BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no.144 of 2022
Date of Institution : 09.03.2022
Date of Decision : 08.05.2024
Sarjeet Kumar (aged about 30 years) son of Shri Krishan Kumar, resident of village Nattar, Tehsil and 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 complainant purchased a Corona Rakshak Policy from ops vide policy No. H0485600 for the period 12.10.2020 to 24.01.2021 and got insured himself. The complainant remitted a sum of Rs.1213.04 as premium for the said policy and sum assured amount under the policy was Rs.2,50,000/-. That on 20.11.2020, the complainant was suffering from high grade fever and cough for 3-4 days and on 20.11.2020 he immediately visited Sanjivani Hospital, Sirsa in OPD where he was advised for COVIDF-19 RT-PCR testing. Thereafter, complainant got conducted his said test from Metropolis Path Labs, Sirsa and as per report dated 22.11.2020, he was found COVID-19 positive. It is further averred that then complainant was admitted in Sanjivani Hospital, Sirsa on 23.11.2020 at 13:55 hours where he remained admitted as an indoor patient w.e.f. 13.55 hours on 23.11.2020 up to 26.11.2020 i.e. more than 72 hours. That as per above policy, the complainant was to get Covid cover lump sum benefit equal to 100% of the sum insured if the complainant remains hospitalized for a minimum continuous period of 72 hours. That as per policy, complainant lodged his claim with the ops and supplied all the original documents as required by them for settlement of his claim, however, very strangely the ops vide their letter dated 11.01.2021 have repudiated his claim on the grounds (i) that his guardian, sister in law and mother denied his hospitalization and covid 19 status of patient, (ii) the policy was purchased by his friend and (iii) clause 8.8 of “Definition of words” of CRB policy. That above observation given by ops is totally false, baseless, wrong and incorrect and same is denied vehemently by complainant because ops have mischievously relied upon the verbal version of family members of complainant. The complainant is not living jointly with his sister in law and mother rather he is living separately from them, so the version given by them has no significance in view of the medical record supplied by complainant and company cannot wriggle out of its liability to indemnify the complainant on the ground that policy was purchased by his friend and further ops have given reference to clause 8.8 of the policy which clause has not all been attracted by the complainant. That complainant has not played any fraud with the company and did not purchase the above policy with any fraud and moreover ops have not clarified in their letter what fraud has been played by complainant upon the company, so the complainant bonafidely believes that ops have made false and baseless excuses in repudiating his claim. It is further averred that claim of complainant has been repudiated in an illegal and unlawful manner by the ops and they have not paid genuine claim despite his several requests and legal notice dated 25.01.2022 and have caused deficiency in service and harassment to the complainant. 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 11.01.2021 on the basis of report of Investigator “Golden Eyes Health Solutions LLP” dated 07.01.2021 as during verification discrepancies were observed that patient’s guardian, sister in law and mother denied of hospitalization and COVID-19 status of patient, the policy was purchased by his friend and with fraud because insurable interest of friend of Mr. Sarjeet 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 patient relatives have confirmed to their verifier that patient was not admitted in hospital during the said period due to covid and the matter seems to be a fraud case just to avail insurance benefit from the insurance company and the claim has been repudiated as per terms and conditions of the policy. It is further submitted that the matter with fraud cannot be decided in summary proceedings like this one before consumer commissions. The case has been rightly repudiated as per terms and conditions of the policy. Remaining contents of complaint are also denied to be wrong 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.C12.
5. On the other hand, ops have tendered affidavit of Sh. Mridul Ranjan General Manager as Ex.R1 and documents Ex.R2 to Ex.R13.
6. From the receipt Ex.C4 produced by complainant and Ex.R3 placed on file by ops themselves, it is evident that complainant had purchased Corona Rakshak Policy from the ops for the period 12.10.2020 to 24.01.2021 with waiting period of 15 days i.e. the end of waiting period was up to 26.10.2020 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.’ According to the complainant he was admitted in Sanjivani Hospital, Sirsa on 23.11.2020 but the said hospital is a private hospital. Further more, in this case the test report of Covid is also not from Government authorized diagnostic centre and is from private laboratory i.e. Metropolis Laboratory. 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.
