PER SHRI. G.H. RATHOD – HON’BLE  MEMBER 

1)        By this complaint the Complainant has prayed to direct the Opposite Parties to pay Rs.1,06,723/- with interest @ 18% p.a. till the actual payment.  The Complainant also prayed to direct the Opposite Parties to pay the lumpsum compensation of Rs.50,000/- for the failure of service, for the loss & injury caused and for mental agony.  It is further prayed that an amount of Rs.10,000/- be granted towards the cost of this proceedings. 

2)        According to the Complainant, he had taken Mediclaim Insurance Policy from the Opposite Party No.1 bearing No.121700/48/2012/2297 and had paid premium of Rs.25,034/- for the period from 20/06/2011 to midnight of 19/06/2012 for the total Mediclaim insurance of Rs.5,00,000/-.  Copy of the policy is at Exh.‘A’ and copy of receipt of premium is at Exh.‘B’. 

                It is submitted that Opposite Party No.1 is Insurance Company incorporated under the Companies Act 1956 and the Opposite Party No.2 is the Authorized TPA  who is entertaining and the paying the claim of the insurer.  The Complainant is customer and consumer of the Opposite Party No.1 as per the Consumer Protection Act, 1986. 

3)        According to the Complainant, he had suffered an Heart Attack on 17/05/2011 and as per the advice of doctor he was admitted in M/s. CritiCare Multi Specialty Hospital, Andheri (W) and the Complainant informed to the Opposite Parties. The doctor of this hospital carried out at the tests required before performing the treatment of Angioplasty and have performed Angiography & as well as Angioplasty medical treatment then after the Complainant receiving the successful treatment he was discharged from the hospital on 20/05/2011 and he has paid total medical bills of Rs.3,96,124/- towards the hospital charges, medical bills and other charges charged by the said hospital.  Copy of the bill is at Exh.‘C’. 

4)        It is alleged that the Complainant had submitted his claim of Rs.3,96,124/- alongwith with the bill of hospital to Opposite Party No.2 out of which the Opposite Party No.2 an amount of Rs.2,89,401/- was sanctioned and on 15/06/2011 forwarded cheque of HDFC Bank dtd.14/06/2011 alongwith their settlement voucher. The Opposite Party No.2 has deducted the amount of Rs.1,06,723/- from the claim amount claimed by the Complainant (Copy of cheque & claim settlement voucher is at page 20 & 21).

5)        It is submitted that the Complainant has received short payment of Rs.1,06,723/- by way of illegal & arbitrary deduction by the Opposite Party No.2.  Then the Complainant through his advocate issued notice for payment and recovery of the deduction made by the Opposite Party No.2. Copy of notice is at Exh.‘E’.   Opposite Party  No.1 informed to the Complainant that the amount deducted & settled by the Opposite Party No.2 is justifiable & appropriate.  The Complainant therefore, prayed that the claim made in the complaint as referred in para 1 of this order may be granted.  

6)        Notice served on Opposite Party No.1 & 2.  The Opposite Party No.2 not appeared before this Forum even though notice served.  The complaint therefore, proceeded against Opposite Party No.2 as ex-parte.  The Opposite Party No.1 though appeared through their advocate has failed to filed their written statement, the complaint therefore, proceeded without statement of Opposite Party No.1.    

7)        The Complainant filed his affidavit of evidence, he also filed written argument.  The Opposite Party No.1 & 2 not filed their written statement as well as written argument.

            We heard the argument of Ld.Advocate Shri. S.G. Mendon on behalf of Complainant.  The Opposite Party No.1 remained absent though served with notice.  Upon going through the settlement voucher dtd.15/06/2011 placed on record by the Complainant, it appears that the Opposite Party No.2 has specifically given the detail reasons as to why the amount of Rs.1,06,723/- has been deducted.  And as per the policy condition No.5.7 it is clearly mentioned that if any grievances about settlement voucher then the Complainant can make the appeal with Insurance Company.  But in this case the Complainant enchased the said cheque and not made any appeal before the Insurance Company after receipt of cheque of Rs.2,89,401/-  with settlement voucher.  The Complainant has not produced any record whatever deductions which are mentioned in the claim settlement voucher dtd.15/06/2011 are against the terms and condition of policy. Furthermore, from the copy of notice produced by the Complainant at Exh.‘E’ it appears that the Complainant had raised the objection and disagreement about the settlement made by Opposite Party No.2 on or about 16/12/2011 i.e. more than 6 months from the letter dtd.15/06/2011 issued by the Opposite Party No.2 regarding the claim settlement voucher.  The Complainant has not produced any material other than legal notice dtd.16/12/2011 to support pleas of protest.  In the notice issued by the Complainant dtd.16/12/2011 there are no averment that amount was accepted under protest.  Furthermore, there is no explanation for delay of 10 months in filing complaint which had been filed on 16/04/2012.  Sleeping over for six months  after  accepting money from Insurance Company  shows  that  the claim made in the complaint is an after thought and amounts to quantum dispute and not a consumer dispute.  The facts alleged in the complaint are identical to the case of M/s. Arora Knitting Industries Pvt. Ltd. V/s. United India Insurance Co. Ltd., reported in 2003 (I) CPR 72 (NC). The similar view is also recorded by the Hon’ble Maharashtra State Commission in the case of Dhaniram Sunderlal V/s. Oriental Insurance Co. Ltd., 2005(I) CPR 236.  It is also pertinent to note that in settlement claim voucher issued by the Opposite Party No.2 it was specifically mentioned that –

“Encashment of cheque shall discharge the liability of Insurer under the said claim.  Any disagreement about the settlement shall be intimated to us within 10 days otherwise the same shall be deemed as your acceptance and would final of the said claim.” 

Considering these observations we hold that as the Complainant did not raise any protest within 10 days as suggested  by the Opposite Party No.2 and as such no further claim is maintainable against the Opposite Parties.  We therefore, hold that the Complainant has failed to prove that the Opposite Party No.2 have wrongly deducted the amounts by mentioning the reasons for such deductions in the claim settlement voucher and same are contrary to the terms and conditions of the policy issued by Opposite Party No.1 and encashment of cheque shall discharge the liability of insurer and the said claim. We thus, hold that the Complainant has failed to prove his entitlement on the basis of the terms of the policy as well as he had intimated his disagreement after six months i.e. on 16/12/2011, thus, claim made in the complaint cannot be granted.  In the result the following order is passed -   

O R D E R 

i.                    Complaint No.77/2012 is dismissed with no order as to cost.   

ii.                 Certified copies of this order be furnished to the parties.