State Consumer Disputes Redressal Commission
1. Mrs.Goolrookh R. Mehta, vs 1.The New India Assurance Co. Ltd., on 29 October, 2014
BEFORE THE HON'BLE STATE CONSUMER DISPUTES
REDRESSAL
COMMISSION, MAHARASHTRA, MUMBAI
First Appeal No. A/14/258
(Arisen out of Order Dated 25/03/2014 in Case
No. 51/2012 of District South Mumbai)
1. MRS.GOOLROOKH R.
MEHTA,
2. MS.ZENIA R. MEHTA,
Both R/at E-41,
Gilder Baug, J.B. Nagar,
Andheri East, Mumbai
400 059.
Maharashtra.
...........Appellant(s)
Versus
1.THE NEW INDIA
ASSURANCE CO. LTD.,
Regd. Office At:
New India Assurance
Building,
87, Mahatma Gandhi
Road, Fort,
Mumbai 400 001.
And Branch Office at:
DO 111400, 22, Mittal
Chambers,
Opp. Inox Theatre,
Nariman Point,
Mumbai 400 021,
Maharashtra.
2. HEALTH INDIA TPA
SERVICES PVT. LTD.,
(Licence No.22),
Anand Commercial Complex,
103-B, L.B.S. Road,
Gandhinagar,
Vikhroli West, Mumbai
400 083.
Maharashtra.
...........Respondent(s)
BEFORE:
HON'BLE MR. JUSTICE
R.C.CHAVAN PRESIDENT
HON'BLE MR. Dhanraj
Khamatkar Member
For the Appellant:
Advocate Mr.M. Shirazi
For the Respondent:
Advocate Mr.H.G. Misar
for Respondent No.1.
ORDER
Per Honble Mr.Dhanraj Khamatkar Member:
(1)This appeal takes an exception to an order 25th March, 2014 passed by the District Consumer Disputes Redressal Forum, South Mumbai.(2)
Facts leading to this appeal can be summarized as under:
The Complainant no.1 has availed the mediclaim policy for the period 30/09/2010 to 29/09/2011 from the opponent no.1. The Complainant no.2 is a daughter of the complainant no.1 and she is also covered under the said mediclaim policy. It is the contention of the Complainants that Complainant no.2 suffered from severe pain in the abdomen and hence, she approached to the Doctor for the treatment and the treating doctor advised her to get admitted in a Holy Spirit Hospital, Andheri East, Mumbai as an indoor patient. It is further contended that the Complainant no.2 after receiving full treatment was discharged from the said hospital on 06/09/2011 and amount of Rs.53,022.23 was spent on hospitalization, medicines, various tests and Doctors visits. The Complainant no.1 had submitted a mediclaim of Rs.53,022.23 to the opponents along with copies of relevant documents. The opponent no.2 processed the claim and dispatched a cheque dated 24/10/2011 of HDFC bank for Rs.22,623/- to the Complainant no.1. Complainant no.1 accepted the said cheque. It is the contention of the Complainant no.1 that he accepted the said cheque on the basis of without prejudice.
It is the contention of the Complainants that while considering the claim the Opponents have illegally and arbitrarily disallowed certain claims under clause nos.2.3 and 2.4 of the mediclaim policy by the Opponent no.2. The Complainant no.1s husband by letter dated 11.11.2011 asked the opponent no.2 the item wise break-up of the disallowed claim, which is replied by the opponent no.2 by letter dated 29/11/2011 giving the details of disallowed claim. It is the allegation of the Complainants that the deductions made by the Opponents are without any right to deduct the same.
Alleging deficiency in service and unfair trade practice on the part of the opponents for deducting amount from the claim submitted, the Complainant has filed consumer complaint and prayed that the opponent be directed to pay an amount of Rs.17,799.23 with appropriate interest, compensation of Rs.2,00,000/- for mental agony and harassment and costs of Rs.30,000/-.(3)
The opponent no.1 had contested the complaint by filing written version contending therein that the Complainants have received a payment of Rs.22,623/- as full and final discharge of the claim. It is contended by the opponent that on the copy of the payment voucher dated 24.10.2011 there is specific note that acceptance of the above mentioned cheque by the insured is full and final settlement of the claim and the insurer stands fully discharge of liability under the mediclaim policy. It is further contended that the Complainants were having option of refusing to accept the amount if the same was not agreeable to them.
The opponent further contended that after accepting the amount the Complainants lose their right to agitate the issue. The complaint of the complainants is after thought. It is prayed that there is no deficiency in service or unfair trade practice on their part and hence, the complaint may please be dismissed.
(4)The Complainants have filed Rejoinder-cum-affidavit of evidence to the written version filed by the opponent no.1.
(5)District Forum after going through the complaint, written version filed by the opponent no.1, the evidence filed by both the parties on affidavits and pleadings of the Advocates, dismissed the complaint with observation that there is no deficiency in service on the part of the opponents. It is against this order that the present appeal is filed.
(6)We have heard Advocate Mr.Shirazi for the Appellants and Advocate Mr.Misar for the Respondent/original Opponent no.1. Apart from the oral arguments both the parties have filed written notes of arguments which are on record. We have gone through the order passed by the District Forum, the arguments advanced by both the parties and the written notes of arguments.
(7)Admittedly, the Appellant no.1 has availed a mediclaim policy from the Respondents which was valid from 30/09/2010 to 29/09/2011. Admittedly the Appellant no.2 is a daughter and is covered under the said mediclaim policy.
Admittedly the Appellant no.2 suffered from severe pain in the abdomen and approached the doctor and on the advice of the doctor she was admitted to Holy Spirit Hospital, Andheri East, Mumbai.
Admittedly after the discharge of Appellant no.2, the Appellant no.1 has submitted claim of Rs.53,022.23 spent on hospitalization, medicines, various tests and Doctors visits along with necessary vouchers. Admittedly the appellants have received from the opponent no.2 a cheque dated 24/11/2011 of the HDFC Bank for Rs.22,623/-. The Appellants have accepted the said cheque (8) The Ld.Counsel for the Appellants has vehemently argued that the Appellants have accepted the cheque without prejudice to the right of the appellants. He further vehemently argued that the Respondents have disallowed certain items of medical expenses illegally and arbitrarily under clause 2.3 and 2.4 of the mediclaim policy. The Ld.Counsel further vehemently argued that after receiving the cheque from the Respondents, the husband of the appellant no.1 has written letter dated 11/11/2011 to the respondent no.2 for furnishing item wise break-up of the disallowed claim, which he has received from Respondent no.2 by letter dated 29/11/2011. It is the contention of the Ld.Counsel for the Appellants that deductions made by the Opponents are without having any right to deduct the same. It is further argued by the Ld.Counsel that the core issue with regard to the mediclaim policy/insurance is to facilitate persons in need to receive prompt medical attention/treatment till they are restored in health. It is further argued by the Ld.Counsel that the Respondent has taken a shelter of Clause nos.2.3 and 2.4 of the policy for disallowing certain claims. It is unreasonable, arbitrary and against the benevolent performance of the Consumer Protection Act. The Ld.Counsel further submitted that on or around 4th November, 2011 the Appellants received closed envelope and acknowledgement of the said envelope was signed on a separate receipt. When the said envelope was opened it was noticed that it contained an unsigned claim discharge voucher dated 24th October, 2011 along with counter foil of H.D.F.C. Bank and a cheque for the sum of Rs.22,623/-. It is also argued that the husband of the Appellant no.1 has written a letter dated 11th November, 2011 and informed the Respondent no.2 that the said cheque was accepted without prejudice basis as the amount offered was not the same what the appellants were expected to under the mediclaim policy as certain items were illegally and/or arbitrarily disallowed/deducted.
(9)The Ld.Counsel vehemently pointed out that the sequence of events cited above will prove that the appellants have acted promptly in lodging their protest and filing the complaint.
By merely accepting a cheque on without prejudice basis, the appellant cannot be estopped from taking recourse to the Consumer Protection Act. The Ld.Counsel has relied on following authorities:
(i) Honble National Commission, Morinda Co-op. Sugar Mills Ltd. V/s New India Assurance Co. Ltd. & Ors., reported in II (2002) CPJ 57(NC).
(ii) Honble National Commission, M/s. Inventa Chemicals Ltd. V/s. M/s. United India Insurance Company Ltd., reported in 2004(1) CPR 107(NC).
(iii) Honble Supreme Court, M/s.United India Assurance Co. ltd. V/s. Ajmer Singh Cotton & General Mills & Ors., reported in II(1999) CPJ 10 (SC).(10)
Admittedly the issue involved in the present appeal is only whether the Appellants have accepted the claim amount sent by the Respondents on without prejudice basis.
At page 108 of the appeal compilation there is a claim discharge voucher. It gives the particulars of the policy, the name of the proposer, claim amount, settled amount and amount not payable. In a claim discharge voucher there is a note kindly note: acceptance of the above mentioned cheque by the insured is in full and final settlement of the claim and the insurer stands fully discharged of liability under the Mediclaim Policy. At page 109, there is a Cash Management Services
- Payment, wherein there is a note In case you do not agree with this payment, kindly return this cheque to us within 10 days. The retention of the cheque and/or encashment of the cheque will automatically be deemed as full and final settlement of your claim. On both the papers there is no endorsement by the Appellant that the appellant is accepting the amount without prejudice to his right. The authorities relied by the Appellants are not relevant in the facts and circumstances of the case.
(11)In the authority quoted by the Ld.Counsel, from II 1999 CPJ 10 (SC), supra, it is observed that consumer has to ratify authority under Act that discharge was obtained by fraud, misrepresentation, undue influence or the like. In the facts and circumstances of case, there is no iota of evidence to prove that discharge was obtained by fraud, misrepresentation, undue influence or the like.
(12)The District Forum after going through the facts and circumstances of the case and appreciating the evidence on record has passed the order and we do not find any illegality or infirmity in the order.
We hold accordingly and pass the following order:
ORDER
(i) Appeal is dismissed.
(ii) The order passed by the District Forum is hereby confirmed.
(iii) No order as to costs.
(iv) Inform the parties accordingly.
Pronounced on 29th October, 2014.
[HON'BLE MR. JUSTICE R.C.CHAVAN] PRESIDENT [HON'BLE MR. Dhanraj Khamatkar] Member ep