BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.              

                                                          Consumer Complaint no.145 of 2022                                                                 

                                                           Date of Institution :    09.03.2022

                                                          Date of Decision   :    08.05.2024

Gurpreet Singh (aged about 30 years) son of Shri Milkha Singh, resident of village Sainpal, Tehsil Rania District Sirsa.

                                ……Complainant.

                             Versus.

1. Iffco Tokio General Insurance Co. Ltd. Regd. Office: Iffco Sadan, C1 Distt. Centre, Saket, New Delhi – 110017 through its Managing Director/ Authorized Signatory.

2. Iffco Tokio General Insurance Co. Ltd. Serving Office : Iffco Tower, Plot No.3, Sector-29, Gurugram, Haryana- 122001 through its Manager/ Authorized Signatory.

…….Opposite Parties.

            Complaint under Section 35 of the Consumer Protection Act, 2019.

Before:       SH. PADAM SINGH THAKUR……. PRESIDENT

                   SMT. SUKHDEEP KAUR……………MEMBER.                               

                   SH. OM PARKASH TUTEJA………..MEMBER

Present:       Sh. JBL Garg,  Advocate for the complainant.

                   Sh. Kapil Sharma, Advocate for opposite parties.

ORDER

                   The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred as Ops).

2.                In brief, the case of complainant is that ops insured the complainant through their employee vide insurance policy number H0511315 product name Corona Rakshak Policy with effect from 31.10.2021 to 12.02.2021 for sum assured amount of Rs.2,50,000/- and premium was paid by complainant to the ops. That complainant suffered from fever, cough and leg pain continued for three days and therefore he went to CHC cum Civil Hospital, Chautala on 04.12.2020 where he was advised for Covid-19 test, CBC and CRP. Thereafter, complainant got his such tests from Metropolis Lab, Sirsa and as per report dated 07.12.2020 he was diagnosed as COVID-19 positive and CT score of complainant was detected/ recorded as 22.6. It is further averred that thereafter complainant got himself treated while remaining in house in quarantine but his health deteriorated and thereafter he got himself admitted in Sanjivani Hospital, Sirsa on 09.12.20204 and undergone various tests and investigations and as per his Hematology report, his Hematocrit (PCV) was found 40.1% whereas reference range is between 42-52 and his RDW-CV was found 11.1%, whereas reference range is 11.5- 14.0. The complainant remained admitted up to 14.12.2020 and even after his discharge he remained under treatment and insurance company was intimated regarding his admission and even copy of COVID-19 report was also delivered to the ops at the time of seeking claim of insurance policy. It is further averred that after discharge from hospital, the complainant applied for claim under the aforesaid policy but claim has been repudiated by ops vide rejection letter dated 28.01.2021 for the only reason that father of insured stated that his son is working in a private hospital and his son did not have COVID-19 which is wrong and illegal because complainant is not working in any hospital and no investigator ever met with father of complainant and as such question of giving alleged statement by his father does not arise at all. It is further averred that in fact no such statement was ever given by father of complainant and such statement, if any is result of manipulation and concocted one and diagnose of COVID-19 is clearly proved from the fact that complainant was also insured with Royal Sundaram General Insurance Company Limited for cashless health insurance and medical bills as well as expenses were paid by said insurance company itself in view of medical records including COVID-19 report, admission as well as discharge summary. That despite this fact, the ops intentionally denied to pay the claim amount of Rs.2,50,000/- to the complainant as per policy for which the risk was covered. It is further averred that complainant several times approached the ops and requested to pay the claim of complainant as per terms and conditions of policy but the ops did not pay any heed and complainant also got served a legal notice dated 25.01.2022 to the ops but to no effect. That such act and conduct of the ops amounts to gross deficiency in service due to which complainant has suffered harassment.  Hence, this complaint.   

3.                On notice, ops appeared and filed written statement taking certain preliminary objections regarding maintainability and that complainant had previously filed the complaint before Insurance Ombudsman Chandigarh dated 08.07.2021 arising out of same cause of action wherein the Insurance Ombudsman Chandigarh in its order dated 06.12.2021 appreciated the relevant policy terms and conditions, facts, documents and dismissed the complaint in favour of insurance company. It is further submitted that on scrutiny of the documents responding insurance company repudiated the claim vide letter dated 28.01.2021 on the basis of report of Investigator “Golden Eyes Health Solutions LLP” dated 22.01.2021 as during verification they received written statement of the father of the insured that his son is working in a private hospital and his son did not have COVID-19 and neighbors of the patient confirmed that patient Gurpreet Singh was not admitted in the hospital and did not have COVID and the above statements clearly indicate that claim is made only to take undue benefit of the insurance policy. It was further observed that the policy was purchased by Mr. Gopi Nath Pandey through online mode with fraud because insurable interest of Mr. Pandey is not proved. Further in the event of anyone else is purchasing policy with his card is violation of the privacy policy. It is further submitted that they discussed with hospital authority regarding meeting with doctor and radiologists but hospital authority did not provide required documents. That as per their verification report patient was not admitted in hospital and hence the relevance of the test becomes irrelevant. It is further submitted that matter seems to be fraud just to avail insurance benefit from the insurance company and the claim has been repudiated as per terms and conditions of the policy and the matter with fraud cannot be decided in summary proceedings and prayer for dismissal of complaint made.

4.                The complainant in evidence has tendered his affidavit Ex. CW1/A  and documents Ex.C1 to Ex.C9.

5.                On the other hand, ops have tendered affidavit of Sh. Mridul Ranjan General Manager as Ex.R1 and documents Ex.R2 to Ex.R10.

6.                From the receipt Ex.C4 produced by complainant, it is evident that complainant had purchased Corona Rakshak Policy from the ops for the period 31.10.2020 to 12.02.2021 with waiting period of 15 days i.e. the end of waiting period was up to 14.11.2020 and complainant paid premium amount of Rs.1213.04 to the ops for the said policy. The sum insured under the policy is Rs.2,50,000/- and the column of coverage regarding covid cover mentions ‘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.’  Although as per Ex.C5 initially on 4.12.2020 complainant visited CHC cum Civil Hospital Chautala, Sirsa where he was advised for COVID-19, CBC, CRP test but the test report of Covid is not from Government authorized diagnostic centre and is from private laboratory i.e. Metropolis Laboratory. According to the complainant he was admitted in Sanjivani Hospital, Sirsa on 09.12.2020 but the said hospital is also a private hospital. The complainant has also not placed on file any document to prove the fact that said Metropolis Laboratory was authorized by Government as diagnostic centre and as such as per terms and conditions of the policy, the complainant is not entitled to claim as claimed by him. So when the basic requirement of terms and conditions of the policy i.e. Corona test from Government authorized diagnostic centre is not fulfilled in this case, therefore, no other point of fraud regarding purchasing of policy in question, forged admission in the hospital etc. raised by ops is to be discussed and decided. The ops have rightly repudiated the claim of complainant on the basis of terms and conditions of the policy which needs no interference. In these circumstances, the complaint of the complainant deserves dismissal.

7.                In view of our above discussion, we do not find any merit in the present complaint and same is hereby dismissed but with no order as to costs. A copy of this order be supplied to the parties as per rules. File be consigned to the record room. 

 Announced.                   Member      Member                          President,

Dt. 08.05.2024.                                                    District Consumer Disputes

                                                                             Redressal Commission, Sirsa.