Adv. For the Complainant: - Sri A.K.Mishra
Adv. For O.Ps :- Sri R.K.Mahakur
Date of filing of the Case :-13.01.2021
Date of Order :- 17.03.2023
JUDGMENT
Fact of the case in nutshell-
(1) The complainant had purchased a CORANA RAKSHAK policy for him self of from the insurer Cholamandalam Ms General Insurance Company Ltd. who is OP No.2 in this case On dated 24/07/2020 vide policy No. 2894/00007473/000/00 paid with a sum of Rs.2,549/- towards premium , which covers Rs2,50,000/- and valid from 24/07/2020 to 04/05/2021 .
During the pandemic season the O.P No.2 attract through its advertisement that the said policy covers lump sum benefit equal to 100/- of the sum Insured shall be payable on positive diagnosis of COVID requiring hospitalization for a minimum continuous period of 72 hours.
In the month of August 2020 the complainant suffering from illness and after test the testing report clearly shows that the complainant was affected by COVID -19 Corona virus and the complainant admitted at COVID care center Larkipali, Bolangir as an indoor patient and on dt 06/09/2020 he
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discharged from the COVID care center . Thereafter as per the guideline of the govt. the complainant lived in his home isolation from dt 07/09/2020 to 16/09/2020.
The complainant has intimated the facts to the OPs soon after his discharge from the home Isolation but the OPs avoided to pay the insured amount on dt 17/11/2020 the complainant sent a pleader notice along with the required documents despite received the pleader notice the OPs not in a mood to pay the insured amount .Hence this order.
(2) To substantiate his case the complainant relies on the following documents.
(1) Copy of insurance certificate issued by the OPs.
(2) Copy of the Discharge slip of COVID care center Larkipali , Bolangir
(3) copy of Discharge Certificate for Home Isolation.
(4) Copy of the advertisement of terms and condition of Ops from the website.
(3) Having gone through the complainants its accompanied documents and on hearing the complainant primafacie it seemed to be a genuine case . hence admitted and notice to the OPs were served and in response they appeared through their council and filed their version,.
(4) The rival contention the Ops only admitted of the insurance policy . The said Corona Rakshak policy covers lump sum benefit equal to 100/- of the sum insured shall be payable only to positive diagnosis of Covid requiring hospitalization for a minimum continuous period of 72 hours and supported by authentic documents issued by the competent authority supported by clinical radiological histological his to pathological and laboratory evidence at the time of claim. But the complainant not complying the same and failed to submit the required documents for which the OP2 constrained to close the file and intimated the same to the complainant . As per the ICMR guideline the patient needs home isolation and hospitalization is not acceptable in this case and the claim is not payable . There is no deficiency on the part of the OP No 2 and the allegations made by the complainant is absurd and base less and liable to be dismissed.
(5) Taking the above facts and circumstances this commission observes and found that being attracted towards the advertisement explained by the agent of the OP No.2 the complainant at that time of covid-19 to save his life by taking financial add insured his life on a good faith that he might be financially helped by the OP No.2 in a crucial period if arise.
(6) Before going to the maintainability and merit of the case , we have to look over the terms and conditions of the policy itself.
Accordingly to the endorsement made by the OPs on their website is as follows.
What is covered under corona Rakshak policy
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(1) Expenses related to any admission primarily for diagnostics and evaluation purposes.
(2) Testing done at a diagnostic center which is not authorised by the Govt. shall not be recognized under this policy.
(3) There is no pre policy medical checkup is required to purchase the policy.
What not covered :-
(1) Expenses related to the treatment of Covid with in 15 days from the first policy commencement date shall be excluded.
(2) Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment.
(3) Any diagnosis expenses which are not related and not incidental to Covid is covered in this policy.
(4) Any claim with respect to Covid manifested prior commencement date of this policy or during the waiting period.
(5) Cover under this policy shall cease if the insured person travels to any country placed under travel to any country placed under travel restriction by the Govt. of India.
The endorsement states lump sum benefit equal to 100% of the sum insured shall be pay able on positive diagnosis of Covid requiring hospital for a minimum continuous period of 72 hours.
After going through the terms and conditions of the policy it is crystal clear that if the policy holder affected and tested through a Govt. agency and hospitalized for 72 hours is entitled for the insured amount.
In the instant case the complaint fulfill all the criteria but the OP No.2 create a story regarding the non- payment of the insured amount it is an afterthought malafide formula to repudiate the contract by claiming the radiological , histological histo- pathological surgical administering of oxygen and also the viral pneumonia CORADS-5 certificate are necessary.
Where in ICMR guideline it is clearly stated that the Corona positive means the person is affected by the viral pneumonia CORADS-5,and all the Covid care center at that pandemic was treated as hospital.
Regarding the question of maintainability it is within the time and all the allegation made on the complaint petition is maintainable and this commission got the Jurisdiction to decide this case.
Earning money by pocketing premium only cannot be the ultimate moto of insurance policy . Here in this case the OP No.2 made a after through story and divided the pandemic in to three stages
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and states this policy is only meant for the serious patients but the terms and condition. Of the policy aid something different as such it is out of consideration.
Moreover such an action was unreasonable and would be a malafide action Just to repudiate the claim the insurer hide the terms and condition while sold the policy to the complainant if the after through story is true which amounts to unfair trade practice.
The insurance contract being a contract of utmost good faith it is a two way door. The standards of conduct as expected under the utmost good faith obligation should be met by either party to such contract a concluded contract governs the parties and when such claim is repudiated the same was held to be a fowl play amounts to deficiency of service.
Insurance contract is a contract of indemnity where the happening of the event is uncertain.
After careful scrutinization of the material on record, we gave our through full consideration in favour of the complainant . Hence Order.
ORDER
The Op No.2 ( Cholamandalam Ms General Insurance Co Ltd. Bolangir Branch) is directed to pay a sum of Rs 1,50,000/- towards compensation @12%interest P.A from the date of incident and Rs.20,000/-towards mental agony and Rs.5000/-towards litigation expencesses within one month from the date of order , failing which the entire amount should be payable @15% interest from the date of filing till realization .
No award as to cost.
PRONOUNCED IN THE OPEN COMMISSION TODAY i.e DATED 17TH DAY OF MARCH’2023.
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(J.MISHRA) (R.K.TRIPATHY)
MEMBER. PRESIDENT(I/C)
