By: Sri. Sri. Mohandasan K., President
Complaint in short is as follows:-
1. The complainant is doing post-graduation in respiratory medicine and as part of the duty at pandemic Mishap she was posted to serve and study at then formulated MES Isolation ward with every likely hood of infection. The duty was adhered with POP protection and with all protective measures. While so complainant received so many telephone calls from several executives of the opposite parties for canvassing insurance protection against Covid 19 Pandemic and on repeated persuasion and instigation the complainant applied online for the insurance indemnification from the opposite parties and the premium was paid as per the instruction given on online portal at the advice of the representatives of the opposite parties. The opposite parties issued insurance policy having number H0351601 dated 03/08/2020, which is effective from 10/08/2020 to 20/02/2021. He paid premium of Rs.2, 118.12 and the insured sum was 2, 50,000/-.
2. The assurance of the opposite parries was that the benefits of the policy will be made available once infected and on hospitalization for 72 hours without any sort of discrimination or intricacies. The complainant took this particular medical insurance policy due to repeated representations from the representatives of the opposite parties. The representatives of opposite parties convinced the complainant that the said policy is suitable to high risk areas which comes under the essential service and the same can be claimed without much formalities.
3. On 29/12/2020 the complainant was admitted in MES medical college hospital Perinthalmanna, diagnosed with Covid 19 category B and was treated till 02/01/2021. According to the direction of the nodal officer, complainant was admitted for the management at the hospital and it was nodal officer took decision to admit for treatment. There is no authority vested with any patient to decide the hospitalization, home quarantine or other mode of treatment and where to be admitted. All those are decided by the nodal officer concerned and by virtue of their decision the complainant was hospitalized. Any circumstances, complainants vouch against it, it will be severe criminal offence and will tantamount to several ineligibilities.
4. While the complainant was hospitalized he had informed the second opposite party regarding the admission to hospital and had collected few details from complainant, thereafter requested to provide details on and after detail negative. Subsequently, complainant informed details after quarantine and hard copies were served on second opposite party. It was promised to make payment by the January end and had contacted several times but of no result. Later the opposite parties by their letter dated 04/02/2021 rejected the insurance claim and committed gross deficiency of service as if they are the rulers of the country and law stood stand under their footing and the nodal offer appointed by the government is not having any authority and as if they are the final word of Covid protocol. The letter,A2 of the opposite party was as follows:-
1) The insured in this claiming for benefit undergone corona rakshak policy, as she underwent treatment of Covid 19 at MES medical Collage.
2) While going through the submitted document it has been observed that the patient had fever, myalgia, sore throat and cough at the time of admission and the me is categorized as mild symptoms and as per guidelines by ministry of family and health welfare patients with mild symptoms does not necessitate hospitalization and the patient could very well have been managed on home isolation basis.
3) Also, vitals at the time of admission were near normal limits
4) Treatment done in this case is in the form of oral medication only (tablet Pando, azee , Ceeplus) which again could very could very well have been given on home isolation basis .
5. In Short, the opposite parties decided that the hospitalization was not required and thus rejected the benefit illegally, malafede and so their service was not only inadequate but is a clear unfair trade practice. The opposite parties challenge the entire medical and legal system illegally and capriciously. The system adopted for Covid positive personal here in is the admission or home isolation is being decided by the nodal officer and there is no voice for the patient for the same. If the same is not adhere by the patient, the law will take its course and take the patient under law and will put in the hospital and while coming out after the treatment will be charged with a criminal offence under epidemic act or violation of law. The complainant submit, the repudiation of claim by the opposite party is incorrect and unsustainable. There is no direction from the ICMR or ministry of health and family welfare guide line asymptomatic/ mild symptoms with Covid case can only be managed with isolation / home quarantine. The direction is only “can be managed isolation / home quarantine “does not mean that in all asymptomatic / mild symptom of Covid case hospitalization is not necessary. It is only when the number of Covid cases arose to a very high level that the ministry was compelled to have such a direction as accommodation was not available in the hospitals. The complainant submitted that whether a Covid patient is to be treated by admitting in the hospital or whether to send house for home quarantine is to be decided by the nodal officer. The patient has no say in the matter of treatment and cannot insist or compel the doctor to give him treatment by keeping own house. Hence the reason shown by the insurance company to repudiate the claim is ridiculous and cannot sustained at all. The Complainant was in treatment at MES medical collage Covid hospital, Perinthalmanna as per the direction of government.
6. The opposite parties are finding out lay excuses to repudiate the genuine claim made by the complainant. There is no valid ground for repudiating the claim of the complainant. The complainant alleges deficiency in services and also unfair trade practice against the opposite party.
7. Through repudiating the claim by the opposite party, the insurance company has caused irreparable loss and mental harassment to the complainant. After luring the complainant with all source of promises and assurances that the claim will be allowed if affected with Covid 19 and the insurance company has gone back on their promise without any valid reason. By repudiating the genuine claim of the complainant the insurance company has caused unnecessary harassment and insult to the complainant. Hence the complainant alleges deficiency in service and unfair trade practice against the opposite parties. The prayer of the complainant is that to direct the opposite parties jointly and severely to pay Rs.2,50,000/- as the insurance premium amount and also pray for the compensation of Rs.2,50,000/- on account of unfair trade practice and also direct to pay Rs.2,50,000/- toward the deficiency of service. The complainant also prays 2,50,000/- rupees toward mental agony, stress and insult caused by way of illegal letter by which it feels that the complainant is admitted to grab the insurance amount. The compliant prayed cost of Rs.50,000/- as part of the complaint.
8. On admission of the complaint notice was issued to the opposite parties and on receipt of notice the opposite parties entered appearance and filed version denying the entire averments and allegations in the complaint. According to them the complaint is not maintainable and deserves dismissal with cost of the opposite parties. It is submitted that there is no deficiency in service on the part of the opposite parties and the claim repudiated as per the terms and conditions of the policy.
9. The opposite parties submitted that they are the insurance company leading in business of general insurance and as per guidelines of IRDAI they introduced a Covid standard benefit-based health insurance policy namely as Corona rakshak policy. The complainant had purchased a Corona rakshak policy, wherein policy number is HO 351601 through online portal of the opposite party and the said policy was valid for the period of 10/08/2020 to 20/02/2021 having sum insured amount of Rs.2,50,000/-. The opposite party submitted the insurance policy is a contract between insurer and policy holder, any benefit under the policy will be governed as per terms and conditions of the insurance policy. The opposite party submitted that they received the claim documents from the complainant and on scrutiny of the same the complainant had availed treatment from MES medical college Covid hospital, Perinthalmanna for the period of 29/12/2020 to 02/01/2021. At the time of her admission, the patient had fever, myalgia, sore throat and cough. The treatment availed was in the form of oral medication only and which could very well have been given on home isolation basis. The symptoms of the patient were categories as mild systems as per guidelines issued by ministry of health and family welfare, government of India.
10. The opposite party submitted that the policy requires 72 hours of in-patient care, but in this complaint in-patient care was not required as the patient having mild symptoms. The patient was discharged from the hospital within 4 days from the date of admission, even when the patient had temperature of 101 Fahrenheit and advised for home isolation, repeat test of Covid 19 on 08/01/2021 as mentioned in discharge summary dated 02/01/2021. The opposite party submitted the Corono Rakshak policy provides clause number 3.7 regarding hospitalization that an admission in a hospital designated for Covid 19 treatment by government, for a minimum period of 72 consecutive “in-patient care “ hours. Clause 3.8 in patient care states that treatment for which the insured person has to stay in a hospital continuously for more than 72 hours for treatment of Covid. The opposite party also submitted that the operative clause of the policy is that if during the policy period the insured person is diagnosed with Covid and hospitalized for more than 72 hours following medical advice of the duly qualified medical practice as per the norms specified by the 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. The Covid cover condition 4.1 states that 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 center.
11. The submission of the opposite party is that considering the documents the opposite party duly repudiated the claim and the letter of repudiation was issued to the complainant which reveals the reason for the repudiation. So the submission of the opposite party is that there is no deficiency in service and unfair trade practice on the part of opposite party and the repudiation is as per the terms and conditions of the policy entered between the parties and the complaint is without any merit and liable to be dismissed with exemplary cost .
12. The complainant and opposite parties filed affidavit and documents. The complainant filed documents and they are marked as Ext. A1 and A2. The documents on the side of opposite party marked as Ext. B1 to B4. Ext. A1 is the copy of insurance policy with policy No. HO 351601 dated 03/08/2020 valid from 10/08/2020 to 20/02/2021. Ext. A2 is copy of repudiation letter dated 04/02/2021. Ext. B1 is copy of insurance policy along with terms and conditions. Ext. A2 is copy of discharge summary dated 02/01/2021. Ext. B3 clinical management protocol of Covid 19. Ext. B4 is copy of repudiation letter 04/02/2021.
13. Heard complainant and opposite parties, perused affidavit and documents.
The following points arise for consideration
- Whether there is deficiency in service and unfair trade practice on the part of the opposite parties?
- Relief and cost?
14. Point No.1 and 2
The documents and affidavit shows that there was a valid insurance policy during the relevant period to cover the financial protection from Covid 19 pandemic. But the opposite party repudiated the insurance claim stating that as per the terms and conditions the complainant was not entitled the insurance claim. The contention of the opposite party is that the Covid 19 was sustained to the complainant in a mild form and for that only home isolation was needed. The symptoms as per discharge summary also states that at the time of admission, she had only fever, myalgia, sore throat and cough. As per the guide line issued by the ministry of health and family welfare, government of India all these can be categorized as mild symptoms of Covid.
15. The submission of the complainant is that the system adopted for Covid positive patient herein is the admission or home isolation is being decided by the nodal officer and there is no voice for the patient for the same. If the advice of the nodal officer is not adhered by the patient, the law will take its course and take the patient under the law and will put in the hospital and while coming out after the treatment will be charged with a criminal offence under epidemic Act for violation of law. The complainant also submitted that the direction from the ministry of health and family is that in case of mild symptoms with Covid cases can only be managed with isolation / home quarantine which does not mean Covid cases hospitalization is not necessary. The submission is that only when the number Covid cases arose to a very high level that the ministry was compelled to have such a direction as accommodation was not available in the hospitals. The submission of the complainant is that a Covid patient is treated by admitting in the hospital or whether to send to house for home quarantine to be decided by the nodal officer. The patient has no say in the matter of treatment and cannot insist or compel the doctor to give treatment by keeping in house. The complainant further submits that the complainant was undergone treatment in MES medical college Covid hospital, Perinthalmanna as per the direction of the government.
16. The perusal of the affidavit and documents it can be seen that the complainant met with Covid 19 and undergone treatment in approved Covid 19 treatment center that too a medical college hospital. His treatment was from 29/12/2020 to 02/01/2021, which shows that he was under the in- patient treatment nearly 4 days as per the terms and conditions, the requirement is hospitalization of 72 hours in approved treatment center. In this case the complainant has undergone more than 72 hours hospitalization affecting Covid 19. The sole reason for repudiation of the claim of complainant is that the nature of Covid 19 was mild and for which hospitalization is not required. We do not admit the contention of the opposite party whether the complainant is to be hospitalized or to undergo home isolation. The contention of the complainant is valid and the approach of the opposite party is against the terms and conditions of the insurance policy. The opposite parries are not entitled to dictate the patient to undergo home isolation against the medical advice. So the approach of the opposite party is unfair trade practice and there is gross deficiency in service.
17. It is evident from the contention of the complainant that he is doing post graduation in respiratory medicine and he was doing his duty at the pandemic mishap and was posted to serve and study at the then formulated MES isolation ward with every likely hood of infection. In such a situation the complainant rightly opted to subscribe the policy of the opposite party called corona Rakshak policy. But, when the complainant met with Covid 19 the opposite party stating lay excuses repudiated the genuine claim of the complainant. The opposite party withdrawn the effect of “RAKSHAK” from corona Rakshak policy. The attempt of the opposite party is to defeat the entire object of insurance scheme called corona Rakshak policy. So we find that there is unfair trade practice and deficiency in service and the complainant is entitled insured amount along with compensation and cost. We consider Rs.50, 000/- as reasonable amount towards the compensation and 10,000/- rupees as cost of the proceedings.
18. In the alight of above fact and circumstances we allow this complaint as follows:-
1) The opposite parties are directed to pay Rs.2, 50,000/- to the complainant as insured amount in accordance with Ext. A1 policy certificate.
2) The opposite parties are directed to pay Rs.50, 000/- as compensation on account of unfair trade practice and deficiency in service and thereby caused inconvenience and hardship to the complainant.
3) The opposite parties are also directed to pay Rs.10, 000/- as cost of the proceedings
The opposite parties shall comply this order within one month from the date of receipt of copy of this order, failing which the complainant is entitled 12% interest per annum for the entire above amount from the date of filing this complaint till date of payment.
Dated this 15th day of December, 2022.
Mohandasan K., President
PreethiSivaraman C., Member
Mohamed Ismayil C.V., Member
VPH
APPENDIX
Witness examined on the side of the complainant: Nil
Documents marked on the side of the complainant: Ext.A1 and A2
Ext.A1: Copy of insurance policy with policy No. HO 351601 dated 03/08/2020 valid
from 10/08/2020 to 20/02/2021.
Ext.A2: Copy of repudiation letter dated 04/02/2021.
Witness examined on the side of the opposite party: Nil
Documents marked on the side of the opposite party: Ext. B1 to B4
Ext.B1: Copy of insurance policy along with terms and conditions.
Ext.B2: Copy of discharge summary dated 02/01/2021.
Ext.B3: Clinical management protocol of Covid 19.
Ext.B4: Copy of repudiation letter 04/02/2021.
Mohandasan K., President
PreethiSivaraman C., Member
Mohamed Ismayil C.V., Member
VPH
