Haryana

Yamunanagar

CC/872/2013

Ajesh Geol S/o .F.C.goel - Complainant(s)

Versus

OIC Ltd. - Opp.Party(s)

Sanjay Dhiman

28 Sep 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA   NAGAR AT JAGADHRI.

                                                          Complaint No.872 of 2013.

                                                          Date of Institution:28.11.2013.

                                                          Date of decision:28.9.2017.

 

Ajesh Goel son of Shri FC Goel resident of B-II, 897, Behind Laxmi Talkies, Yamuna Nagar, District Yamuna Nagar age 48 years.

                                                                                      …Complainant.

                             Versus

1.       The Oriental Insurance Co. Ltd. branch office: opp. Hindu Girls College, Court Road, Jagadhri, through its Branch Manager.

2.       M/s Genius India Ltd. Building No.1736/1, Opposite Hari Palace Road, Ambala City, District Ambala through its Branch Manager.

3.       Vipul Medcorp TPA Private Limited 515, Udyog Vihar, Phase-V, Gurgaon, Haryana PIN 122016 through its Branch Manager.

                                                                                      … Respondents.

 

BEFORE:   SH.SATPAL, PRESIDENT.

SH.S.C.SHARMA, MEMBER.       

                   SMT. VEENA RANI SHEOKAND, MEMBER.

 

Present: Sh. Sanjay Dhiman, Advocate, counsel for complainant.   

               Sh.Sushil Garg, Advocate, counsel for OP No.1.

               OP No.2 given up.

               OP No.3 ex parte.

 

ORDER: (SATPAL, PRESIDENT)

                            

1.                Complainant has filed this complaint Under Section 12 of the Consumer Protection Act 1986 against the respondents (hereinafter the respondents shall be referred as OPs).

2.                Brief facts of present complaint as alleged by the complainant are that the complainant had purchased a Family Health Insurance Policy (Medi-claim policy) from OP No.1 for himself and his family consisting his wife Smt. Ritu Goel, sons Rishi Goel and Aniket Goel, after payment of premium.  The policy No.261701/48/2009/774, having Cover note No.260000623271 was valid w.e.f.3.9.2008 to 2.9.2009.  During the currency of the policy, the wife of the complainant namely Smt.Ritu Goel who was covered under the above said policy suffered some gynecologic related disease and to get treatment of gynecologic related disease i.e. Post LAVH Vesico Veginal Fistula (VVF).  Smt. Ritu Goel got treatment from S.P.Infirtility and Surgical Centre Pvt. Ltd. And later she got treatment from Medanta Global Health Pvt. Ltd. Gurgaon and Robotic surgery (computer assisted surgery developed to overcome the limitation of minimally-invasive surgery and to enhance the capabilities of surgeons performing open surgery), the said surgery was very much required in the case of Smt.Ritu Goel due to severity of disease suffered by Smt. Ritu Goel.  The complainant spent more than Rs.6,50,000/- on the treatment and the wife of the complainant remained admitted getting treatment.  After treatment, the complainant lodged his claim through Op No.3 to Op No.1 and completed all the requisite formalities along with all the relevant documents and bills to entire satisfaction of the Ops.  But it was very appalling and astonishing for the complainant that instead of admitting the claim of the complainant in whole, the Op No.1 admitted the claim of the complainant only for an amount of Rs.1,20,104/- instead of admitting the same in whole and the said amount was paid by the Ops through cheque and the same was received by the complainant under protest.  Thereafter, the complainant feeling aggrieved lodged his complaint in respect of the less payment of the claim amount to the complainant and communicated the Ops repeatedly.  There is deficiency in service on the part of the Ops and prayed for acceptance of complaint by directing the Ops to pay balance insured amount Rs.80,000/- under the afore said policy and Rs.100,000/- as compensation for mental agony, harassment and Rs.5,000/- as cost of litigation.

2.                Upon notice the Op No.1 appeared and filed written statement by taking some preliminary objections that there is no deficiency in service on the part of the answering OP as the answering OP settled the claim amount pertaining to the Medi-claim policy, in strict terms, rightly and legally as admissible and permissible as per the conditions of the policy in question and paid an amount of Rs.1,20,104/- being the full and final settlement amount to the complainant, hence, the present complaint is not maintainable; the complainant has no cause of action to file the present complaint; the complainant has no locus standi to file the present complaint; the complaint is false and frivolous and baseless; this Hon’ble Forum has got no jurisdiction to entertain and decide the present complaint.  On merits, the Ops have controverted the pleas taken by the complainant and reiterated the stand taken in the preliminary objections.  There is no deficiency in service on the part of the answering OP and prayed for dismissal of complaint. 

4.                The counsel for the complainant has given up the OP No.2 being un-necessary party by making a statement and accordingly, OP No.2 was given up being un-necessary party vide order dated 9.2.2015.

5.                The OP No.3 was proceeded against ex parte vide order dated 15.4.2014.

6.                To prove his case the complainant tendered into evidence his own affidavit as annexure CW/A, documents such as copy of policy as annexure C.1, copy of individual mediclaim as annexure C.2, copy of individual mediclaim policy schedule as annexure C.3, copy of policy as annexure C.4 & C.5, copy of discharge voucher as annexure C.6 and closed the evidence on behalf of complainant.

7.                On the other hand, the learned counsel for the OP tendered into evidence affidavit of Sh. Abhas Toppo as annexure R-1/A, documents such as copy of discharge summary as annexure R.1/1, copy of hospital bill as annexure R.1/2, copy of claim form as annexure R.1/3, copy of letter dated 22.12.2012 as annexure R.1/4, copy of letter dated 18.9.2014 as annexure R.1/5, copy of individual claim policy schedule as annexure R.1/6 and closed the evidence on behalf of the OP.

5.                We have heard the learned counsel for the parties and gone through the pleadings as well as documents placed on the file.  The learned counsel for the complainant reiterated the stand taken in the complaint and draw the attention of this Forum towards authority 2016(2) CPR P.736 (NC) titled as National Insurance company Ltd. Vs. Mukundan Raman, wherein it has been held that, “Although hypertension falls within exclusion clause but coronary syndrome evolving anterior MI which led to PTCA to LAD and to ram us is not detailed in list of disease given in clause 4.3-By strict application of insurance contract expenses incurred on that disease by complainant are covered under insurance policy-repudiation of insurance claim was not justified-Finding of Fora below upheld-Revision petition dismissed.  Lastly prayed for dismissal of complaint.

6.                On the other hand the learned counsel for the Op No.1 reiterated the stand taken in the written statement and draw the attention of this Forum towards authority II(2013) CPJ P.386 (NC) titled as A.P.Jos vs.ICICI Lombard General Insurance Company Ltd. wherein it has been held that, “Insurance-Full and final settlement-Cheque accepted without protest-Alleged deficiency in service-Consumer-District Forum dismissed complaint-State Commission dismissed appeal-Hence revision-Once Petitioner has received the amount unconditionally and has also got the cheque encashed, petitioner ceases to be consumer-Privity of contract or relationship of consumer and service provider came to an end-Mala fide intention on part of petitioner in filing complaint-Compliant not maintainable”.  Lastly prayed for dismissal of complaint.

7.                After hearing the learned counsel for the complainant as well as Op No.1 and going through the pleadings as well as documents placed on the file, it is clear that the complainant purchased the Family Health Insurance Policy bearing No.261701/48/2009/774 w.e.f. 3.9.2008 to 2.9.2009.  This fact is also clear that the wife of the complainant got the treatment of gynecologic related disease about which the complainant alleged that he had spent Rs.6,50,000/- on her treatment.  This fact is also admitted that the claim was lodged with the OP, which was processed and the OP No.1 had passed the claim of the complainant to the tune of Rs.1,20,104/- and the Op No.1 paid the said amount vide discharge voucher dated 14.2.2013.  The only point of controversy to be decided is whether the complainant is entitled for the remaining claim amount of Rs.80,000/- or not? The complainant has accepted the payment of Rs.1,20,104/- as full and final payment as is clear from the perusal of Discharge Voucher dated 14.2.2013 (Annexure C.6), which bears the signature of the complainant along with his account number name of the bank and IFSC code of the bank.  The plea of the complainant that he accepted the payment under protest is not tenable because the aforementioned discharge voucher does not contain any such kind of remarks of the complainant.  Further, it is not the case of the complainant that he accepted the said payment as full and final as a result of any fraudulent act, coercion or mis-reorientation on the part of the Ops.  Moreover, there is no document on the record to show that the complainant was compelled by the Op at any stage to settle the claim at lesser amount than the claim made by him.  There is also not even an iota of evidence on the file to show that any official of the Op at any stage compelled the complainant to settle the claim at lesser amount.  It means that the complainant accepted the payment of Rs.1,20,104/- as full and final settlement out of his free will and consent.  The law laid down by the Hon’ble National Commission as referred by the counsel for the OP is fully applicable to the facts and circumstances of the present case.   However, the authority (supra) referred by the complainant is not disputed but not identical to the facts and circumstances of the case in hand.

8.                In view of the above discussion, we are of the considered view that the complainant is not entitled for any relief.

9.                Resultantly, we find no merits in the complaint of the complainant, hence, the same is hereby dismissed with no order as to costs.  Copies of this order be sent to the parties concerned free of costs as per rules. File be consigned to the record room after due compliance.

Announced in open court.28.9.2017.        

                                                                             (SATPAL)

                                                                             PRESIDENT,

                                                                                               

       (VEENA RANI SHEOKAND)                  (S.C. Sharma)

        MEMBER                                                   MEMBER.