IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated, the 30th day March, 2023.
Present: Sri. Manulal V.S. President
Smt. Bindhu R. Member
Sri. K.M. Anto, Member
C C No. 283/2021 (Filed on 26-11-2021)
Petitioner : Remyamol V.G.
W/o. Bibin P.R.
Vayalil House,
Anickadu P.O. Elampally,
Kottayam – 686 503
(Adv. G.R. Panicker)
Vs.
Opposite party : Cholamandalam MS General
Insurance Co. Ltd.
2nd Floor, Dare House,
2, N.S.C. Bose Road,
Chennai – 600-001
(Adv. Agi Joseph)
O R D E R
Sri. Manulal V.S. President
The case is filed under Section 35 of Consumer Protection Act, 2019
Crux of the complaint is as follows:
The complainant and her husband availed Corona Rakshak health insurance policy from the opposite party . The prospectus of the opposite party insurer describes the said policy as a single premium fixed benefit policy and offered lump sum benefit equal to 100 % of the sum assured is Rs.1,50,000/- if the insured person is diagnosed covid positive. On 16-4-2021 the complainant was tested for covid -19 rapid Antigen test at S.H. medical centre Kottayam and was diagnosed as covid positive . He was admitted there from 16-4-2021 to 29-4-2021. Complainant spent Rs.1,08,188/- for the her treatment.
The complainant sent claim form to the opposite party on 22-5-2021 along with the documents through the registered post. Though the opposite party received the claim form on 9-6-2021, they did not pay the amount as offered by them. According to the complainant the act of the opposite party amounts to unfair trade practice and deficiency in service and she had suffered huge mental agony and hardship and financial loss due to the actions of the opposite party. Hence this complaint is filed by the complainant praying for an order to direct the opposite party to pay Rs. 1.5 lakhs and to pay Rs.1,08,188/- which is the hospital expenses and to direct the opposite party to pay compensation of Rs. 10,000/ and Rs.5,000/- as cost of this litigation.
Upon notice opposite party appeared before the commission and filed version.
Version of the first opposite party is as follows:
The policy issued to the complainant is a Corona Rakshak policy for the period from 30-10-2020 to 26-07-2021 for a sum insured of Rs.1,50,000/- which is subject to the terms and conditions and exclusions of the policy. The complainant has not submitted the proper claim form and relevant records to the opposite party. The claim is not admissible for the reason that the treatment given during the hospitalization does not warrant inpatient admission and there is no active line of treatment. It is contented in the version that the discharge summary reveals that the complainant had Type II diabetics mellitus which was not disclosed while proposing for the policy. Thus, the non disclosure of material information, the contract of insurance becomes void and no claim is payable under the policy. According to the opposite party there was no deficiency in service or unfair trade practice on their side.
Complainant filed proof affidavit in lieu of chief examination and marked exhibit A1 to A7.Manjusha.V. , who is the Deputy Manager, Claims of the opposite party filed proof affidavit and exhibit B1 and B2 marked from the side of the opposite party.
On evaluation of complaint, version and evidence on record we would like to consider the following points.
- Whether there is any deficiency in service or unfair trade practice on the part of the opposite party?
- If so what are the reliefs and costs?
For the sake of convenience we would like to consider the point number 1 and 2 together.
There is no dispute on the facts that the complainant had availed a Corona Rakshak health insurance policy from the opposite party vide policy number 2894/00055838/000/00 for a period from 15-10-2020 to 26-7-2021. It is proved by exhibit A1 policy that the sum assured was Rs. 1,50,000/-. It is proved by Exhibit A3discharge summary issued by medical officer S.H. Medical Centre Kottayam that the complainant was admitted in the hospital on 16-4-2021 and discharged on 29-4-2021 when she became covid negative. Exhibit A4 proves that the complainant had spent Rs.1,05,188/- for the treatment after deducting Rs. 3000 which was a discount given by the hospital authorities.
Complaint was resisted by the opposite party, stating that the treatment given during the hospitalization does not warrant inpatient admission and there is no active line of treatment. The complainant has produced the discharge summary wherein it is stated that the covid pneumonia /type 2 DM, date of admission and discharge is also mentioned, drugs also prescribed. From the above record it is clear that the complainant was admitted in the hospital as per the guidelines issued by the Health Ministry.
The Hon'ble National Commission while dealing with a similar set of facts, in Sunil Kumar Sharma Vs. TATA AIG Life Insurance Company and Ors. bearing case no. RP no. 3557/2013 decided on 01.03.2021 held as under:-
14. Moreover the claim had been repudiated only on the ground that the insured was suffering from diabetes for a long time. So far as life style diseases like diabetes and high blood pressure are concerned, Hon'ble High Court of Delhi in Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., W.P.(C) No. 656 of 2007, decided on 17.09.2007 held as under:
"Insurance-Mediclaim-Reimbursement-Present Petition filed for appropriate directions to respondent to reimburse expenses incurred by him for his medical treatment, in accordance with policy of insurance-Held, there is no dispute that diabetes was a condition at time of submission of proposal, so was hyper tension-
Petitioner was advised to undergo ECG, which he did-Insurer accepted proposal and issued cover note-It is universally known that hypertension and diabetes can lead to a host of ailments, such as stroke, cardiac disease, renal failure, liver complications depending upon varied factors-That implies that there is probability of such ailments, equally they can arise in non-diabetics or those without hypertension-It would be apparent that giving a textual effect to Clause 4.1 of policy would in most such cases render mediclaim cover meaningless-Policy would be reduced to a contract with no content, in event of happening of contingency-Therefore Clause 4.1 of policy cannot be allowed to override insurer's primary liability-Main purpose rule would have to be pressed into service-Insurer renewed policy after petitioner underwent CABG procedure-
Therefore refusal by insurer to process and reimburse petitioner's claim is arbitrary and unreasonable-As a state agency, it has to set standards of model behaviour; its attitude here has displayed a contrary tendency-Therefore direction issued to respondent to process petitioner's claim, and ensure that he is reimbursed for procedure undergone by him according to claim lodged with it, within six weeks and petition allowed."
Though the opposite party contended that the complainant is a known case of diabetics mellitus which is a pre- existing disease they did not produced any previous medical history of the complainant to prove their case. The onus of proving the fact that the insured had prior knowledge that he was suffering from fatal diseases and as such he deliberately suppressed these material facts at the time of filling up the proposal form was on the insurance company.
Further, it was noted that, there was no evidence on record to show that the insured had knowledge that she was suffering from fatal diseases prior to taking the policy and there was inadequate evidence to support that she had deliberately suppressed her medical condition.
On perusal of operative clause of B1 policy wordings we can see that, If during the policy period the Insured Person is diagnosed with COVID and hospitalized for more than seventy-two hours following Medical Advice of a duly qualified Medical Practitioner as per the norms specified by Ministry of Health and Family Welfare, Government of India, the Company shall pay the agreed sum insured towards the Coverage mentioned in the policy schedule. . On perusal of exhibits A2 and A3 we cannot see that the admission of the complainant was only for the purpose of investigation and for the evaluation of the ailment which he had. It is argued by the counsel for the complainant that he was treated as per the guidelines issued by the Ministry of Health and Family Welfare, Government of India, and Govt of Kerala at that time. It is pertinent to note that the opposite party has not produced any evidence to prove that the complainant has not treated with the guidelines and protocol for which was issued by the Ministry of Health and Family Welfare, Government of India and government of Kerala at that time.
As per Clause 4.1 of the terms conditions of the policy COVID Cover is a 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. The positive diagnosis of COVID shall be from a government authorized diagnostic centre.The payment will be made only on Hospitalisation for a minimum continuous period of 72 hours following positive diagnosis for COVID.
Under such circumstance, we have to keep in mind very sound and salutary principle of "better protection of the right of the consumer" which is clearly stated in the preamble of Consumer Protection Act, 2019, and even if it is believed for the sake of argument that there was some inconsistency in reports, however, looking to the aforesaid hospital papers as we discussed, we are of the considered opinion that complainant was suffering from Covid-19 positive, hence repudiation is not sustainable. Therefore, we hold that the present complainant is covered under the policy of Corona and 100% of insured amount of Rs.1,50,000/- requires to be given under policy.
Therefore, we hold that act of the opposite party is against the principles of natural justice and fair play and very niggardly and hyper technical approach has been taken, with a myopic view of the opposite party in denying the claim amount. Therefore, we do not accept the ground stated by the opposite party for not honoring the claim of the complainant. Thus, we are of the opinion that the said act of the opposite party amounts to deficiency in service and unfair trade practice.
In the result following final order is passed.
- The complainant is entitled to recover the amount of Rs.1,50,000/-(Rupees One Lakh Fifty Thousand only)from the opposite party with the interest at the rate of 9% p.a. from the date of the filing (26-11-2021) of this complaint till realization..
- The complainant is entitled to recover the amount of Rs.10,000/- (Rupees Ten thousand Only) under the head of mental pain and suffering from the opposite party
- The complainant is entitled to recover Rs.5,000/- from the opposite party as cost to this litigation.
Aforesaid all amount to be paid to the complainant within 30 (thirty) days from the date of receiving the copy of the order , in default the compensation amount will carry further 9% interest from the date of this order till realization.
Pronounced in the Open Commission on this the 30th day of March, 2023
Sri. Manulal V.S. President Sd/-
Smt. Bindhu R. Member Sd/-
Sri. K.M. Anto, Member Sd/-
Appendix
Exhibits marked from the side of complainant
A1 – Copy of policy schedule with claim form
A2 – Copy of medical records in the name of complainant by SH medical Centre, Nagampadom, Kottayam
A3 – Copy of discharge summary dtd.29-04-2021 by SH Medical Centre
A4 – Copy of discharge bill dtd.29-04-2021
A5 – Copy of detailed discharge bill dtd.29-04-2021 issued by SH Medical Centre
A6- Postal receipt
A7- Postal AD card
Exhibits marked from the side of opposite party
B1 – Copy of policy with terms and conditions
B2 – Clinical Management protocol: Covid 19
By Order
Sd/-
Assistant Registrar
