By Sri. Mohamed Ismayil.C.V, Member
The complaint is filed under Section 35 of Consumer Protection Act 2019:-
1. The complainant is an employee working in Akshaya Centre, Edavanna. The first opposite party is the Insurance Company, the second opposite party is the regional office of the first opposite party and third opposite party is the intermediary agent of the first opposite party. When the complainant approached the third opposite party for a banking purpose, then the representative of the third opposite party introduced an insurance policy of the first opposite party named Corona Rakshak Policy and canvassed to subscribe the same. Being a person regularly contacting with public, the complainant believed in the assurance of the third opposite party as benefits will be available as per the terms and conditions of the policy. So the complainant subscribed the Corona Rakshak Policy of the opposite parties to meet the contingency due to Covid 19 pandemic. All details were filled by the representatives of the third opposite party and there was no access to the complainant for doing the same directly. The number of subscribed insurance policy is H0425588 and it is valid from 10/09/2020 to 21/06/2021. The amount of assured sum is Rs. 2,00,000/- (Rupees Two lakh only) and paid premium is Rs. 1,754.06/- for availing the above said Medical Insurance Policy. The complainant was affected by Covid 19 disease and she was admitted to Government Medical College Hospital, Manjeri on 23/10/2020. It is stated in the complaint that she continued her treatment as in-patient in the hospital up to 02/11/2020. After the discharge, the complainant applied for insurance benefit on 11/12/2020 with required documents. But the first opposite party repudiated the claim of the complainant on the ground that the hospitalisation of the complainant is not justified as ICMR and departmental guidelines asymptomatic/mild symptoms with isolation/home quarantine. It is stated by the complainant that the reason for repudiation of the claim is not valid and the opposite party was acted against the prevailing norms related to Covid 19 pandemic. The complainant contended that the direction of the authority as it can be managed with isolation/home quarantine does not mean that in all asymptomatic/ mild symptoms of covid cases should be treated without hospitalisation. The asymptomatic or mild symptoms of covid-19 can be treated in isolation or home quarantine only when there is high level increase in the number of covid 19 patients and deficiency in accommodation in hospitals. It is contended by the complainant that the treating doctor is the decision maker in providing the nature of treatment and place of treatment. It is stated by the complainant that the Corona Rakshak Policy issued by the opposite party is providing insurance coverage to the subscriber, who affected with Covid 19 and availed treatment in hospital. The repudiation of the claim from the side of the opposite parties are untenable, illegal and violation of terms and conditions of the policy. The opposite parties committed deficiency in service by denying the legal claim of the complainant. The act of the opposite parties caused irreparable loss and damaged to the complainant and she also suffered mental agony and hardship. So the complainant claimed compensation from the opposite parties. The complainant prayed for a direction to the opposite parties to pay an amount of Rs.2,00,000/- to the complainant as the amount guaranteed by the opposite parties to the complainant as per the terms of the policy. The complainant claimed for a direction to the opposite parties to pay Rs. 2,00,000/-(Rupees Two lakh only) as compensation to the complainant for sufferings of mental agony and hardship due to the deficiency of service committed by the opposite parties. The complainant also claimed Rs. 50,000/-(Rupees Fifty thousand only) from the opposite parties as the cost of the proceedings.
2. The complaint is admitted on file and issued notice to the opposite parties. The opposite parties received notice and appeared before the Commission through counsels. The first and second opposite parties filed version jointly and third opposite party filed version separately.
3. The version of the first and second opposite parties vehemently opposed the contentions raised by the complainant. The issuance of Corona Rakshak Policy in favour of the complainant is admitted by the opposite parties. It is contended by the opposite parties that the rights and liabilities of the parties are governed by the terms and conditions of policy i.e, contract of insurance policy. The opposite parties stated that as per terms 4.1 of the policy contract lump sum benefit equal to 100% of the Sum Insured shall be payable on positive diagnosis of Covid-19, requiring hospitalisation for a minimum continuous period of 72 hours. The positive diagnosis of covid-19 shall be from a government authorised diagnosis centre. According to the opposite parties, the operative word is ‘requiring hospitalization’ and not whether the person was actually hospitalised. It is further stated that as per the ICMR and Ministry of Health and Family Welfare Guidelines “asymptomatic/mild symptoms with covid-19 cases can be managed with isolation/ home quarantine so hospitalisation no justified. The opposite parties contended that the complainant treated at Government Medical College hospital, Manjeri without specific complaints or complications and so the complainant had to be kept under home isolation/covid case centre for isolation. Moreover, the documents produced by the complainant shows that the patient was only isolated in Covid Care Centre without major symptoms. It is also stated by the opposite parties that mere admission to a hospital for isolation purpose do not make a person eligible for benefits under the policy coverage. There was no arbitrary repudiation. The complainant is an educated person and terms and conditions of the policy are clearly spelt out in the policy. It is categorically stated in the version by the opposite parties that no promises were given to the complainant and no deficiency in service committed by the opposite parties. So the opposite parties prayed for dismissal of the complaint with cost.
4. The third opposite party admitted the subscription of policy by the complainant. The opposite party contended in the version that the complainant was fully aware of the terms and conditions of the policy. According to the opposite party allegations are false and against the facts of the case. The opposite party stated that, the liability is to be fastened on the Insurance Company. The opposite party denied the allegations of the complainant that it acted as an intermediary agent of the first opposite party and canvassed the subscription of the policy. There was no inducement on the part of the opposite party to force the complainant to subscribe the insurance policy as alleged in the complaint. It is admitted in the 3 paragraph of the version that the opposite party had given advices and assisted the complainant to complete the formalities to avail the insurance policy. The averments in the complaint that representative of the opposite party could convince the complainant that the said policy is suitable for an Akshaya Employee like the complainant which comes under essential services and the same can be claimed without much formalities is also denied by the opposite party. It is stated that the application for subscription of insurance policy was made online and payment of premium also made online and the opposite party assisted the complainant to avail the insurance policy and the policy got issued in the name of the complainant. The opposite party further averred that the incident of hospitalisation and denial of insurance policy claim by the first and second opposite parties were not known. The opposite party declined to interfere in the matter of repudiation as it does not affect the answering opposite party. According to the opposite party, the statement in the complaint that whether a covid patient is to be treated by admitting in the hospital or whether he is to be send to his house for home quarantine is to be decided by the treating doctor is believed to be true and correct. According to the opposite party the patient has no say in the matter of his treatment and he cannot insist or compel the doctor to give him treatment by keeping him in his own house is found genuine. There is no deficiency in service from the side of the opposite party, as it never becomes part of decision of repudiation. It is apparent from the documents that the claim was put forth to the Insurance Company. The cause of action of the complaint does not raise against the third opposite party as there is no allegation of deficiency in service against the third opposite party and the opposite party is prayed for dismissal of the complaint with compensatory cost.
5. The complainant and the opposite parties filed their affidavits. Both parties also produced documents. The complainant produced documents and marked as Ext. A1 to A5 documents. Ext. A1 document is the copy of insurance policy issued by the first opposite party to the complainant. Ext. A2 document is the copy of repudiation letter dated 11/12/2020 issued by the first opposite party to complainant. Ext. A3 document is the copy of discharge card dated 02/11/2020 issued to the complainant by the Government Medical College hospital, Manjeri. Ext. A4 document is the copy of treatment certificate dated 15/12/2020 issued by the Medical Officer, Family Health Centre, Odakkayam. Ext. A5 document is the copy of Covid-19 test report dated 23/10/2020 issued by Government, Medical College Hospital, Manjeri. The first and second opposite parties produced documents and marked as Ext. B1 to B2 documents. Ext. B1 document is the copy of policy issued by the first opposite party to the complainant. Ext. B2 document is the copy of Clinical Management Protocol issued by Ministry of Health and Family Welfare, Government of India.
6. Heard both sides. Gone through all documents produced by the parties including affidavits. So this Commission considered the following points:
- Whether the act of the opposite parties amounted to deficiency in service?
- If yes, then what will be the relief and cost to be given to the complainant?
7. Point No.1 and 2:-
The grievance of the complainant is that the opposite parties did not complied the terms and conditions of the insurance coverage named Corona Rakshak Policy and thereby rejected his insurance claim under the policy. The complainant stated that he availed insurance policy issued by the first and second opposite party. The third opposite party is the intermediary agent of the first opposite party for initiating subscription of the policy. The complainant produced copy of the policy issued by the opposite parties and marked as Ext. A1 document. Ext. A1 document also reveals that the third opposite party was the intermediary agent of the first opposite party. The contention of the complainant is that as per terms and conditions of the policy lump sum benefit equal to 100% of the sum insured shall be payable on positive diagnosis of cov-19, requiring hospitalisation for a minimum continuous period of 72 hours. The positive diagnosis of covid-19 shall be from a Government authorised diagnosis centre. So the opposite parties are liable to disburse the claim of the complainant, who treated for covid -19 diseases as per policy coverage. Hence, in this, case as evident from the documents produced by the complainant that the complainant was hospitalised on 23/10/2020 due to covid -19 disease and treated therein about 10 days thereafter discharged on 02/11/2020. The complainant produced the discharge summary issued by the Government Medical College Hospital, Manjeri and same is marked as Ext. A3 document. The complainant also produced test report issued from the laboratory approved for covid -19 test by Indian Council of Medical Research, Government of India through Department of Health and Family Welfare, Government of Kerala and marked it as Ext. A5 document. Ext.A5 document shows that the complainant was affected by Covid -19 disease. Both Ext. A3 and A5 documents reveals that the complainant had undergone treatment as per the terms and conditions of the policy issued by the opposite parties. The complainant also produced treatment certificate issued by the Medical Officer, Family Health Centre and same is marked as Ext. A4 document. Later the complainant submitted a claim application before the opposite parties for Rs. 2,00,000/- as per the terms of the policy. But the opposite parties repudiated the claim of the complainant stating that the complainant was asymptomatic and as per the ICMR and Ministry of Health and Family Welfare guidelines asymptomatic or mild symptoms with covid-19 cases can be managed with isolation or home quarantine and so the hospitalisation of the complainant is not justified. The copy of repudiation letter dated 11/12/2020 issued by the first opposite party is produced and marked as Ext. A2 document.
8. The opposite parties admitted the issuance of policy to the complainant and hospitalisation took place during the period of policy coverage. The opposite parties contended that the repudiation of the claim of the complainant is legally sustainable as terms and conditions of the policy categorically announced that the lump sum benefit equal to 100% of the sum insured shall be payable on positive diagnosis of covid-19, requiring hospitalisation for a minimum continuous period of 72 hours. According to the opposite parties, the operative word is requiring hospitalization and not whether the person was actually hospitalised. The opposite parties also produced the copy of insurance documents and marked as Ext. B1 document. Ext. A1 document as well Ext. B1 document serves same purpose in the evaluation of evidence. It is also averred by the opposite parties that the hospitalization of the complainant is without specific complaints and the patient was required only isolation or home quarantine as he was asymptomatic. The opposite parties produced the copy of Clinical Management Protocol issued by the Ministry of Health and Family Welfare, Government of India and same is marked as Ext.B2 document by the Commission. The third opposite party admitted that had given advices and assisted the complainant to complete the formalities to avail the insurance policy.
9. Analysing the evidence presented by the parties in the proceedings, the Commission finds that the repudiation of the claim of the Complainant by the opposite parties are not legally sustainable. Going through Ext. A3 document, it can be find that the complainant was symptomatic and suffered from Myalagia, sore throat, cough, fever and head ache. The complainant had spent almost ten days in a Government Hospital for treating covid -19 disease. Ext. A4 and Ext. A5 documents also strengthen the contention of the complainant. Moreover the third opposite party, who was acted as intermediary agent of first opposite party also favours of the case of the complainant. According to the third opposite party whether patient is to be treated for covid-19 disease by admitting in the hospital or whether he is to be sent to his house for home quarantine is to be decided by the treating doctor. The Commission also holds same view and the opposite parties cannot dictate the terms and mode of treatment to its policy holder of medical insurance coverage. Moreover the opposite parties did not produce any expert evidence before the Commission to challenge the physical condition of the complainant in connection with the terms and conditions of the policy. Here, in this case, the complainant undergone treatment for 10 days i.e, more than prescribed period in policy conditions. The documents produced by the complainant are varied with the terms and conditions of the policy. So the Commission finds that the act of the first and second opposite parties can be considered as violation of terms and conditions of the policy. The reason stated for repudiation of the claim is without applying prudent of a common men. It can be also seen that there is no violation of terms and conditions by the complainant and the argument put forwarded by the opposite parties are not sustainable. Here, the complainant had undergone treatment for 10 days i.e, more than prescribed period in policy conditions. The documents produced by the complainant are corresponding with the terms and conditions of the policy. So the Commission finds that the act of the first and second opposite parties can be considered against the contract and with malafide intention. The Commission also finds that there is no merit in the contention as the complainant was asymptomatic patient. The act of the opposite parties were agonized the complainant and he had suffered much hardship. The negligent and unlawful act of the opposite parties are liable to be compensated. The exclusion clause seen in Ext.B1 document does not speak of about nature treatment for covid -19 disease. Ext.A3 document and Ext.A4 document advised the complainant to take home quarantine after the discharge from Government Medical College Hospital, Manjeri. So the contention of the opposite parties that the complainant required only home quarantine instead of hospital treatment can be considered as baseless and false and intended to make disturbance to the complainant. The Commission finds that the first and second opposite party committed deficiency in service towards the complainant. The Commission is considering the argument of the third opposite party that there was no involvement of third opposite party in the repudiation of the claim. In this situation, the third opposite party is exonerated from liability. The Commission considers the prayer of the complainant with respect of claim of the insured sums of Rs. 2,00,000/- in favour of the complainant. Considering the grave act of deficiency in service and subsequent denial of claim in a flimsy manner, the first and second opposite parties are liable to pay compensation of Rs. 1,00,000/- to the complainant . The Commission also considers the claim for cost of proceedings to the tune of Rs. 10,000/- to the complainant. Hence the Commission allows the complaint in the following manner:-
- The first and second opposite parties are directed to pay Rs. 2,00,000/-(Rupees Two lakh only) to the complainant as the insured amount under the policy coverage.
- The first and second opposite parties are directed to pay Rs. 1,00,000/- (Rupees One lakh only) to the complainant as compensation for the deficiency of service committed against the complainant.
- The first and second opposite parties are also directed to pay Rs. 10,000/-(Rupees Ten thousand only) as cost of the proceedings to the complainant.
The opposite parties are directedto comply this order within 30 daysfrom the date of receiptof copy of this order otherwise the entireamount shall bear 9% interest per annum, from the date of order till its realisation.
Dated this 24th day of April, 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.A1to A5
Ext.A1 : Document is the copy of insurance policy issued by the first opposite
party to the complainant.
Ext. A2 : Document is the copy of repudiation letter dated 11/12/2020 issued by
the first opposite party to complainant.
Ext. A3 : Document is the copy of discharge card dated 02/11/2020 issued to the
complainant by the Government Medical College hospital, Manjeri.
Ext. A4 : Document is the copy of treatment certificate dated 15/12/2020 issued
by the Medical Officer, Family Health Centre , Odakkayam.
Ext. A5 : Document is the copy of Covid-19 test report dated 23/10/2020 issued by
Government, Medical College Hospital, Manjeri.
Witness examined on the side of the opposite party : Nil
Documents marked on the side of the opposite party : Ext. B1 & B2
Ext.B1 : Document is the copy of policy issued by the first opposite party to the
complainant.
Ext.B2 : Document is the copy of Clinical Management Protocol issued by Ministry
of Health and Family Welfare, Government of India.
MOHANDASAN K., PRESIDENT
PREETHI SIVARAMAN C., MEMBER
MOHAMED ISMAYIL C.V., MEMBER
