Dt. of filing- 06/02/2018
Dt. of Judgement- 11/09/2019
Mrs. Sashi Kala Basu, Hon’ble President.
This complaint is filed by the complainant namely Mukta Jain and Tikshan Jain under Section 12 of the Consumer Protection Act against the Opposite Parties namely (1) New India Assurance Company Ltd. (2) & (3) M.D. India Health Services (TPA) Pvt. Ltd. alleging deficiency in services on the part of the Opposite Parties.
Complainants’ case in short is that they were covered under a Mediclaim Policy being No.51010034172500000977 issued by OP Insurance Company against payment of appropriate premium. The insurance policy covered the insured for the period from 18.06.2017 to 17.06.2018. Total sum insured was Rs. 8,00,000/- each and cumulative bonus Rs. 1,30,000/- and Rs. 1,15,000/- respectively. Complainant namely Tikshan Jain aged about 12 years underwent a “Tonsillo-adenoidectomy” surgery under general anaesthesia on 28.06.2017 at Apollo Spectra Hospital. So, said complainant/insured lodged claim of Rs. 1,81,047/- with the insurance company /OP No.1. But insurance company through the OP No.2 & 3 settled the claim at Rs. 56,117/- and forwarded a claims payment statement to the complainant. OP thus has arbitrarily and malafidely deducted a sum of Rs. 1,24,930/-. So, being aggrieved and dissatisfied with the said arbitrary act of the OP, complainant Mukta Jain sent a letter dated 16.08.2017 demanding entire payment but the OP No.1 replied on 10.10.2017 refusing to pay the deducted amount. So ultimately, present complaint has been filed by the complainant praying for directing the OP to pay balance amount due to the principal claim of Rs.1,81,047/- , to pay compensation of Rs.25,000/- and Rs. 25, 000/- as litigation cost.
Complainant has annexed with the complaint petition, copy of the insurance policy, copy of the discharge summary issued by Apollo Spectra Hospital, copy of the claims payment statement, copy of the notice sent by the complainant Mukta Jain on 16.08.2017 to the OP and the reply dated 10.10.2017 sent by the OP.
OP No.1 has contested the case by filing the Written Version denying and disputing the allegations made in the complaint. It is contended by the OP that by a letter sent to the complainant no.1 by OP No. 2 and 3, it was informed that the claim has been settled for Rs. 56,117/- only in full and final settlement on account of treatment of “Tansillo adenoid Hypertrophy” and the complainant has accepted the above payment without any disputes. So, the present complaint is not maintainable and thus liable to be dismissed.
During the course of the evidence, complainants filed their evidence which was followed by filing of questionnaire by the OP but no reply was filed by the complainant against the questionnaire of the OP. The evidence was also filed by the OP followed by filing questionnaire and reply thereto. Ultimately, argument has been advanced by both the parties. OP No.1 has also filed a written notes of argument.
So, the following points require determination:
- Whether there has been any deficiency in service on the part of the OPs?
- Whether complainants are entitled to the relief as prayed for?
Decision with reasons
Both the points are taken up together for a comprehensive discussions. The claim of the complainants that they were covered by a mediclaim policy during the relevant period of the treatment of the complainant Tikshan Jain, same has not been disputed and denied by OP No.1. A copy of the said policy is also filed by the complainant. However, the main contention raised by the OP is that towards full and final settlement, an amount of Rs. 56,117/- has already been paid to the complainant as admissible under Rules. According to OP, complainants have accepted the payment without any dispute. It is also the contention of the OP that circular issued by IRDA dated 24.09.2015 regarding ‘discharged vouchers in settlement claim’ was not related to the instant case because PPN rate applicable for cashless and reimbursement claims in “PPN hospital /N.H.S” was intimated by the OP to the complainant vide their letter dated 10.10.2017. According to OP the rate for Aden tonsillectomy surgery is Rs. 41,400/- but complainant have been paid Rs.44,700/-inadvertently. So excess of Rs.3300/- has been paid to the complainant. It is also contended by OP that Complainant submitted pre and post hospitalisation charge of Rs. 13,948/- out of which of Rs. 11,417/- has been paid deducting Rs. 2,531/- charge due to the non –submission of appropriate money receipt.
It may be pertinent to point out, even though complainants have claimed that the medical bill of Rs.1,81,047/- was raised by the said Apollo Hospital, which also appears to have been communicated to the OP but before this Forum, complainants have not filed copy of the medical bill in order to see the amount paid towards surgery and other charges paid towards pre and post hospitalisation. Final bill was necessary to consider whether the complainants were entitled to the entire amount because specific contention of the OP is that deduction was made because of non-admissibility of the entire amount as per the rules.
It further appears from the documents filed by the OP as well as the complainant that as per claims payment statement, an amount of Rs. 1,24,930/- was deducted and the amount settled to be paid was Rs. 56,117/-. Admittedly, complainant has admitted the said full and final settlement without raising any protest and dispute. A discharge voucher has also been issued towards the said full and final settlement. So, if the amount which was paid to the complainant was accepted by the complainant without any protest, at this stage claiming further amount will not be maintainable as same is nothing but an afterthought. The OPs have put specific question to the complainant in their questionnaire being question no. 4 that “ Do you know, once you have taken the statement of account without dispute against your claim, your further claim will be relinquished as per settled principle of law and terms and conditions of Mediclaim Policy ?” Complainants have not answered the said question. On the contrary, it appears from the order dated 29.11.2018 that the complainants submitted that they do not intend to file any affidavit in reply to the questionnaire put by the OP. So, it suggest that the complainants had accepted the amount as full and final settlement without raising any disputes or protest and relinquished their further claim. In the case law relied upon by the OP reported in IV (2012) CPJ N.C. 483 ( Laxmi Devi Kakhoni – vs. – Oriental Insurance Company Ltd. ) it has been held by the Hon’ble National Commission that full and final settlement of claim and discharged vouchers executed by insured voluntarily and no objection raised protesting against the said settlement, then complainant was not entitled to relief of further claim.
In this case also, it is not the claim of the complainants’ that the discharged voucher was not executed by them voluntarily or that it was executed under any force or coercion. So in such view of the matter, complainants are not entitled to the relief as prayed and thus the complaint is liable to be dismissed.
Hence,
Ordered
CC/54/2018 is dismissed on contest against the OP No.1 and exparte against OP No. 2 and 3.
