IN THE CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM
Dated this the 28th day of February, 2023
Present: Sri.Manulal.V.S, President
Smt.Bindhu.R, Member
Sri.K.M.Anto, Member
CC No.72/2022 (Filed on 02.04.2022)
Complainant : Thomas V.Muppathy
Muppathiyil House
Vadavathoor P.O
Kottayam-686010
(By Adv.Tomy K James)
Vs
Opposite party : Future Generali India Insurance
Company Ltd
2nd Floor, Urumbil Signature Towers
6/75, Kanjikuzhy, Kottayam-686004.
(By Adv.Shamon Shaji)
O R D E R
Sri. Manulal V.S, President
The complaint is filed under section 35 of the Consumer Protection Act 2019.
Crux of the complaint is as follows: The complainant 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 as Rs.2,50,000/- if the insured person is diagnosed covid positive.
On 19-09-2020 the complainant was tested for covid -19 rapid Antigen test by DDRC diagnostic centre and was diagnosed as covid positive. He was admitted at CFLTS Muttamabalam from 19-09-2020 to 29-09-2020 and thereafter has been in room isolation for seven days until 06-10-2020.
The complainant lodged claim to the opposite party on 16-12-2020 along with the documents. But the first opposite party repudiated the claim stating that “there was no active line of treatment observed during hospitalization patient received only oral medication”.
The opposite party illegally repudiated the genuine claim of the complainant. 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 complainant is filed by the complainant praying for an order to direct the opposite parties to pay Rs.2.5 lakhs along with interest and to direct the opposite parties to pay compensation of Rs.1,00,000/- and Rs.10,000/- as cost of this litigation.
Upon notice opposite party appeared before the commission and filed separate version.
Version of the opposite party is as follows: On receipt of proposal form and premium the opposite party issued the policy to the complainant vide policy number CRP-59-20-7518186-0-000 for a period from 22-07-2020 to 02-05-2021. The opposite party received a claim informing that the insured was hospitalized from 19-09-2020 to 29-09-2020 for the treatment of Covid 19. As per discharge summary the patient was tested negative for covid 19 and suggested for 7 days isolation. According to forensic expert complainant was hospitalized mainly for isolation / investigation / evaluation purpose only. The isolation / investigation / evaluation and treatment for symptoms faced, could easily have been managed on OPD basis. The hospitalization was not justified as the patient could have been treated as an outpatient. As per circular issued by Government MOHFW dated 17-03-20, mild symptoms does not require hospitalization. The complainant was covid-19 positive asymptomatic and was managed conservatively. The opposite party is liable to compensate the complainant only according to the terms and conditions of 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 A4. Marsirdin Shaik, who is the legal compliance of the opposite party filed proof affidavit and Exhibit B1 to B7 were 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 CRP-59-20-7518186-0-000 for a period from 22-07-2020 to 02-05-2021. It is admitted by the opposite party in version that the sum assured was Rs.2,50,000/-. It is proved by Exhibit A3 discharge card issued by duty medical officer of CFLTC Muttambalam that the complainant was admitted in the CFLTC which is Covid First Line Treatment Centre on 19-09-2020 and discharged on 29-09-2020 when he became covid negative. On perusal of Exhibit A4 which is the quarantine release certificate, post admission covid positive issued from the PHC Paramuzha we can see that the complainant was admitted at CFLTC Muttamablam, after being tested positive for covid -19 on 19-09-2020 and was discharged on 29-09-2020 and he continued in quarantine till 06-10-2020.
Complaint was resisted by the opposite party, stating that as per exhibit B6 forensic expert report, complainant was hospitalized mainly for isolation /investigation/ evaluation purpose only. The isolation/investigation/evaluation and treatment for symptoms faced, could easily have been managed on OPD basis. The opposite party vide exhibit A1 repudiation letter relied on clause 6 of the terms and conditions of the policy, which is reproduced hereunder,
6. Exclusions:
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:
6.1. Investigation & Evaluation (Code- Excl04)
- Expenses related to any admission primarily for diagnostics and evaluation purposes.
- Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment
6.2. Any diagnosis which is not related and not incidental to COVID is not covered in this Policy
6.3. Testing done at a Diagnostic centre which is not authorized by the Government shall not be recognized under this Policy
6.4. Any claim with respect to COVID manifested prior to commencement date of this policy or during the waiting period.
6.5. Cover under this Policy shall cease if the Insured Person travels to any country placed under travel restriction by the Government of India.
On perusal of Exhibit B6 we can see that the same is a document prepared by Dr.C.H. Asrani on 11-02-2021. On perusal of Exhibit B6 we can see that some part of another document is scanned and affixed thereon as “course in CFLTC was uneventful symptomatically better hence discharged”. Moreover it is pertinent to note that the said Dr. Asrani prepared exhibit B6 without examining the complainant. However Exhibit B6 does not speak about from where he collected these details. Similarly on perusal of Exhibit B3 which is claimed to be a discharge summary we cannot see the name of the hospital, name of the issuing medical officer and the seal and signature of the issuing medical officer. A document which does not contain the details of the issuing medical officer and his /her signature we cannot consider the same in evidence. Thus we are not inclined to look into exhibit B3.
On perusal of Exhibit A3 which is the discharge card issued by the duty medical officer on 29-09-2022 we can see that the complainant was treated there with oral medications.
Exhibit A2 is the claim repudiation letter dated 19-02-2021. In A2 it is stated by the opposite party that hospitalization means admission in a hospital for covid 19 treatment by government, for a minimum period of 72 hours consecutive “in-patient care hours”.
In Star Health and Allied Insurance Company Ltd v. Avinash T. and other Hon’ble High Court of Kerala held that "CFLTCs are Primary Level Health Care Centres set up for providing care to less serious cases and referral of serious cases to COVID hospitals, so as to avoid crowding in COVID Hospitals and avoid wastage of resources. It can therefore be unhesitatingly held that CFLTCs are designated as hospitals for the treatment of COVID-19".
As discussed earlier it is proved by Exhibit A3 and A4 is that the complainant was admitted at CFLTC Muttambalam, after being tested positive for covid-19 on 19-09-2020 and was discharged on 29-09-2020 and he continued in quarantine till 06-10-2020.
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 Exhibit 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 of 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 and 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 hospitalization 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.2,50,000/- requires to be given under the policy.
Therefore, we hold that letter of repudiation dated 23-12-2020 and 19-02-2021 was passed 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 in the letter of repudiations accordingly it cannot be acted upon. 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.2,50,000/-(Rupees Two Lakh Fifty Thousand only) from the opposite party with the interest at the rate of 9% p.a. from the date of the filing of this complaint till realization.
- The complainant is entitled to recover the amount of Rs.25,000/- (Rupees Twenty Five 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 28th day of February, 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- Claim repudiation letter of Future Generali Total Insurance Solutions dated 23.12.2020.
A2- Claim repudiation letter of Future Generali Total Insurance Solutions dated 19.02.2021.
A3- Discharge card issued by CFLTC Muttambalam.
A4- Copy of quarantine release certificate, post admission, covid positives of PHC Parampuzha
Exhibits marked from the side of opposite party.
B1- Copy of the customer information sheet issued by Future Generali Total Insurance Solutions.
B2- Copy of health insurance claim form of Future Generali Total Insurance Solutions.
B3- Copy of the discharge card issued by CFLTC Muttambalam.
B4- Copy of the guidelines on clinical management of Covid-19
B5- Copy of Covid-19 advisory for patient admission to covid CFLTC issued by Govt.of Kerala.
B6- Copy of policy and claim details of Thomas V Muppathy.
B7- Copy of claim repudiation letter from Future Generali Total Insurance Solutions.
By order
sd/-
Assistant Registrar
