IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated, the 28th day of October, 2022.
Present: Sri. Manulal V.S. President
Smt. Bindhu R. Member
Sri. K.M. Anto, Member
C C No. 23/2021 (Filed on 29-01-2021)
Petitioner : Aneesh K.G.
S/o. Gopinathan Nair K.
Ambadiyil House, Vakayar P.O
Konni – 689698
Now residing at
Padinjareplakkiyil House,
Kumaranalloor, Kottayam
Pin - 686028
(Adv. D Zaibo)
Vs.
Opposite party : The Manager,
IFFCO TOKYO GIC Ltd.
3rd Floor, Payyil Building,
Sankranthi, Kottayam – 686016
(Adv. Agi Joseph)
O R D E R
Sri. K.M. Anto, Member
The case is filed under section 35 of the consumer Protection Act 2019.
The brief of the complainant’s case is as follows. The complainant had availed CORONA RAKSHAK health insurance policy from the opposite party on 08-09-2020 and paid Rs.2839/- as the premium. The said policy is a single premium fixed benefit policy, and offered a lump sum benefit equal to the 100% of the sum insured if the insured person diagnosed covid positive and hospitalized for more than seventy-two hours following medical advice by a qualified medical
practitioner. The opposite party issued policy no.H0421845 covering the period from 22-09-2020 to 19-06-2021 for the insured sum of Rs.250000/-. The complainant was diagnosed as covid positive on 23-11-2020. And was hospitalized at CFLTC Hospital, Athirampuzha, Kottayam for 11 days from 23-11-2020 to 03-12-2020.The complainant filed a claim for the sum insured with
all supporting documents. But the claim of the complainant was repudiated by the opposite party stating that the claim is raised for the benefit of home quarantine from 23-11-2020 to 10-12-2020 and the treatment done was in the form of oral medication which does not necessitate hospitalization. The opposite party is legally and contractually liable to pay the insured sum along with interest. The petitioner suffered huge mental agony, financial loss and hardships due to the actions of the opposite party. The act of the opposite party amounts to unfair trade practice and deficiency in service. Hence this complaint.
On admission of the complaint copy of the complaint was duly forwarded to the opposite party. The opposite party appeared and filed their version.
In the version the opposite party states that the petitioner was not given any offer of 100% of sum insured if the insured person is covid positive. The complainant has not hospitalized at CFLTC Hospital for treatment of Covid 19. The Government of Kerala gave a direction that all covid patient shall be quarantined till the result of covid test is negative. On the basis of this direction the complainant was kept in quarantine at the CFLTC Athirampuzha. The CFLTC hospital Athirampuzha is not a hospital within the definition of hospital in CORONA RAKSHAK policy given by the opposite party. The petitioner has no complications for inpatient treatment continuously for a period of 72 hours. The CFLTC hospital Athirampuzha is not having 15 inpatient
beds and there is no population of 10 lakhs in Athirampuzha panchayat. Hence CFLTC Athirampuzha is not a hospital coming within the definition of Hospital
in clause.3.6 of policy condition. The complainant is not entitled to get insurance claim. The reason for repudiation is true and correct.
The complainant filed proof affidavit and marked exhibits. A1 to A9. The opposite party filed proof affidavit and marked documents Ext B1.
On the basis of the complaint, proof affidavit filed by the complainant and
version of the opposite party and evidence adduced the following points were
framed for consideration.
1) Whether there is Unfair Trade practice or deficiency in service on the part of
the opposite party?
2) If so, what are the reliefs and costs.?
For the sake of convenience, we would like to consider point no,1 & 2 together.
Points 1 &2
From the complaint, proof affidavit of the complainant and version of the opposite party and evidence on record it is clear that the complainant had availed Corona Rashak insurance policy from the opposite party on payment of Rs.2389/-, on 08-09-2020.The opposite party issued Policy with Number, H0421845 on 08-09-2020 having a period of cover from 22-09-2020 to 19-06-2021 for a sum of RS.2,50,000/-.
Exhibit A3 is the Policy details issued by the opposite party on 08/09/2020 with policy no.H0421485, policy effective from 08/09/2020 to 19/06/2021. Rs.2839/- is seen paid as the premium amount.
Exhibit A4 is the discharge card issued from CFLTC Athirampuzha to the complainant. As per exhibit A4 the complainant got admitted on 23/11/2020 and discharged on 03/12/2020.Complainant tested positive on 23/11/2020 and tested negative on 03/12/2020.Treatment given for fever, headache and breathlessness and on discharge he was advised home quarantine for 3 days and self-monitoring for 7 days.
Ext A5 is the claim repudiation letter from the opposite party intimating the complainant that the claim was rejected on the following ground
1 The insured in this case is claiming benefit under covid Rakshak policy for
home quarantine he did from 23/09/2020 to 10/12/2020 in a diagnosed case
of covid 19
2 Also treatment done in this case was in the form oral medication only which
does not require hospitalization
The complainant is not eligible for the insurance claim as per the clauses
3.6,4.1 and 3.7 of Definition of CRP Policy issued by the opposite party.
Exhibit A6 is an application filed under RTI Act filed before the Public Information officer PHC Athirampuzha and A7 is the replay received. Ongoing through Ext A6and A7 it can be seen that CFLTC Athirampuzha was functioning for the period 10-09-2020 to 28-12-2020 and treatment was provided there for covid patients, 100 beds, Doctors and Nurses were available in the Centre.
The opposite party marked Exhibit B1 the copy of the policy with conditions.
The claim was rejected as per clause 3.6,4.1 and 3.7 of Ext B1.Clause 3.6of the Ext B1 read as follows.
3.6. Hospital means any institution established for in-patient care and day care treatment of disease/injuries and which has been registered as a hospital with the local authorities under the Clinical Establishments (Registration and Regulation) Act2010 or under the enactments specified under Schedule of Section 56(1) of the said Act, OR complies with minimum criteria as under:
1 has qualified nursing staff under its employment round the clock;
2 has at least 10 inpatient beds, in those towns having a population of less than ten lakhs and 15 beds inpatient beds in all other places;
3has qualified medical practitioner(s)in charge round the clock;
4 has a fully equiped operation theatre of its own where surgical procedure is
carried out
5 maintains daily records of patients and shall make these accessible to the
company’s authorized personnel
6 For the purpose of this policy any other set up designated by the government as hospital for the treatment of Covid-19 shall also be considered as hospital.
3.7. Hospitalization means admission in a hospital designated for COVID-19 treatment by Government, for a minimum period of seventy-two (72) consecutive Inpatient care hours.
4.1. Covid Cover. Lump sum benefits 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.
On a thoughtful evaluation of the above discussion, it is clear from Ext A4 that the complainant was admitted in CFLTC Athirampuzha on 23-11-2020 being covid positive and undergone treatment for covid-19 up to 03-12-2020. From Ext A6 and Ext A7 it is evident that CFLTC Athirampuzha was having facility of 100 beds, Doctors and nurses were also available in the centre. Moreover, as per clause 3.6(6) of Ext B1 policy any setup designated by the government as hospital for the treatment of covid-19 shall be considered as hospital under this policy. Hence CFLTC Athirampuzha will be a hospital as defined in the Covid Rakshak policy of the opposite party
The Complainant was tested covid positive in the government authorized
CFLTC hospital Athirampuzha and had undergone continuous treatment for more than 72 hours. Thus, as per clause 3.6,3.7 and 4.1 of Ext B1 policy conditions the complainant is eligible to get the benefits equal to 100% of the sum insured.
The act of the opposite party in rejecting the genuine claim of the complainant is deficiency in service on their part. Hence point no 1 and 2 were found in favor of the complainant. We allow the complaint and pass the following orders.
1) The opposite party is directed to allow the claim of the complainant and to give Rs,250,000/- to the complainant with interest 6% per annum from the date of this order till realization.
2) the opposite party is directed to give Rs.25,000/- as compensation for the mental agony and sufferings with cost Rs.5000/-.
The order shall be complied within 30 days from the date of receipt of this order in default the amounts will carry 9% interest pa till realization
Pronounced in the Open Commission on this the 28th day of October, 2022
Sri. K.M. Anto, Member Sd/-
Sri. Manulal V.S. President Sd/-
Smt. Bindhu R. Member Sd/-
Appendix
Exhibits marked from the side of complainant
A1 – Copy of circular dtd.26-06-26 regarding guidelines on covid standard
benefits based health policy.(Subject to objection)
A2 – Copy of circular dtd.04-03-2020 regarding guidelines on handling of claims reported under corona virus (Subject to objection)
A3 – Policy details issued by the opposite party
A4 – Discharge summary dtd.03-12-20 by CFLTC, Athirampuzha
A5 – Copy of repudiation letter dtd.07-01-21 issued by opposite party to complainant
A6 – Copy of application dtd.16-07-22 under RTI Act to Primary Health Centre, Athirampuzha
A7 – Reply to the RTI by Public Information Officer, Primary Health Centre, Athirampuzha to complainant
A8 – Copy of discharge card dtd.30-10-2020 CFLTC Athirampuzha
A9 – Copy of statement of account dtd.09-12-20 issued by Federal Bank, Kottayam branch
Exhibits marked from the side of opposite party
B1 - Copy of policy with terms and conditions
By Order
Assistant Registrar
