By. Smt. Renimol Mathew, Member:
The complaint is filed under section 12 of the Consumer Protection Act against the opposite party to get the balance claim amount as per policy No. P/18315/01/2016/000202.
2. Brief of the complaint:- The complainant is the policy holder of opposite party's Family Health Optima Insurance Policy covering two persons for the period from 26.04.2014 to 25.04.2015 and renewed the same for the period up to 25.04.2016 as per policy No.P/18315/01/2016/000202 for a sum insured of Rs.3 lakh. In claim No.286254, the complainant was admitted at Leo metro Hospital(Wayanad) on 12.03.2015 and was diagnosed with Recent anterior wall MI,CAG and COPD for which he underwent angioplasty and discharged on 16.03.2015. On discharge from Hospital, the complainant had submitted all the relevant claim documents, claiming reimbursement for the hospitalization expenses incurred by him but after processing the claim the opposite parties had given only Rs.86,000/- to the complainant. As per the bills complainant is entitled to get Rs.1,76,350/-. Hence filed this complaint alleging deficiency of service from the part of opposite party and to get reimbursement of the balance amount of Rs.90,350/-.
3. On receipt of Notice, opposite party appeared before the Forum and version filed. In the version opposite party stated that the complaint is not maintainable before this Forum. In this case complainant was diagnosed with Recent anterior wall MI, CAG and CODD for which he underwent angioplasty. In this case the complainant has accepted settlement of the claim by signing the discharge voucher without any protest. Once petitioner has received the amount unconditionally and has also got the cheque encashed, petitioner ceases to be a consumer as per Consumer Protection Act, 1986. Privity of contract between parties, if any, came to an end the moment the petitioner accepted the claim payment unconditionally and also got the cheque encashed. There is Malafide intention on the part of the complainant to file such a complaint before the Forum. It is a settled position of law as observed in M.L. Spinners Pvt Ltd Vs. United India Insurance Co Ltd by the Honorable National Commission. By considering the above facts, this complaint is not maintainable before this honorable forum as the complainant is not a consumer within the meaning of Consumer protection Act, 1986. On discharge from Hospital, the complainant had submitted all the relevant claims documents, claiming reimbursement for the hospitalization expenses incurred by him. After processing the documents, this Opposite Party had offered settlement of the claim for an amount of Rs.86,000/- as per the terms and conditions of policy. The complainant had accepted the offer of settlement and accordingly this Opposite Party had settled the claim vide Cheque No.397473 dated 06.08.2015 in full and final settlement of the claims. The complainant accepted the amount as full & final settlement on 22.08.2015 without any protest & signed the discharge voucher also and the cheque was encashed on 26.08.2015. No objections has been raised by the complainant to the opposite party with regard to the payment till this date. It is submitted that there is no deficiency in service as alleged by the complainant in his complaint as the complainant has accepted the amount as full & final settlement. Further opposite party stated that there is no deficiency of service from their part and hence prayed to dismiss the complaint.
4. Complainant filed chief affidavit and examined as PW1. Ext.X1 series document were marked to prove his case. Ext.X1 series are the claim document, hospital records and hospital bills produced by opposite party as per the order in I.A.508/2015. Complainant alleged that altogether he had spent Rs.1,76,350/- as expenses for the treatments at Leo Metro Hospital, Kalpetta. On receipt of the claim request opposite party sanctioned only Rs.86,000/-. Hence filed this complaint to get the balance amount from the opposite party.
5. Opposite party adduced evidence as OPW1 and Ext.B1 to B4 documents were marked to oppose their case. Ext.B1 is the Authorization Letter. Ext.B2 is the copy of Family Health Optima Insurance Plan. Ext.B3 is the Claim Forum. Ext.B4 is the copy of Discharge Voucher. Opposite party objected the complaint stating that on receipt of the claim request opposite party had offered settlement of the claim for an amount of Rs.86,000/- as per the terms and conditions of the policy. The complainant had accepted the offer and received the amount as full and final settlement on 22.08.2015 without any protest and signed the discharge voucher also and the cheque was encashed on 26.08.2015. No objections has been raised by the complainant to the opposite party with regard to the payment till this date. It is submitted by opposite party that there is no deficiency in service on the part of them as alleged by the complainant.
6. On perusal of complaint, version and documents the Forum raised the following points for consideration:-
1. Whether there is any deficiency of service from the part of opposite party?
2. Relief and Cost.
7. Point No.1:- In this case complainant was admitted at Leo Metro Hospital Wayanad on 12.03.2015 and was diagnosed with Recent anterior wall MI, CAG and COPD for which he underwent angioplasty. On discharge he submitted claim form, after processing the claim amount of Rs.86,000/- was offered as full and final settlement of the claim. The complainant had accepted the offer of settlement and accordingly opposite party had settled the claim vide cheque No.397473 dated 06.08.2015 in full and final settlement of the claim. The complainant accepted the amount without any protest and signed the discharge voucher and cheque was encashed on 26.08.2015.
8. Complainant's counsel argued relaying on the findings reported in AIR(SCW) 2008-0-1905, SC-2008-2-173 that “mere execution of the discharge voucher and acceptance of the insurance claim would not estop the insured from making further claim from the insurer”. On going through this citation we found that the circumstances are different in both the cases. In this case Honorable Supreme Court observed that “there is no dispute that the discharge voucher had been signed by the complainant. There has to be an adjudication as to whether the discharge voucher was signed voluntarily or under coercion. Hence remit the matter to the District Forum for fresh consideration”. In the above said matter, immediately after the so called settlement was arrived at grievance was lodged with the authority stating that settlement was not free and fair. In the instant matter complainant accepted an amount of Rs.86,000/- as full and final settlement of the claim. In case he was not satisfied with the amount offered by the opposite party he ought not to have accepted the aforesaid payment or he could have at best accepted the said payment under protest and as part payment. There is no such endorsement on the discharge voucher. Moreover no notice/letter was sent by the complainant to the insurance company soon after the receiving of the aforesaid payment of Rs.86,000/- claiming that he had accepted the aforesaid amount only as a part payment and not in full and final settlement of his claim under policy.
9. On perusal of Ext.B4 we finds that the complainant accepted Rs.86,000/- as full and final settlement of the claim without any protest. Since Ext.B4 document is not objected by the complainant till the date of complaint. Complainant is estopped from making any further demand against insurance company after accepting amount voluntarily in full an final settlement of the claim. In RP No.3637 of 2014 reported in 2015 (1) CPR 102(NC), Honorable National Commission held that “Complainant is estopped from making any further demand against insurance company after accepting amount voluntarily in full an final settlement of the claim”. More over in this case, the complainant never alleged and no pleadings to the effect that there is any undue influence, fraud, misrepresentation or coercion in the complaint and in affidavit in accepting the cheque as full and final settlement.
10. On going through the evidences, documents and submissions we are of the opinion that in case he has not satisfied with the amount offered by the company, he ought not to have accept the payment or he could have accept the payment under protest as part payment. However there is no such endorsement on Ext.B4 and we cannot accept the allegation that the aforesaid payment was accepted by the complainant as a part payment. Hence we are of the opinion that there is no deficiency of service from the part of opposite party. Point No.1 is found accordingly.
7. Point No.2:- Since the Point No.1 is found in favour of opposite party, there is no Order as to cost and compensation.
In the result, the complaint is dismissed. No Order as to cost and compensation.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 8th day of April 2016.
Date of Filing:11.09.2015.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
/True Copy/
Sd/-
PRESIDENT, CDRF, WAYANAD.
APPENDIX.
Witness for the complainant:-
PW1. Ealias. Complainant.
Witness for the Opposite Party:-
OPW1. Mrudula. Executive, Legal , Star Health and Allied
Insurance Co Ltd.
Exhibits for the complainant:
X1 series. Claim Document, hospital records and hospital Bills.
Exhibits for the opposite party:-
B1. Authorization Letter. Dt:04.01.2016.
B2. Copy of Family Health Optima Insurance Plan.
B3. Claim Form.
B4. Discharge Voucher.
Sd/-
PRESIDENT, CDRF, WAYANAD.
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