Order No. -10 Dt.-19/01/2015
Shri Asoke Kumar Das,President
F I N A L O R D E R
Complainant’s case in short is that she took Health Insurance Policy from O.P., United India Insurance Co.Ltd. for herself and her 2 sons namely Gourav Sinha and Sourav Sinha on 29/09/1999. That policy was renewed year to year and the coverage period of the policy was from 29/09/2014 to 28/09/2015 being policy no.0351002814P103842601 . Her yourger son suffered from acute abdomen pain and he was admitted to Samaritan Clinic(P) Ltd., Kolkata for operation of appendix on 24/02/2015 wherefrom he was discharged on 28/02/2015. The complainant submitted bill for Rs.50,826 to O.P. but that bill was settled at Rs. 19,815. Hence, this case.
The O.P. United India Insurance Co. Ltd. contested the case by filing a Written Version denying and disputing the claims and contention of the complainant with prayer for dismissal of the case .
Their specific stand is that the alleged claim of the complainant is beyond the terms of the policy and the amount claimed should be properly vouched by authentic document and must be included in the nursing home bill on headwise in detail but that was not done and as the complainant has already received and accepted Rs.19,815 towards full and final settlement of her claim from O.P. through NEFT without protest she is estopped from making any further claim against the O.P. which is contrary in terms and condition of the Insurance Policy.
POINTS FOR CONSIDERATION
- Is the case maintainable ?
- Is the complainant a consumer?
- Is the O.P. guilty for deficiency in service as alleged?
- Is the complainant entitled to get the reliefs as prayed for?
DECISION WITH REASONS
All points are taken up together for consideration and decision.
After due consideration of pleadings of both the parties the Written Arguments, the documents filed by both the parties and the arguments advanced by the Ld. Lawyers of both sides we find that admittedly the complainant purchased Health Insurance Policy no. 0351002814P103842601 from O.P. United India Insurance Co.Ltd. for herself and her two sons and that was valid from 29/09/2014 to 28/09/2015. Furthermore admittedly this Forum has pecuniary and territorial jurisdiction to hear and to dispose of this case..
Admittedly complainant submitted a bill of Rs.50,826 to O.P. which she had to incurr for operation of appendix of her younger son, purchase of medicine, treatment etc. Admittedly the O.P. Insurance Company settled the claim of the complainant at Rs.19,815 which they sent to the complainant through NEFT and was accepted by the complainant without any protest and she even didn’t return back the said amount of money to the O.P. intimating her dissatisfaction. In Oriental Insurance Company Ltd. vs. T.Gopal case reported in 111(2015)CPJ311(NC), Hon’ble National Consumer Disputes Redressal Commission, New Delhi, has held that, “ In our view having accepted the aforesaid amount of Rs.11,94,798 in full and final settlement of all his claims arising under the policy in question the complainant is estopped from making any further payment against the petitioner company. In case he was not satisfied with the amount offered by the petitioner company 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.” In our present case admittedly the complainant had received and accepted Rs.19,815 sent by O.P. through NEFT towards full and final settlement of her claim without any protest or under protest as part payment. Therefore in view of the said decision of the Hon’ble National Commission the complainant is estopped from making any further claim against the O.P. Insurance Company and therefore the claim of the complainant is not tenable. That apart the complainant has submitted her claim of Rs.50,826/- to O.P. not complying the terms and conditions of the Health Insurance Policy in question. In this view of the matter we find sufficient reasons to hold that the O.P. United India Insurance Co.Ltd. is not guilty for deficiency in service as alleged and accordingly the complainant is not entitled to any relief in this case.
All points are disposed accordingly.
In the result the case fails.
Hence, it is
O R D E R E D
that the case /application is dismissed on contest but in the circumstances we make no order as to cost.
Let copy of this final order be supplied free of cost forthwith to the parties/ their Ld. Advocates/agents on record by hand under proper acknowledgement/sent by ordinary post, in terms of Rule 5(10) of West Bengal Consumer Protection Rules 1987.
