BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM RAICHUR.
COMPLAINT NO. (DCFR) CC. 24/2013.
THIS THE 25th DAY OF OCTOBER 2013.
P R E S E N T
1. Sri. Prakash Kumar B.A. LLB. PRESIDENT.
2. Sri. Gururaj, B.com.LLB. (Spl) MEMBER.
3. Smt. Pratibha Rani Hiremath,M.A. (Sanskrit) MEMBER.
*****
COMPLAINANT :- Pallakki Mallikarjun S/o. Pallakki Dodda
Narasanna, Age: 65 years, Occ: Retd., Bank Employee, R/o. H.No. 1-3-290/161, Vijayanagar Colony, Ashapur Road, Raichur.
//VERSUS//
OPPOSITE PARTY :- United India Insurance Company Ltd.,
Represented by Divisional Manager, Divisional Office, V.V. Sukhani Complex, 1st floor Near Gandhi Chowk, Raichur.
Date of institution :- 03-04-2013.
Date of disposal :- 25-10-2013.
Complainant represented by Sri. M. Mallangouda, Advocate.
Opposite party represented by Sri. Vikaram Nair, Advocate.
ORDER
By Sri. Prakash Kumar, President:-
The complaint is filed by the complainant against the Respondent U/sec. 12 of Consumer Protection Act 1986.
2. The complaint in brief is that, the complainant obtained Health Insurance Policy from Respondent’s Insurance Company which was valid from 06-03-2012 to 05-03-2013 for which the premium payable was Rs. 9,640/- and the sum assured was Rs. 2,00,000/-. During the validity of the said policy the complainant had undergone treatment of his left eye at Maxi Vision Laser Contra Pvt. Limited, Hyderabad. He had visited the hospital at different dates and expenses incurred was Rs.80,000/-. Thereafter the complainant submitted the claim with the Respondent for payment of the amount spent for treatment. However the Respondent sent a cheque for Rs.31,930/- only. The complainant received the said cheque under protest and asked the Respondent to settle the entire claim made by him. But the Respondent has not considered the same. It amounts to deficiency in service on the part of the Respondent. Therefore the complainant got issued legal notice to the Respondent calling them to settle the claim within 15 days. Though the said notice was served on the Respondent till this date the Respondent has not settled the claim of the complainant nor cared to reply to the notice. Therefore the complaint seeking reliefs as prayed for.
3. The Respondent filed written version stating that the complaint is based on false and frivolous allegations which is devoid of any material and is liable to be dismissed deficiency in service or unfair trade practice can be attributed on the Respondent so as to make out a case under the C.P. Act. The complainant is a matured person of 65 years, well educated, a retired employee of a public sector bank and he understood the seriousness of executing the voucher in full discharge of his claim. Since the complainant has accepted the claim and signed the discharge voucher as full and final settlement of claim he is estopped from reopening the claim. Consequently the complainant is not entitled for any monetary benefits from the Respondent. It is denied that the complainant had received the amount under protest. Liability of the Respondent if any is as per the terms and conditions of the policy. The standard form contract conditions in the policy are in the nature of contract between the insured and insurer and therefore are binding between the parties. The coverage as per the terms of the policy for treatment are,
A. Room, Boarding and Nursing expenses as provided by the Hospital/Nursing Home not exceeding 1% of the sum insured per day or the actual amount whichever is less. This also includes nursing care, RMO charges, IV Fluids/Blood transfusion/injection administration charges and similar expenses. Accordingly 1% of the sum insured towards injection is Rs. 2000/- and the same has been paid to the complainant as such no deficiency nor unfair trade practices can be attributed against the opponent.
B. Intensive Care Unit (ICU) expenses not exceeding 2% of the sum insured per day or actual amount whichever is less.
C. Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fee.
D. Anesthetic, Blood, Oxygen, Operation Theatre Charges, surgical appliances, Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, cost of artificial limbs, Cost of prosthetic devices implanted during surgical procedure like pacemaker, orthopedic implants, infra cardiac valve replacements, vascular stents, relevant laboratory/diagnostic tests, X ray and other medical expenses related to the treatment.
E. Hospitalization expenses (excluding cost of organ) incurred on donor in respect of organ transplant to the insured.
That the complainant is guilty of approaching this forum with a malafide intention only to hold this Respondent to ransom and to derive undue and illegal monetary gains. The legal notice got issued by the complainant is just to create a false cause of action. The complainant had received the entire compensation amount as per the terms and conditions of the policy and signed the discharge voucher in full and final settlement of his claim. Therefore the complaint is not maintainable and deserves to be dismissed with exemplary cot. The payment of interest is specifically excluded under the terms of the policy. The claim is highly exaggerated, excessive, speculative and is on the higher side. There is no cause of action to file the complaint and alleged one is false. All other allegations which are not specifically traversed are denied as false. Hence the complaint is liable to be dismissed.
5. Complainant to prove his case filed his affidavit which is marked as PW-1 and relied on eighteen documents which are marked as Ex.P-1 to Ex.P-18. The Respondent to prove his case filed affidavit of one Vasanth N. Jalihal, which is marked as RW-1 and relied on three documents which are marked as Ex.R-1 to Ex.R-3.
6. Arguments heard on both sides.
7. The points that arise for our consideration are:
1. Whether the complainant proved deficiency in service on the part of the Respondent against him.?
2. Whether the complainant is entitled for the reliefs prayed for.?
3. What order?
8. Our answer on the above points are as under:
(1) In Negative
(2) In Negative.
(3) As per final order:
REASONS
POINT NO.1 :-
9. The complainant claimed that for the treatment of his left eye he had spent Rs.80,000/- i.e, Rs. 1,350/- bed charges, Rs.23,382/- surgeon’s charges, Rs.9,450/- operation theater charges, Rs.40,168/- for Intravitreal Avastine & OZURDX Injection, Rs. 4,000/- Anesthesia charges, Rs.400/- Special visit charges, Rs.1,250/- Post operation treatment etc., and stated that the Insurance Company had paid only Rs. 31,930/- towards the expenses incurred by him for the treatment of his eye. As per the policy conditions payment is to be made by the Insurance Company as per different parameters under different heads. For example as per condition No. 1.2(A) Room, Boarding and Nursing expenses are payable at the rate of 1% of the sum insured per day or the actual amount whichever is less and this includes nursing care, RMO charges, IV the fluids/blood transfusion/injection administration charges and similar expenses. As per condition No. 1.2(C) Surgeon Anaesthetist, Medical practitioner, consultants, Specialists fees. As per condition No.(D) Anaesthetic blood, oxygen, operation theater charges shall be at the rate applicable to the entitled room category and in case the insured person opts for a room with rent higher than the entitled category charges payable under shall be limited to the charges applicable to the entitled category. However the condition No.1.1 entitles the complainant to claim the entire hospitalization expenses for medical/surgical treatment at any nursing home/hospital as an inpatient in India which are reasonably or necessarily incurred by him for his treatment. As per this condition the complainant is entitled for bed charges, surgeon’s charges operation theater charges, Intravitreal Avastine & OZURDX Injection charges, etc., totaling to Rs. 80,000/- as claimed in the complaint. However the Respondent’s Insurance Company paid only Rs. 31,930/- to the complainant towards treatment charges though he is entitled for the entire amount of treatment which is Rs. 80,000/-. The contention of Respondent that the complainant is entitled for 1% of the total amount assured towards injection charges, however he claimed Rs. 40,168/- and for which he is not entitled, for cannot be upheld because no such condition is found in the policy of insurance issued in favour of the complainant by the Respondent’s Insurance Company. Besides, this the injection comes within purview of the term medicine and cannot be considered as different one from medicines and the complainant is entitled for the injection charges as per condition No. 1.2(D) which includes medicines and drugs as the injection comes within the purview of the medicines and drugs. However now this forum is estopped from granting compensation to the complainant as prayed for by him in the complaint because as per rulings of the higher fora when the insured receives the amount towards the compensation without protest, he cannot reopen the claim and ask for balance of the amount. In this regard we rely on the decision of the Hon’ble National Commission reported in II(2013) CPJ 178 (Yogesh Kumar Sharma (Dr) V/s. National Insurance Company), wherein it is held that once petitioner had received the amount unconditionally, then he ceases to be consumer as per Act 1986 as the privity of contract or relationship of consumer and service provider comes to an end. Here in support of this contention the counsel for the Respondent’s Insurance Company produced the copy of the disbursement (claims) voucher accepted and signed by the complainant for having received the amount of Rs. 31,930/- towards full and final settlement of the claim which is marked as Ex.R-2 it shows that the complainant had received the amount as full and final discharge of his claim and signed it. The contention of the complainant that he never signed such an voucher cannot be accepted because the signature found in the said voucher Ex.R-2 when compared with this admitted signature in the complaint as well as in the vakalatnama is found similar. If the signature found in Ex.R-2 is disputed by the complainant he should have asked for sending the same along with the admitted signature to an expert to give his opinion whether the said signature found in the voucher is that the complainant or not. But he did not choose to do so. Further if it is the case of the complainant that his signature was forged on Ex.R-2 he should have taken legal action against the Insurance Company. But he did not choose to do so. Therefore the contention of the complainant that he never signed Ex.R-2 is liable to be rejected. Therefore the rejection of the claim of the complainant for payment of balance amount by the Insurance Company is found proper and legal it does not amount to deficiency in service. Accordingly this point is answered in the negative.
POINT NO.2:-
10. As complainant has not made out deficiency in service on the part of the Respondent he is not entitled for any of the reliefs prayed for in the complaint. Accordingly this point is answered in Negative.
POINT NO.3:-
11. As per order below:
ORDER
The complaint filed by the complainant is dismissed.
There is no order as to cost.
Intimate the parties accordingly.
(Dictated to the Stenographer, typed, corrected and then pronounced in the open Forum on 25-10-2013)
Smt.Pratibha Rani Hiremath, Sri. Gururaj Sri. Prakash Kumar,
Member. Member. President,
District Consumer Forum Raichur. District Consumer Forum Raichur. District Consumer Forum Raichur.
