. on 13.3.2014 an amount of Rs.73,700/- was reimbursed to him, whereas his sum assured was Rs.3,00,000/- + Rs.30,000/- as CB. He has next pleaded that the opposite parties had paid only a sum of Rs.84,700/- (Rs.11,000/- for Angiography + Rs.73,700/-) to him. But on the contrary, he was entitled to the amount of Rs.3,30,000/- i.e. sum assured of the policy. However, he has paid Rs.3,88,317/- to the Hospital authorities for his treatment. The opposite parties have failed to pay the amount of Rs.2,45,300/- to him after deduction of Rs.84,700/- from the sum assured i.e. Rs.3,30,000/- to which the opposite parties are legally bound to repay the same to him.  He visited the office of the opposite party no.1 for so many times and requested them to make the reimbursement of the balanced amount but the opposite parties failed to redress his grievances. Due to this act and conduct of the opposite parties, he has suffered mental, physical harassment and also suffered monetary loss.  Hence, the present complaint was preferred with the prayed relief as herein above.

3.       Upon notice the opposite party no.1 appeared and filed its written reply through its counsel by taking the preliminary objections that complaint is not maintainable; the complainant has failed to set out any deficiency in service or unfair trade practice on the part of the opposite party; the complainant has clear cut violated the terms and conditions of the insurance policy and as such the complainant is not entitled to any relief. That the complainant had concealed the material facts from the Hon’ble Forum and moreover the claim of the complainant had been settled as per the terms and conditions of the insurance policy and the payment in respect of the claim of the complainant has been made as per the terms and conditions of the insurance policy; the complainant is estopped by his act and conduct from filing this present complaint and the opposite parties have already paid the amount legible as per the terms and conditions of the insurance policy and moreover the said amount has already been received by the complainant and now if there is any dispute in respect of the amount of the claim that can only be adjudicated by the Civil Court as the latter requires detailed evidence and as such the matter in dispute is beyond the scope jurisdiction of the Hon’ble Forum and the complainant has filed a false, frivolous and infractuous complaint without any merits and as such the complainant is not entitled to any claim. On merits, it was admitted that complainant had got insured with opposite party. It was further submitted that the opposite party have no knowledge as to the fact that on 14.12.2013 the complainant suffered with chest pain and it is also matter of record and complaint be put on strict proof of the facts as alleged by him.  It was denied that the complainant had never suffered from any medical problem relating to his heart or any other critical disease. As a matter of fact as per the records available the patient suffered from HTN and DM since five years. It was next submitted that the claim of the complainant has been settled and payable as per the terms and conditions of the insurance policy. The opposite party had already paid the legible amount to the complainant as per the terms and conditions of the policy. Other averments made in the complaint have been denied. Lastly, the complaint has been prayed to be dismissed.

4.       Counsel for the complainant tendered into evidence affidavit of complainant Ex.C1 along with other documents Ex.C2 to ExC8 and closed the evidence. 

5.       Counsel for the opposite party no.1 tendered into evidence affidavit of Tarsem Lal Sr. Divisional Manager N.I.C. Ex.OP1/1 alongwith copy of National Mediclaim Policy Ex.OP-1/2 and closed the evidence.

6.     Notice of the complaint was issued to the opposite party no.2 but they did not appear in the Forum despite service, therefore, it was proceeded against exparte vide order dated: 3.6.2014.

7.       We have carefully gone through the pleadings of the parties; arguments advanced by their respective counsels and have also appreciated the evidence produced on record with the valuable assistance of the learned counsels for the purpose of adjudication of the present complaint.

8.      From the pleadings and evidence on record we observe with the judicial precision that the OP1 insurers have apparently settled the med-insurance claim with the Policy SI (Sum Insured) determined at an amount of Rs.1.0 Lac (paragraph ‘5’ of the written reply) in terms of printed Policy Clause pertaining to ‘waiting period’ applicable to ‘enhanced SI’ (page ‘2’ of Ex.C2) read as: “For increasing SI the waiting periods as in exclusions 4.1/ 4.2/ 4.3 of the Policy shall apply on the enhanced SI as if it is ‘new-policy’. The benefit shall accrue for PED or waiting period diseases once the policy with enhanced SI completes the waiting period noted in the policy for these diseases.” Thus, we find that the OP1 insurers have settled the impugned claim in terms of the ‘settled’ and mutually accepted terms of the related Policy and the complainants have somehow not ‘categorically’ contested the same on this very count and that amounts to the judicial presumption of ‘passive acceptance’. Moreover, the award amount of the settled claim has also been duly accepted (sans any protest) by the ‘complainant’ and that terminates the ‘consumer’ relationship under the Act; imparting the ‘hue’ of ‘after-thought’ to the very complaint and depriving it of the litigable merit.  

9.       In the light of the all above, we do not find any worthwhile legal ‘merit’ in the present complaint under the Act and thus ORDER for its dismissal with however no orders as to its costs.

10.     Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.

               (Naveen Puri)

                                                                                  President

ANNOUNCED:                                                 (Jagdeep Kaur)

May 12,2015.                                                              Member

*MK*