D.O.F:08/02/2021
D.O.O:20/06/2024
IN THE CONSUMER DISPUTES REDRESSAL COMMISSION KASARAGOD
CC.39/2021
Dated this, the 20th day of June 2024
PRESENT:
SRI.KRISHNAN.K : PRESIDENT
SMT. BEENA. K.G : MEMBER
Mrs. Margaret D’souza (aged 37 years)
W/o Thomas, Residing Badiadka,
Perdala Post,
Kasaragod Taluk and District .671541. : Complainant
(Adv: ShivashankarBhat).
And
1. Future Generali India Insurance Co.Ltd,
Building – A, G-O Square, Sr. No.249+250,
Near MankarChowk, Pune, - 411057.
(Adv: M. MadhavanMalankad)
2. UCO Bank, : Opposite Party
Branch Office, 1st floor, Kalpaka Arcade,
Nulllipady, Kasaragod- 671121.
(Adv: Sathyashankara.M)
ORDER
SRI.KRISHNAN.K : PRESIDENT
The complainants case is that he obtained Corona Rakshak Insurance Policy covering for the period from 20/07/2020 to 30/04/2021, issued by Opposite Party No:1 through Opposite Party No:2 with a coverage of 100% sum insured on positive diagnosis of covid requiring hospitalization for more than 72 hours. He suffered throat pain fever, cough. He was admitted in Care well hospital Kasaragod from 27/08/2020 till 30/09/2020. The complainant submitted claim before Opposite Party No: 1. But Opposite Party No: 1rejected the claim. The act of Opposite Party No: 1 is deficiency in service and unfair trade practice for which complainant claim compensation of Rs. 1,00,000/- and full insured covered amount and cost of litigation.
The Opposite Party No:1 filed written version denying the allegations in the complaint. The case of Opposite Party No:1 is that it is a risk commencement policy valid from 04/08/2020 till 30/04/2021. Client information form such as other forms were required. The Opposite Party came to know that complainant has been suffering mild symptoms of covid-19 which she was given oral treatment decease and under medication with institutional isolation. The Complainant has not receive any active treatment and no in-patient treatment is needed. No hospitalization is required therefore claim rejected. The Opposite Party admitted insurance policy. But policy has got waiting period from 22/07/2020to 05/08/2020 and effective date 06/08/2020 till 02/05/2021. There is no promise of 100% payment in each and every case unless eligibilities are fulfilled and prayed to dismiss the complaint.
The Opposite Party No:2 filed written version denying any insurance liability to complainant. Further contended that there is no privity of contract between Opposite Party No:2 and complainant. The complainant obtained insurance policy from Opposite Party No:1 is liable to pay. The Opposite Party No: 2 is bank the entire responsibility of fulfilling the conditions of the insure policy lies upon Opposite Party No:1 and prayed to dismiss the complaint against Opposite Party No: 2.
The complainant filed chief affidavit and was cross examined for Opposite Parties Ext A1 to A4 documents marked from their side. Ext A1 is the policy, Ext A2 is the covid test report, Ext A3 discharge summary and Ext A4 is claim repudiation message issued by the OP.
The Opposite Party No: 1filed Ext B1 to B8 documents. Ext B1 is the policy, Ext B2 is the policy guidelines, Ext B3 is the health insurance claim form, Ext B4 is the nurses record,Ext B5 is document recovery intimation, Ext B6 is the Guidelines on clinical management, Ext B7 is the customer information sheet, Ext B8 is the claim repudiation letter.
Following points arise for consideration in the above case:
- Whether complainant is entitled for insurance benefits claimed in the case whether repudiation of claim is justifiable as per terms and conditions of the policy?
- Whether complainant is entitled for compensation? And if so for what reliefs.
All the points are considered together for convenience.
The grievance of the complainant is that Opposite Party repudiated the claim of insurance benefits without valid reason. The Opposite Party No:1 justified the rejection of the claim for the reason hospitalization not required. People prefers health insurance policy to meet the unexpected needs. During the time of covid – 19 pandamic in the country so many insurance companies offered Corona Risk Policies. People attracted to the policy mainly because of any one can affect the decease at any time.
In this case complainant obtained Ext A1 policy from Opposite Party having policy No: CRP-44-20-7515212-00-000 of Corona Rakshak Policy covers for the period from 04/08/2020 to 30/04/2021 of 285 days. The Opposite Party No:2 is the authorized inter mediatory of Opposite Party No:1. The above said policy covers Lumpsum benefit of 100% of the insured shall be payable on positive diagnosis of covid -19 requiring hospitalization for a minimum continuous period of 72 hours.
The Opposite Party No:1 admitted the insurance policy. The policy obtained on 20/07/2020 and valid till 30/04/2021, the risk commencement of the policy valid from 04/08/2020 till 30/04/2021. The complainant hospitalized on diagnosing as covid positive on 27/08/2020 and was inpatient up to 30/08/2020, that is within risk covering period. The Opposite Party No:1 rejected the claim on the ground that complainant it is simple case and no hospitalization is required. No active hospital treatment taken and only quarantine required.
If a party approaches for insurance benefits the denial on baseless grounds amounts deficiency in service and unfair trade practice.
The complainant has lead evidence in the case and the opposite parties has cross examined the complainant but failed to bring out from the complainant that if he had required only quarantine as narrated in the repudiation letter issued by the Opposite Party No: 1 Opposite Party has not given any evidence in the case to prove their contentions.
So there is willful negligence on the part of Opposite Party No: 1 rejecting the claim amount. In a claim against the insurance company for compensation it was for the insurance company disprove such claim with evidence if any, vide Shobika Attire Vs New India Assurance Co Ltd (2006) 8 SCC35.
In the light of above discussion the Opposite Party No:1 Insurance Company is liable to make the payment of the insurance claim under the policies for the complainant amounting Rs. 2,50,000/- with interest assured thereon. And also compensation for deficiency in service we are of the opinion that an amount of Rs. 10,000/- is reasonable in the head and Rs. 5000/- allowed as cost of litigation.
In the result complaint is allowed in part directing Opposite party No:1 to pay an amount of Rs. 2,50,000/- (Rupees Two Lakh Fifty thousand only) as insurance policy amount being with 6% interest from the date of complaint till realization and Rs. 10,000/- (Rupees Ten thousand only) for deficiency in service and Rs. 5000/- (Rupees Five thousand only) cost of litigation to the complainant within 30 days of the receipt of the order. The opposite Party No:2 exonerated from liability.
Sd/- Sd/- MEMBER PRESIDENT
Exhibits
A1- The policy
A2- Covid test report
A3- Discharge summary
A4- Claim repudiation message
B1- The policy
B2- Policy guidelines
B3- Health Insurance claim form,
B4- Nurse record
B5- Document recovery intimation
B6- Guidelines on clinical management
B7- Customer information sheet
B8- Claim repudiation letter
Witness Examined
Pw1- Margaret D’souza
Dw1-Sudheesh.C
Sd/- Sd/-
MEMBER PRESIDENT
Forwarded by Order
Assistant Registrar
Ps/
