PER SHRI. S.M. RATNAKAR – HON’BLE  PRESIDENT

1)        By this complaint the Complainant has prayed that the Opposite Parties be directed to pay Rs.1,46,202/- which was deducted towards the claim lodged by the Complainant with interest @ 18% p.a. from the deduction of the said amount till it’s realization.  The Opposite Parties be directed to pay Rs.25,000/- as compensation towards mental torture and harassment.  The Complainant has further prayed that the Opposite Parties directed to pay Rs.30,000/- being the fees of the advocate and cost of this complaint.

2)        According to the Complainant, during the period 07/11/2010 to 06/11/2011 he was insured with the Opposite Parties.  The copy of the said policy is at Exh.‘A’.  The Opposite Party No.2 is the Agent of the Opposite Party No.1.  The sum insured under the policy was Rs.1,50,000/-. The Complainant was admitted in the hospital on 04/02/2011 for medical treatment of illness laser PVP of Prostate.  The copies of the medical papers are marked as Exh.‘B’. It is submitted that the Complainant had incurred total expenses of Rs.2,19,434/-. The copies of the bills are marked as Exh.‘C’.  It is submitted that the Complainant lodged the claim of Rs.2,19,434/- with the Opposite Party No.2 and the Opposite Party No.2 allowed the claim to the tune of Rs.73,232/- and deducted Rs.1,46,202/-.  The copy of the claim form is marked as Exh.‘D’ and the copy of the letter issued by the Opposite Party granting claim of Rs.73,232/- is marked as Exh.‘E’.  It is submitted that the Complainant by notice dtd.20/07/2011 requested the Opposite Party No.1 to pay the balance amount but the Opposite Party No.1 did not reply to it.  It is alleged that the Opposite Party No.2 deducted the amount of Rs.1,46,202/- without applying its mind.  The action of the Opposite Parties regarding deduction of claim is not valid legal and proper and it amounts to deficiency of service and unfair trade practice. The Complainant has therefore, prayed that the reliefs claimed in para 1 of this order may be granted against the Opposite Parties. 

3)        The Opposite Party No.1 contested the claim by filing written version and contended that the Opposite Party No.1 had issued policy for Rs.1,50,000/- in favour of the Complainant. It is contended that there was break in Policy No.120100/48/07/97/00009120 and the said policy was cancelled as the premium cheque given by the Complainant was dishonoured. Subsequent policies are therefore, treated and considered as new and fresh policies.  The copy of the policy is enclosed with the written statement in the claim form submitted by the Complainant he has declared him as Advocate and therefore, he knows the terms, conditions & instructions of the policy.  It is submitted that there is no deficiency of service on the part of Opposite Parties.  It is submitted that the Opposite Parties have settled the claim as per the condition no.1.2 of the policy.  The admissible claim amount was sent to the Complainant.  It is contended that the Opposite Parties are not liable to pay any further amount. It is contended that the complaint be dismissed with cost of Rs.15,000/-.

4)       The Opposite Party No.2 though served remained absent. The complaint therefore, proceeded ex-parte against Opposite Party No.2.           

5)       The Complainant has filed affidavit of evidence.  The Opposite Party has filed affidavit of the D.S. Tulankar, Sr. Divisional Manager.  Both the parties filed their written arguments. We heard Shri. S.N. Chataule, Ld.Advocate for the Complainant and Shri. D.R.N. Char, Ld.Advocate for the Opposite Party No.1.  We have perused all the documents placed on record by both sides. 

6)        While considering the claim made in this complaint it is necessary to be considered that under the policy at Exh.‘A’ the sum insured for the Complainant is shown as Ra.1,50,000/-. The Complainant had lodged claim to the Opposite Party to the tune of Rs.2,19,434/- as mentioned in the document at Exh.‘E’.  The said claim in our view was beyond the sum insured. The Opposite Party No.2 vide settlement advice at Exh.‘E’, dtd.14/03/2011 approved the claim to the tune of Rs.73,232/- by stating detail reasons for deduction of each item and sent cheque of the said amount in favour of Complainant.  In the document at Exh.‘E’ there is endorsement “We will not entertain any clarification in respect of Non Admissible amount after 7 days from the date of settlement.”  In the said document it is also noted that “Acceptance of the above mentioned cheque by insured is in full & final settlement of the claim and the insurer stand fully discharged of its liability under the mediclaim policy.”  The Complainant as per the documents placed on record had not raised any objection regarding the wrong approval of claim by the Opposite Party No.2 within 7 days and informed Opposite Parties that he had accepted Rs.73,232/- under protest. From the notice issued by the Complainant, it appears that he had raised his grievance that he received less amount than the claim lodged to the Opposite Party No.2 and it was accepted by him under protest for the first time on 20/07/2011.  We therefore, hold that the claim made in this complaint is itself cannot be entertained in view of the settlement advice issued by Opposite Parties at Exh.‘E’.  The Complainant has also filed this complaint after many months of receiving the cheque of Rs.73,232/- from the Opposite Party No.2.  In the complaint there are no pleading that the Complainant has accepted the said cheque or payment under protest or it was accepted by him under coercion, fraud, undue influence, etc.   It cannot be believe that the amount was received by the Complainant under protest.  It is settled legal position that once the amount is received towards full & final settlement of the complaint, complaint for rest of the amount is not maintainable.  We therefore, hold that the claim made in the complaint for the remaining amount of Rs.1,46,202/- cannot be entertained as the same is beyond the sum insured amount as well as the Complainant has accepted an amount of Rs.73,232/-as full and final settlement.  In the result we hold that the Complainant has failed to prove any deficiency of service or unfair trade practice on the part of the Opposite Parties.  In view of the above discussion we find that the Complainant is not entitled to the reliefs sought in the complaint.  The following order is therefore, passed -       

O R D E R

                         i.         Complaint No.285/2011 is dismissed with no order as to cost.

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