By Sri. Mohamed Ismayil C.V., Member.
The grievance of the complainant is as follows:-
1. On 28/12/2020 the complainant had availed an insurance coverage known as Corona Rakshak policy from the opposite party. The complainant had paid premium of Rs. 2,191.99/- as premium amount and the opposite party thereby assured to cover the medical expenses and other reliefs of treatment for Covid 19. It is averred that policy was a health plan and opposite party shall pay agreed sum insured to the complainant for any and all treatment and other reliefs of covid 19 disease. On 08/09/2021 the complainant had admitted to Government Medical College Hospital, Manjeri and diagnosed for covid 19 disease. On 09/09/2021 the complainant was tested positive in antigen test at Molecular Diagnosis Laboratory, Department of Micro Biology, Government Medical College, Manjeri. It is averred that the complainant had undergone treatment at Government Taluk Hospital Wandoor and thereafter he was observed home quarantine as per covid 19 protocol of Government of Kerala. It is averred by the complainant that he had made a claim application for Rs. 2,50,000/- as sum assured as per policy No.H0581724 by the opposite party. But the opposite party rejected the claim application without valid reason. It is averred by the complainant that the opposite party is liable to pay sum insured as the complainant had complied all requirements as per terms and conditions of the policy. According to the complainant, he had been in continuous treatment for 7 days as inpatient in the hospital. Moreover the complainant had submitted all necessary documents before the opposite party along with claim application. It is alleged by the complainant that the opposite party has committed deficiency in service towards him. The act of the opposite party has caused mental agony and inconvenience to the complainant. Hence the complainant has prayed for a direction to the opposite party to pay Rs. 2,50,000/- to the complainant towards the policy amount. In addition, the complainant also claimed Rs.1,00,000/- (Rupees one lakh only) from the opposite party as compensation for the sufferings of mental agony and physical strain. The complainant claimed Rs. 10,000/- as cost of the proceedings.
2. The complaint is admitted and issued notice to the opposite party. The opposite party appeared and filed version.
3. The opposite party denied allegations of the complainant. The opposite party admitted that the complainant had purchased Corona Rakshak policy No.H0581724 from them. It is contended by the opposite party that they had not received any claim under this policy from the complainant. There is no document from the side of the complainant to support his pleadings. It is also contended by the opposite party that documents are required from the complainant to consider any claim under the policy coverage. There is no deficiency in service on the side of the opposite party. Hence the opposite party stands for dismissal of the complaint.
4. The complainant and opposite party have filed affidavits in lieu of evidence. The complainant did not produce documents to support the pleadings made out in the complaint. The documents produced by the opposite party is marked as Ext. B1 document. Ext. B1 document is the copy of claim repudiation letter with regard to claim No. 2021020301195 issued to policy No.H 0486041 of one Mr.Muhammed Rashid.
5. Heard both sides in detail perused affidavits and document of the opposite party. The Commission considered the following points:-
i) Whether the complainant has proved his allegations of deficiency in service
against the opposite party?
ii) Relief and cost?
6. Point No.(i) and (ii)
The Commission is considering both points together for the sake of convenience. The argument of the complainant is that he had availed an insurance policy from the opposite party on 28/12/2020 on basis of assurance given by the opposite party that the opposite party had promised to pay a sum insured of Rs.2,50,000/- for the treatment of Covid 19 disease, if affected. The opposite party has admitted issuance of policy No. H05817424 to the complainant as pleaded in the complaint. The grievance of the complainant is that on 08/09/2021 he was admitted in Government Medical College Hospital, Manjeri and on 09/09/2021 he was found positive of Covid -19 disease through antigen test conducted at Molecular Diagnosis Laboratory, Department of Micro Biology, Government Medical College, Manjeri. Thereafter the complainant was shifted to safa hospital, Kalikavu which was covid- 19 special treatment centre and associated with Government Medical College Hospital Manjeri. It is argued that the complainant had undergone 7 days of inpatient treatment in the hospital and he was discharged on 06/01/2021. Thereafter the complainant had observed home quarantine also.
7. It is argued by the complainant that he had forwarded a claim numbered ID 2021020301195 before the opposite party claiming Rs. 2,50,000/- under the policy coverage and submitted all relevant documents. But on 05/02/2021, the opposite party had issued claim rejection letter to the complainant stating that the patient was affected with mild covid and required to be kept under home isolation and the policy covers the treatment of 72 hours of in patient care. It is argued by the complainant that the rejection of claim was baseless and without valid reason. The act of the opposite party is amounted to deficiency in service and the opposite party is liable to pay sum insured to the complainant.
8. On the contrary, it is argued by the opposite party that the complainant did not submit any claim application under policy No. H0581724. It is argued by the opposite party that if the complainant had submitted claim application along with required documents they were ready to consider the same as per terms and conditions of the policy, but no application was submitted by the complainant so far. Moreover the claim number stated by the complainant is related to policy No.H0486041 subscribed by Mr.Muhammed Rashik. T and not that of the complainant.
9. In the evaluation, of evidence it can be seen that the complainant has failed to adduce evidence to support his pleadings in the complaint. Even though the complainant had availed with sufficient opportunity to produce documents before the Commission but no attempts were made by the complainant. According to the complainant he had submitted a claim application numbered as 2021020301195 before the opposite party. But as per Ext. B1 document produced by the opposite party claim No. 2021020301195 was submitted by one Mr. Muhamed Rashik T, who subscribed policy No.H0486041. There is no evidence available before the Commission to show that the complainant had submitted a claim application under policy No. H0581724. In the complaint, it was pleased that the complainant had undergone treatment at Government Taluk Hospital, Wandoor. But in the affidavit it is stated that the complainant had undergone treatment at CSLTC, Safa hospital, Kalikavu. The Commission find that there is no evidence available before the Commission to prove the treatment undergone by the complainant. Moreover the details of policy and its terms and conditions are not available before the Commission. The Commission find that the complainant is failed to substantiate his pleadings before the Commission and there is no merit in the complaint. Hence complaint is dismissed
Dated this 30th day of April, 2024.
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: Nil
Witness examined on the side of the opposite party : Nil
Documents marked on the side of the opposite party : Ext. B1
Ext.B1: Copy of claim repudiation letter with regard to claim No. 2021020301195
issued to policy No.H 0486041 of Muhammed Rashid.
MOHANDASAN.K, PRESIDENT
PREETHI SIVARAMAN.C, MEMBER
MOHAMED ISMAYIL.C.V, MEMBER
