This Complaint coming up before us for hearing on 17-03-11 in the presence of Sri C. Satyanarayana, advocate for the complainant and of Sri G. Srinivasu, advocate for OP, upon perusing the material on record, upon hearing both sides and having stood over till this day for consideration this Forum made the following:-

O R D E R

Per Sri A. Hazarath Rao, President:-

        The complainant filed this complaint U/S 12 of Consumer Protection Act, 1986 seeking payment of Rs.50,000/- being the balance claim and a sum of Rs.50,000/- as damages for mental agony and costs of the complaint.

        2.    In brief the averments of the complaint are these:

        The complainant insured his family members took the                 mediclaim policy bearing No.620902/34/08/7/00000079 covering himself, his wife, daughters and mother.   Originally the complainant insured the medical claim of his mother and daughters for RS.50,000/-and later enhanced further by another sum of Rs.50,000/- for his mother and daughters.   The complainant paid Rs.8798/- in all on 11-08-08.   The said policy was in force from 13-08-02 to 12-08-09.  While so, mother of the complainant namely Lakshmi Tulasamma went bypass surgery on 05-05-09 in Star hospitals, Hyderabad.   The complainant incurred Rs.2,00,000/- towards medical expenses of his mother.   The complainant submitted all bills to the opposite party.   The complainant was shocked to receive a cheque for Rs.50,000/- stating as towards full and final settlement. Having received the premium for Rs.1,00,000/- the opposite party failed to fulfill the service and it amounted to deficiency of service. For the legal notice dated                      09-10-09 the opposite party kept quite.  The complaint therefore be allowed.  

3.    The contention of the opposite party in brief is hereunder:

          The complaint is guilty of suppression of material facts.   The complaint is barred by time.   The complainant took mediclaim policy for himself and his family members.   Initially the sum assured by the complainant for his mother was Rs.50,000/-.   In the subsequent policy the sum insured was enhanced to Rs.1,00,000/-.  After receiving the claim the opposite party submitted claim forms to 3^rd party administrator i.e, Heritage Health Services Private Limited to process the claim.  The said administrator issued a cheque for Rs.50,000/- in full and final settlement of the claim.    The 3^rd party administrator came to a conclusion that symptoms started when the 1^st policy for RS.50,000/- was in force and i.e, why it issued cheque for RS.50,000/- towards full and final settlement of the claim.  Thus the opposite party did not commit any deficiency of service.  The complaint therefore be dismissed. 

4.     Exs.A-1 to A-6 on behalf of the complainant were marked.    No documents were marked on behalf of the opposite party.  

5.      Now the points that arose for consideration are:

1. Whether the opposite party committed deficiency of service?
2. Whether the complainant is entitled to any damages and if so to what amount?
3. To what relief?

6.     Admitted facts in this case are these:

1. The complainant took mediclaim policy for himself and his family members inclusive of his mother.
2. The sum insured for complainant’s mother was Rs.1,00,000/-
3. The policy was in force when complainant’s mother was hospitalized.
4. The complainant submitted claim form along with bills.
5. The opposite party sent the claim form submitted by the complainant to 3^rd party administrator.
6. The 3^rd party administrator settled the claim of the complainant for Rs.50,000/-.
7. The complainant encashed the cheque for Rs.50,000/- which was sent by 3^rd party administrator.

7.     POINTS.1&2:-      The relevant document in this case is Ex.A-6 i.e., voucher dated 08-04-09 coupled with the letter dated 09-04-09.         In the voucher it was mentioned that the said amount of Rs.50,000/- was towards full and final settlement.   In the accompanying letter it was mentioned “encashment of enclosed cheque shall mean your acceptance of full and final payment against above claim and your agreeing to subrogate both us and the insurer for further claims and/or liabilities relating thereto”. 

8.     In Oriental Insurance Company Limited vs. Vallabhbhai Naranbhai Dobaria (2011) CTJ 344) it was held that mere execution of discharge voucher and acceptance of insurance claim would not stop insured from making further claim from the insurer under the circumstances which can be termed as exercise of undue influence or coercion or the like.   

9.     In Oriental Insurance Company Limited vs Government Tool Room and Training Centre, (I 2008 CPJ 2667 (SC) it was held that it is a wrong practice followed by insurance companies in not paying single pie without having discharge voucher, it is a coercive bargaining as insured has no option to sign the discharge voucher, mere execution of discharge voucher and acceptance of insurance claim will not stop the insured from making further claim.  

10.   The same view has been reaffirmed by the National Commission in National Insurance Company Limited vs. Vasavi Traders (2008 (I) CPJ 487) and SM Herbals Limited vs. New India Assurance Company Limited (2009 (4) CPJ 50 NC).

11.   The recitals of Ex.A-6 voucher and letter as extracted above clearly indicate that the opposite party was coercing or playing undue influence on the complainant to accept the sum of Rs.50,000/- towards full and final settlement of claim.   Under those circumstances, it can be said that the complainant accepted the amount of Rs.50,000/- as had no other option and preferred this claim.  

12.   Having given the mediclaim policy for Rs.1,00,000/- for complainant’s mother it is not open to the opposite party  to reduce the claim contending that she suffered ill health between the 1^st policy and its renewal.  The opposite party for the reasons best known to it did not file the order of the 3^rd party arbitrator into Forum.   Reducing the claim by Rs.50,000/- having accepted the policy in our considered opinion amounted to deficiency of service.    Awarding interest on the remaining sum of Rs.50,000/- from 08-04-09 will meet ends of justice.

13.   Reduction of claim amount by opposite party certainly might have caused mental agony and harassment to the complainant.    Awarding a sum of Rs.5,000/- on this count will meet ends of justice.  In view of the aforementioned discussions these points are answered accordingly in favour of the complainant.

14.     The 3^rd party administrator settled the claim of the complainant at Rs.50,000/- on 08-04-09.   The complainants filed this complaint on 07-01-10.  Therefore the contention of the opposite party regarding limitation is devoid of merit.  

15.   POINT No.3:-    In view of above findings, in the result, the complaint is allowed partly as indicated below:

1. The opposite party is directed to pay RS.50,000/- being the balance of insured amount together with interest @9% pa., from 08-04-09 till payment.
2. The opposite party is directed to pay a sum of Rs.5,000/- towards deficiency of service and Rs.1,000/- towards costs.
3. The amounts ordered above shall be paid within a period of six weeks from the date of receipt of the copy of the order.

        Typed to my dictation by Junior Steno, corrected by me and pronounced in the open Forum dated this the 29th day of              March, 2011.

MEMBER                                             MEMBER                                             PRESIDENT

APPENDIX OF EVIDENCE

DOCUMENTS MARKED

For Complainant:

For opposite party :   NIL

                                                                                           PRESIDENT