By Sri. MOHANDASAN.K, PRESIDENT

                 The complaint in short is as follows:-

1.            The complainant subscribed a insurance policy called “Corona Rakshak Claim” which is introduced by the opposite party to protect the life and welfare of persons affected by Corona 19 pandemic. The insurance policy number was 442400/48/2021/3500. As per the insurance scheme the insurance company is bound to meet the expenses of complainant in case, he is affected by Covid 19 and he under goes treatment for a specified period. As per the scheme, ones the insured under goes treatment for the specified period, is entitled to get the total amount insured.  The opposite party has not served the copy of policy or any records related to the scheme.  It was under taken by the opposite party that it would provide all necessary and relevant papers at a later stage. But so far the opposite party has not provided the same to the complainant.

2.         The complainant submitted that he was affected by Covid 19 and was got admitted at Moulana hospital Perinthalmanna which is one of the net work hospitals of the opposite party as per the policy. The complainant admitted in the hospital on 03/05/2021 at 10.41 AM.  Prior to the admission in the hospital the complainant was tested positive.  So at the time of admission itself treatment started and the complainant was discharged at 1.08 PM on 06/05/2021.  Hence the complainant was undergone active treatment for more than 74 hours in the hospital.  Thereafter discharge and after the quarantine period complainant preferred claim on 15/05/2021 before the opposite party. As per the direction from the opposite party the complainant has enclosed all original documents relating to treatment with the claim application. 

3.         Thereafter the opposite party informed the complainant on 10/09/2021 that the opposite party found  no grounds for considering the complainants calm and so the file was closed as “no claim“. In the said letter the opposite party referred to the alleged exclusion clause No. 6.1 and clauses 3.7 and 3.8. Those clauses are as under respectively, as per the rejection notice sent by the opposite party.

            “6.1     the company shall not be liable to make any payment under the policy, in respect of any expenses incurred in connection with or in respect of: (i) Expenses related to any admission primarily for diagnostics  and evaluation purposes .  (ii) Any diagnostic expense which are not related or not incidental to the current diagnosis and treatment”.

            3.7 hospitalization means admission in a hospital designated for Covid 19 treatment by government for a minimum period of (72) consecutive “ In patient care” hours.

`           3.8 in patient care means treatment for which the insured person has to stay in a hospital continuously for more than 72 hours for treatment of Covid “.

4.         The complainant submitted that from the medical records submitted by the complainant before the opposite party, the claim put forth by the complainant is not at all expense related to any admission primarily for diagnostics and evaluation purposes.  The complainant spent more than 72 hours in the hospital for the treatment of Covid itself is disclosed by the case records. On admission itself the treatment started for the illness and the complainant stayed in the hospital for more than 72 hours for treatment of covid alone.  It is submitted that the hospital concerned is a hospital designated for covid 19 treatment and so clause 3.7 and 3.8 are complied with.

5.         The complainant submitted that the opposite party introduced the scheme and entered into the region of a service scheme. The alleged scheme and the documents related to it , including the  agreement are unilaterally prepared and drafted by the opposite party. The complainant has got no involvement at all in those matters and the complainant was actuated to accept the scheme on the humanitarian and service factors exhibited by the scheme.   Since area of the scheme is internationally dreaded pandemic, covid 19, the opposite party is expected to carry out the scheme most benevolently in favor of the affected parties.  Hence the opposite party is expected to give no room for any negligence or deficiency in service in the matter. Exactly because of this reason, the affected party including the complainant cannot be tangled with technicalities and cannot be prohibited from seeking redressal  before this Consumer Disputes Redressal Commission  against the patent negligence, lack of care and deficiency of service  of the opposite party.   Hence the complainant   prays for the insured amount of Rs.2,50,000/- along with cost and compensation.

6.         On admission of the complaint notice was issued to the opposite party and on receipt of notice, the opposite party entered appearance and filed version. The opposite party denied all the material allegations in the complaint and submitted that the complaint is not legally maintainable, devoid of merits and is liable to be dismissed with cost.

7.         The opposite party submitted that the complainant has approached the opposite party and requested to issue “ Corona Rakshak policy “ and the opposite party has issued the policy conditions of the above policy and the complainant  has accepted the policy conditions  and had  remitted the policy premium and the opposite party issued  corona Rakshak policy certificate No. 442400/48/2021/3500  in favor of the complainant for the period commencing form 17/9/2020 to 28/06/2021 and the liability of the opposite party  is subject to the terms , conditions , exceptions and limitations of the policy .

8.         The opposite party submitted that the claim under health insurance policies are dealing by third party administrators (TPA ) company  holding IRDA license  to perform as third party administrators  (TPA ) named  M/s : Vidal health insurance TPA private limited , Bangalore.  The complainant submitted a claim  under the above policy to M/s : Vidal health insurance TPA private limited , Bangalore  for the hospitalization at M/S Moulana hospital Perinthalmanna from 03/05/2021 and  discharged on 06/05/2021and on receipt of claim documents, the clam was reviewed by team of panel doctors who are in opinion that  the claim should be investigated and accordingly the investigation  was conducted  and  on a scrutiny of the doctors certificate attached to the claim document would show that complainant was  fit for discharge on the third day of  diagnosis for covid positive and  it is noted in the discharge summary that the complainant was admitted in the above hospital for fever and cough  since two days and on routine examine he was found to be positive and hence the complainant  was admitted for  further observation  and medication  and the complainant was discharged on 3rd day of admission and there is no proper explanation for early discharge from hospital though he stated to be covid positive patient .

9.         The opposite party submitted that  the claim documents, discharge summary  and other medical / lab records attached to the claim form, it is clear that the expenses  incurred by the complainant are primary for evaluation  and diagnostic purposes  only and there is no situation warranting hospitalization and no active  line of treatments and medication  followed  as  per the investigation report  and so  the doctor stated in the discharge note  that complainant is  fit for discharge  that is on the 3^rd day of diagnosis of covid positive and there is no proper explanation  for early discharge from the said hospital.  It is further submitted that as per the policy condition the sum insured is payable only on positive diagnosis of covid 19 warranting hospitalization for a minimum continues period of 72 hours and the expenses if any related to any admission primary for diagnostic and evaluation purposes are not covered under the policy.  The claim of the complainant is not admissible as per clause 6.1 and clauses 3.7 and 3.8 of the exclusions of the policy conditions and hence the claim was repudiated as “No Claim”. The opposite party reproduced exclusion clauses 6.1, 3.7 and 3.8. It is submitted that the exclusion clauses are known to the complainant at the time of taking the policy and this opposite party has timely intimated the repudiation of the above claim to the complainant vide letter dated 10/09/2021 and the reason for the repudiation of the above claim also stated  in the above letter. The opposite party submitted that the  repudiation  of the claim is all valid and convincing reasons and the continuation  in the hospital for 72 hours is not  a ground for  admitting the claim and the hospitalization  for 72 hours is not a ground for  admitting the claim  and the hospitalization  should be in a hospital designated for covid 19 treatment by government for a minimum period of 72 consecutive “in patient for hours “ and  the inpatient care means treatment for which the insured person has to staying a hospital continually for more than 72 hours for treatment of covid 19 and so the treatment of the complainant was not as required  under clause 3.7 and 3.8 of the policy conditions .   

10.       The opposite party denied the contentions of the complainant that as per the scheme, the complainant is entitled to get the total amount insured and the opposite party has not served the copy of the policy or any records related to the scheme and it was undertaken by the  opposite party  that it would  provide  all necessary and relevant papers at a later stage , but so far the opposite party has not provided  the same etc.  The opposite party submitted that they had issued the policy conditions and explained to the complainant and the complainant has accepted the policy conditions and subsequently remitted the policy premium.  Subsequently the opposite party issued the policy certificate also.

11.       Hence the submission of the opposite party is that the complaint is filed only on experimental basis, the complainant is not entitled the relief as prayed and the complainant is liable to be dismissed with the cost of the opposite party.

12.       The complainant and opposite party filed affidavit and documents.  The documents on the side of complainant marked as Ext A1 to A 12 and the documents on the side opposite party marked as Ext. B1 to B3. Ext. A1 is repudiation letter issued by opposite party to the complainant dated 10/09/2021. Ext.A2 is copy of lawyer notice dated 29/09/2021. Ext. A3 is copy of reply lawyer notice dated 12/10/2021.  Ext. A4 is copy of insurance claim form Ext. A5 is copy of Covid 19 rapid antigen test dated 03/05/2021 issued by Moulana hospital Perinthalmanna .  Ext. A6 copy of laboratory investigation report dated 03/05/2021.Ext A7 certificate issued from Moulana hospital revealing antigen test positive on 03/05/2021. Ext. A8 certificate issued from Moulana hospital revealing admission period i.e., from 03/05/2021 at 10.45am to 06/05/2021 1.08 pm dated 11/05/2021.  Ext. A9 is discharge summary dated 06/05/2021.  Ext.A10 is discharge bill for Rs.25,792/- dated 06/05/2021.  Ext.A11 is   copy of admission verification form issued from Moulana hospital Perinthalmanna. Ext. A12 is copy of photo copy of doctor’s order and progress note. Ext. B1is copy of Corona Rakshak policy - oriental insurance policy schedule –UIN: OICHLIB21064V012021, policy No.442400/48/2021/3500 from 17/09/2020 to 28/06/2021 – along with policy document.  Ext. B2 is copy of lawyer notice issued by Adv. M. Kesavan nair to the opposite party dated 29/09/2021. Ext. B3 is copy of replay notice issued by adv. P.C Chacko to adv. M. Kesavan Nair dated 12/10/2021.

13.       Heard complainant and opposite parties, perused affidavit, and documents. The following points arise for consideration.

1. Whether the complainant is entitled for the insurance coverage?
2. Relief and cost?

14.       Point No.1 and 2

            The opposite party admitted the issuance of Corona Rakshak claim policy as per policy No. 442400/48/2021/3500 to the complainant. But the opposite party submitted that the complainant is not entitled for the insurance claim since the complainant has not undergone treatment for the corona ailment as stipulated in the policy condition. According to the opposite party the complainant is not necessary to undergo hospitalization for the Covid 19 which the complainant sustained. The opposite party submitted that the complainant submitted a claim under the policy to M/s Vidal health insurance TPA private limited Bangalore  for the hospitalization  at M/s Moulana hospital, Perinthalmanna from 03/05/2021 discharged on 06/05/2021 and on receipt of the claim document,  the claim was reviewed by team of panel doctors who are in opinion  that the claim should be investigated and accordingly the investigation was conducted and on a scrutiny of doctors certificate attached to the claim document would show the  complainant was fit for discharge on the third day diagnosis for covid positive and it is noted in the discharge summary that the complainant was admitted in the above hospital for fever and cough since two days  and routine examination he was found to be positive and hence the complainant was admitted for further observation and medication  and the complainant was discharged on 3^rd day of admission and there is  no proper explanation for early discharge from hospital  though he stated to be covid positive patient.  The opposite party further contended the insured sum is payable only on positive diagnosis of covid 19 warranting hospitalization for a minimum continues period of 72 hours and the expenses if any related to any admission primary for diagnostic and evaluation purposes are not covered under this policy.  The opposite party contended the claim is not admissible as per clause 6.1 and clauses 3.7 and 3.8 of the exclusions of the policy conditions and so the claim was repudiated as per Ext. A1 document.

15.       Now the question arises whether the complainant was undergone treatment for 72 hours after detecting covid positive or not. The complainant produced    Ext. A5 covid 19 rapid antigen test revealing result as positive and which is dated 03/05/2021.  Ex.t A7 is a certificate issued from Moulana hospital which also reveals the complainant was admitted in the hospital due to complaint of high-grade fever / cough for two days and rapid antigen test was found to be positive on 03/05/2021.  Hence patient was admitted for further observation and medication. Exit A8 and A9 reveals the complainant was in the hospital from 03/05/2021 at 10:41 AM to 06/05/2021 at 1:08 PM. The discharge summary Ext. A9 reveals that the complainant was admitted with complaint of high fever and cough for two days and rapid antigen test positive on 03/05/2021, he was treated by team of doctors to deal covid ailment.  Ext. A9 further reveals the complainant was managed as covid 19 category B and improved symptomatically.  He was advised strict home quarantine for 14 days, during the hospitalization he was treated with antiviral, steroid, anticoagulant and steroid and other supportive care as per medical board advice.  So, the perusal of the documents it is established that the complainant was detected Covid 19 positive on 03/05/2021 and after 3 days of admission he was discharged with advice to undergo strict home quarantine for 14 days.  It is established that the complainant   was treated in a approved and recognized treatment center of Covid 19 and also undergone 72 hours of hospitalization as stipulated by the policy condition issued by the opposite party to the complainant which is produced by the opposite party as Ext. B1.  It is further revealed from the document that the complainant submitted the claim along with documents to TPA / company within the prescribed time limit as contended in clause 7.2 in the Ext.B1. Hence the facts are being so the opposite party is liable to issue the insurance benefit to the complainant as contended in the complaint. The non issuance of the insurance policy benefit amounts deficiency in service and so we find that there is deficiency in service on the part of the opposite party.

16.       The complainant rightly held in the complaint that the opposite party entered in to the region of a service scheme during the covid pandemic occasion. The scheme and documents including the agreement are unilaterally prepared and drafted by the opposite party.  The complainant has got no say in the matter of terms and conditions but to accept the scheme introduce by the opposite party. The area of the schme is internationally dreaded pandemic, covid 19. The opposite party is expected to carry out the scheme most benevolently in favor of the effected parties. Hence the submission of the complainant is that the affected parties cannot be tangled with technicalities   and cannot be prohibited from seeking redressal from the appropriate authorities. It is also relevant to note that the impact of covid ailment is not limited to the few days of hospitalization. Considering the nature of pandemic, the scheme was introduced to pay the lump sum amount on undergoing hospitalization for 72 hours after detection of covid positive. Hence the denial of insurance to the rightful claimants amounts unfair trade practice also.  The policy called Corona Rakshak Policy was introduced as social welfare measure to provide protection to the interest of public at large.  The opposite party through the denial of the benefit cuts the very root of the intention of the scheme, which cannot be allowed. In this complaint the complainant availed the policy and as per the policy condition the opposite party is liable to pay the full amount of insured money of Rs.2,50,000/- to the complainant. The Commission do not find any reason to deny the claim of the complainant for the insured sum. Hence the opposite party is directed to pay the insured sum to the complainant   from the date of filing this complaint with the interest at the rate of 6% per annum to till payment.  Considering the nature of claim we are not considering the compensation for the deficiency of service on the part of opposite party but we direct the opposite party to pay cost of Rs.10,000/- to the complainant.

17.       In the light of above facts and circumstances of the complaint, we allow this complaint as follows; -

1. The opposite party is directed to pay the lump sum amount of policy Rs.2,50,000/- (Rupees Two lakh fifty thousand only) to the complainant with interest at the rate 6% per annum from the date of complaint to till date of payment.
2. The opposite party is directed to pay Rs.10,000/- (Rupees Ten thousand only) as cost of the proceedings. 

The opposite party shall comply this order within one month from the date of receipt of copy of this order, failing which the opposite party is liable to pay the interest at the rate of 9% per annum for the entire above amount from the date of order to till date of payment.

Dated this 31^st  day of  July, 2023.

Mohandasan . K, President

     Preethi Sivaraman.C, Member

     Mohamed Ismayil.C.V, Member

APPENDIX

Witness examined on the side of the complainant: Nil

Documents marked on the side of the complainant: Ext.A1 to A12

Ext.A1: Repudiation letter issued by opposite party to the complainant dated

             10/09/2021.

Ext.A2: Lawyer notice dated 29/09/2021.

Ext A3: Reply lawyer notice dated 12/10/2021. 

Ext A4: Insurance claim form

Ext A5: Covid 19 rapid antigen test dated 03/05/2021 issued by Moulana hospital

             Perinthalmanna .

Ext.A6: Laboratory investigation report dated 03/05/2021

Ext.A7: Certificate issued from Moulana hospital revealing antigen test positive on

             03/05/2021.

Ext A8: Certificate issued from Moulana hospital revealing admission period i.e from

            03/05/2021 at 10.45am to 06/05/2021 1.08 pm dated 11/05/2021.

Ext A9: Discharge summary dated 06/05/2021. 

Ext A10: Discharge bill for Rs.25,792/- dated 06/05/2021.  

Ext.A11: Admission verification form issued from Moulana hospital perinthalmanna.

Ext.A12: Doctor’s order and progress note. 

Witness examined on the side of the opposite party: Nil

Documents marked on the side of the opposite party: Ext. B1 to B3

Ext.B1: Corona Rakshak policy - oriental insurance policy schedule –UIN:

           OICHLIB21064V012021, policy No.442400/48/2021/3500 from 17/09/2020 to

           28/06/2021 – along with policy document.

Ext.B2: Lawyer notice issued by Adv. M. Kesavan nair to the opposite party dated

           29/09/2021.

Ext.B3: replay notice issued by adv. P.C Chacko to adv. M. Kesavan Nair dated

      12/10/2021.

Mohandasan . K, President

     Preethi Sivaraman.C, Member

                                               Mohamed Ismayil.C.V, Member