OFFICE  OF  THE  DISTRICT  CONSUMER  DISPUTES  REDRESSAL FORUM, KAMRUP,GUWAHATI-03

C.C.20/2014

Present:-

1) Md.Sahadat Hussain, A.J.S.         -      President

2) Smti Archana Deka Lahkar          -       Member

3) Md Jamatul Islam                         -       Member

Sri Shiv Prakash Agarwal                                                          -Complainant

S/O- Lt Banwari Lal Agarwal

R/O-Budhia Bhawan, Sati Jayanta Road,Athgaon

Basu bazar,Pin-781001,Dist-Kamrup,Assam

  -VS-

1) United India Assurance Co. Ltd.                                          -Opp.party

Registered office at 24, Whites Road,

Chennai-600014                                                                                                 

2)   The Regional Manager,

 United India Assurance Co. Ltd .

Regional Office -G.S.Road,

Dispur,Guwahati-781005  

3)  The Branch Manager,

United India Assurance Co. Ltd .

Branch Office-Fancy Bazar,

Near Crossing of Danish & J.C.Das Road,

Panbazar,Guwahati,Assam-781001  

Appearance:

For the complainant - Mr Prakash Agarwalla

For the opp. party -Mr Amarjyoti Kakati

Date of argument -29/05/2018  

Date of judgment -28/06/2018   

JUDGMENT

This is a proceeding U/S- 12 of the Consumer Protection Act, 1986

1. The complaint filed by Sri Shiv Prakash Agarwal against United India Assurance Co.Ltd.. Chennai, Regional Manager , United India Assurance Co.Ltd., Guwahati , Branch Manager , United India Assurance Co.Ltd., Fancy bazaar branch and Heritage Health TPA Pvt.Ltd.  ,Hare Street-1 ,Kolkata was admitted on 21/02/14 and notices were properly served upon all the opposite parties and Opp.Party No-1 , 2 and 3  filed joint written statement but the case against Opp.Party No-4 is proceeding on exparte vide this forum’s order dtd.04/08/16 . The complainant side filed his evidence on affidavit on 01/09/2016 and he was cross examined by the Opp.Party No-1, 2 and 3 side but after taking so many adjournments , the Opp.Party No-1, 2 and 3 side failed to adduce their evidence and as a result the hearing of evidence of Opp.Party No-1 ,2 and 3 side is closed vide our order dtd.07/02/18 . Thereafter both side’s  Ld counsels filed their written argument and finally on 29/05/2018 we heard oral argument of Ld advocates Mr Prakash Agarwalla  for the complainant and of Ld advocate Mr  Tridib Kalita  for Opp.Party No-1 , 2 and 3 side and today  we deliver our judgment with reasons given below-
2. The complainant ‘s case in brief is that, he had purchased one Mediclaim Insurance Policy vide No-130105/48/08/9700000110 from the opp. party which was effective 22/05/2008 till midnight of 21/05/2009 covering him and his wife , but during effectiveness of the said policy his wife was hospitalized in SWAGAT ENDOLEPROSCOPIC SURGICAL RESEARCH INSTITUTE ,Guwahati on 14/05/2009 for operation of Gallbladder  stone as she was suffering from severe stomach pain and the operation was successfully done and she was released  on 16/05/2009 and the opp. party was reported about that fact and ; he on , 27/05/2009 wrote a letter to the opp. party for reimbursement of expenses of Rs.49,670/- which he had incurred for treatment  of his wife but they forwarded a cheque of Rs.28,397/- only to him on 23/09/2009 with a letter containing some objection  for which they had deducted some amount from the claim amount . After receiving said letter he on 23/10/2009 wrote a letter to M/S Heritage Health IPA Pvt.Ltd.  clarifying the objection raised by the opp. party and returned the cheque to the insurance company which was duly received by the insurance company on 28/10/2009 but they did not accept the said cheque and asked him to encash the cheque with a surety that the balance amount will be refunded to him separately  and accordingly they on 07/12/2009 issued another cheque amounting to Rs.7,791/- and the letter which contained reason for deducting some amount from the claimed money and then on 24/12/2009 , wrote a  letter to the opp. party company clarifying the objection raised with  submitting documents but they again on  01/06/2010 asked him to clarify some further objections and he also replied back on 18/06/2010  clarifying the objections and  replying the letter the insurance company on 09/07/2010 asked him to provide required documents  and accordingly he again on 28/07/2010  providedd all the documents and particulars etc., but they  did not settle the matter and then he approached  Hon’ble Ombudsman on 01/10/2010 and Ombudsman  closed the case by passing an order that he has encashed the cheque amount and has voluntarily  consulted to such settlement and accepted the settled amount at his own and being highly aggrieved by such order he on 04/06/2012 approached Insurance Regulatory and Development Authority but they advised him to take the matter with the insurance company and he again approached the insurance company on 18/09/2012 but they vide their letter dtd.09/09/2013 treated the order of ombudsman  as final settlement and closed his case without reimbursing the non-settled amount. The said letter is not binding on him and as such repudiation  letter is not valid in the eye of law he prays for putting direction to the opp. parties to pay him the balance amount of the bill with interest @12% per annum from the date of submission of bill as well as Rs.50,000/- as compensation  and also to pay cost of the proceeding.
3. The pleading of the Opp.Party No-1 ,2 and 3 is that the insurance policy of the complainant as stated issued from their Panbazar branch which was effective from 22/05/2008 till 21/05/2009 . The complainant on 27/05/2009 wrote a letter to them for reimbursement of expenses of Rs.49,674/- incurred by him in treatment of his wife and had also annexed documents and cansmemos and other particulars but those documents are baseless  and he also failed to submit the required documents in proper formats despite several request and reminders issued. They issued a cheque of Rs.28,397/- with a forwarding letter issued on behalf of Heritage Health IPA Pvt.Ltd. and they deducted an amount from the total claimed amount of Rs.49,674/- on account  of non furnishing of required medical papers, cashmemos , registered no of the treating doctors etc. The complainant encashed a cheque of Rs.28,397/- without any objection and that deem to have accepted the full and final payment and settlement of the claim. They have also  issued another cheque of Rs.7,791/- on 07/12/2009 considering the new documents submitted by the complainant vide letter dtd.23/10/2009 and that cheque was also encashed by the complainant without any objection and after issuing the insurance cheque they requested the complainant to furnished required documents vide letter dtd.02/02/2010, 13/02/2010, 14/04/2010 etc. through Heritage Health IPA Pvt.Ltd.  . The letter dtd.01/06/2010 is self explicit to the fact that the remaining amount of the claim of complainant was open for  consideration and the saying had not deen  settled for want  of necessary documents . Thereafter on 09/07/2010,they requested the complainant to submit documents i.e. Money Receipt issued by the doctors afresh , but the complainant had paid no heed to their request nor fulfill their requirement to settle the claim. They issued first 2 cheques within a very short span of time  from the date of furnishing required documents  by the complainant. The  complainant inspite various reminders failed to submit required documents and in such situation they had no option  but to close the matter and as such repudiation letter dtd.09/09/2013 is valid in the eye of law and the further claim for balance amount cannot be entertained for non filing of necessary documents by the complainant and thertefore the complaint is liable to be dismissed .
4. After perusing  the pleading and evidence of the parties , it is found that both sides admit that the complainant purchased an insurance policy (Mediclaim Policy) bearing No-130105/48/08/97/00000110 from Fancybazar branch of United India Assurance Co.Ltd.  for period w.e.f 22/05/2008 to 21/05/2009 covering the complainant and his wife and during the effectiveness of the said policy the complainant’s wife had suffered from stomach pain and she was hospitalised in SWAGAT ENDOLEPROSCOPIC SURGICAL RESEARCH INSTITUTE , Guwahati on 14/05/2009 and was diagnosed as having gallbladder stone and she was operated for removing  gallbladder stone and the operation was successful  and  she was released on 16/05/2009 and the complainant informed the opp. party vide letter dtd.14/05/2009 (Exhibit-2) about the said matter  and lodged also a claim for reimbursement of medical expenses amounting to Rs.49,674/-  which he had allegedly incurred  in the operation of his wife and opp. party through  Opp.Party No-4 vide letter dtd.23/09/2009 forwarded a cheque No-402478 dtd.23/09/2009 for Rs.28,397/- towards full and final settlement of the claim and they also after receiving further documents sent 2^nd cheque of Rs.7,791/- . The plea of the opp. party is that , both cheques were received and  encashed by the complainant. The complainant  in his cross examination states that it is fact that out of Rs.49,674/- the opp. party paid him Rs.36,188 in total (first cheque of Rs.28,397 and 2^nd cheque of Rs.7,791/-). Thus the plea of the opp. party that they had paid the complainant Rs.36,188 in total  against the total claim of Rs.49,674/- (through 1^st cheque Rs.28,397/- and 2^nd cheque Rs.7,791/-) is clearly established.                                                                   The complainant admits that , the ombudsman rejected his plea for further amount against his total claim. The complainant also admits in his cross examination that the opp. party after issue of the 2^nd cheque vide letter dtd.09/07/2010 (Exhibit-11)asked him to produce printed no., individual money receipt issued by the doctor on his own letter head indicating his registered no but he did not produce fresh money receipt of the doctor but sent only Registration No. of the doctor in a separate sheet. Thus , it is clearly establish that after payment of Rs.36,188/-against the total claim of the complainant i.e. Rs.49,674/- the opp. party again asked the complainant to submit printed numbered individual separate money receipt issued by the doctor afresh on his own letter head indicating the registration no. of the doctor but the complainant did not file those money receipt rather send the registration no. of the doctor in a separate sheet. Thus it is crystal clear that for the failure of the complainant to submit the separate printed and individual money receipt from the Doctor who treated his wife the opp. party failed to reconsider the balance amount of his total claim i.e Rs.13,486/- and closed the claim of the complainant and repudiated his further claim informing him by their letter dtd.09/09/2013 (Exhibit-7) . Thus we are of opinion that, the repudiation of further claim of Rs.13,486/-of the complainant by the Opp.Party No-1, 2 and 3 is a lawful act meaning thereby they have not committed any deficiency of service towards the complainant nor committed unfair trade practice and the complaint has no merit which is liable to be dismissed.

          Given under our hands and seal today on this 28^th June,2018.

          (Smt Archana Deka Lahkar)   (Md.Jamatul Islam)        (Md.Sahadat Hussain)                                                

                     Member                                 Member                            President