Adv. For the Complainant: - Sri R.Rath and others
Adv. For O.Ps :- Sri S.S.Mishra and others
Date of filing of the Case :- 01.06.2021
Date of Order :- 31.05.2023
JUDGMENT
Smt. Jyotsna Rani Mishra , Member
Facts of the case in nutshell : -
The complainant has opened a health insurance policy. Under JEEVAN AROGYA for the whole family members in the year 2015. Accordingly he obtained the bond of the policy having the policy No. 594941446 dt. 28.03.2015 and claim id is 11012000 .
Complainant suffered from COVID 19 and was under treatment being admitted in shree Narayan Hospital, Raipuir from dt. 27.02.2020 to 03.10.2020 . Total amount of medical expenses as per the bill given by the hospital is Rs.1,74,917/- ( One Lakh Seventy four thousand Nine hundred seventeen only) . Due to impact of COVID 19 , the complainant lungs was effected in to a higher level for which he was oxygenated and put in to ICU ventilator. Besides this, around 50,000/- was spent by7 the family members of the complainant towards lodging and boarding staying at Raipur to look after the matter of the complainant.
The complainant submitted claim petition to the O.P. will all details along with the medical documents to the OP for reimbursement of the total expenses met him. However , the
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OP repudiated the claim of the complainant as the sickness is classified as an Epidemic by the Central govt. or a State Govt.
Neither in the scheme nor at any time, the OPS has averred that a customer under the said JEEVAN AROGYA health insurance scheme is not entitled to get any benefits on other heads which is specifically denied.
Recently vide its letter dt. IRDAI/HLT /REG/CIR/054/03/2020 dt. 04.03.20 IRDA has issued guidelines to deals with the claims reported under Corona Virus. But the Op deals with as if that circular is valueless and ineffective.
Relay on the following documents-
A. Copy of policy Bond.
B. Copy of Medical Documents.
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E. Any other document if felt necessary to be filed at the time of hearing.
The rival contention as per their version OP.1 denied all the contents and stated that-
After investigation and scrutiny of the claim under code Ho Sickness Classified as an epidemic by (Central or State Govt.) The claim has been reconsidered on Ex-gratia basis as a special case as per C.O circular HI/claims dated 01.02.2021. and an amount of Rs.10,400 was sanctioned and credited to the account of L.A / complainant on dt.12.10.2021, So there is no deficiency of service.
Taking all the evidence and argument plaid on record in to consideration I assumed that deficiency in service is based on not paid claim amount. The complaint is suffering from mental agony . Hence Order :-
ORDER
In the view of above in details I directed to pay the claim amount with Rs.2,14,515 /-
10 % interest P.A I further directed to pay 20,000 for mental agony and 5000/- towards litigation Expenses.
Failing which the OPs is directed to pay the total amount @12 % P.A from the cause of action arose. Till realization.
No award as to cost.
Accordingly the case is disposed off.
PRONOUNCED IN THE OPEN COMMISSION TODAY I.E DATED 31th DAY OF May’2023.
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(J.MISHRA) (R.K.TRIPATHY)
. MEMBER PRESIDENT(I/C)
