IN THE CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM
Dated this the 27th day of April 2023
Present: Sri.Manulal.V.S, President
Smt.Bindhu.R, Member
Sri.K.M.Anto, Member
CC No. 254/2022 (Filed on 24.11.2022)
Complainant : Aneesh P Mohan, S/o Mohan
Karikulathil House, Nendoor P.O
Kaipuzha Village, Kottayam Taluk
Kottayam District-686 601
(By Adv.Bindhu Pramod)
Vs
Opposite party : The Manager,
Universal Sompo General
Insurance Company Ltd
TR/54/3106-C
2nd Floor, Grace Corner
Kadavanthra, Kochi-682020
O R D E R
Sri.K.M.Anto, Member
The complaint 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 Policy of the opposite party having Policy Number 2856/62001746/00/000 for the sum assured amount of Rs 2,50,000/-. The policy is valid from 18/09/2020 to 29/06/2021.
On 29/01/2021 the complainant attended Medical College Kottayam outpatient unit due to fever, cough and rhinitis and the complainant was tested Covid Positive. On 30/01/2021 the complainant was admitted at Caritas Hospital and was treated as an inpatient from 30/01/2021 to 03/02/2021. The complainant incurred a hospital bill of Rs.31,914/-. The complainant claimed the lump sum amount including the hospital bill of Rs.31,914/- from the opposite party.
The opposite party repudiated the claim on 27/03/2021 and informed the complainant that Hospitalization for monitoring/Observation/Isolation purpose is not payable by the opposite party. Insured could have been managed on home quarantine basis. The rejection of the sum assured by the policy including the hospital bill of Rs.31,914/- of the complainant without any sufficient reason is deficiency in service and unfair trade practice on the part of the opposite party.
This complaint is filed for getting a direction to the opposite party to pay the assured sum of Rs.2,50,000/- as per Corona Rakshak policy coverage including the hospital bill of Rs.31,914/- and for getting a compensation of Rs.4,00,000/- for mental agony and hardship and sufferings caused to the complainant, With cost Rs.10,000/-.
On admission of the complaint, copy of the complaint was duly served to the opposite party. The opposite party neither cared to file their version or to appear before the commission to defend their case. Hence the opposite party was set exparte.
On the basis of the complaint and evidence adduced by the opposite party we would like to consider the following points.
- Whether there is unfair trade practice or deficiency in service on the part of the opposite party.
- If so what are the reliefs and costs?
On going through the complaint and evidence on record it is clear that the complainant had availed a Corona Rashak Policy vide Policy No 2856/62001746/00/000 from the opposite party and the policy is valid up to 29/06/2021.
Ext A1 is the letter dated 06/12/2020 issued by opposite party to the complainant having corona Rakshak Policy vide no. No.2856/62001746/00/000 with Policy expiry date on 06/29/2021 offering 5% additional loyalty discount on the applicable premium for the Arogya Sanjeevani Policy being a privilege Customer. Ext A2 is the OP ticket with Serial Number 290102 dated 29/1 issued from Govt. Medical College, Kottayam. Ext A2 clearly shows that the complainant attended the Outpatient unit of Medical College Kottayam with history of fever, cough and rhinitis and was advised for RTPCR test.
As per Ext A3 Covid-19 Test report issued by sars- cov 2 pcr lab, Department of Microbiology, Government Medical College, Kottayam on 29/01/2021 the complainant was test ted Covid-19 Positive in RTPCR Test.
Ext A4 is the Discharge summary issued from Caritas Hospital stating that the complainant was admitted on 30/01/2021 in Covid Care ward and treated by Dr.Covid Care Team. The complainant was discharged on 3/02/2021as tested negative in Covid 19 antigen test. Ext A5 is the salient features of the Corona Rakshak Policy of the opposite party stating that the sum insured options were Rs.50,000/- to Rs.2,50,000/- and the policy period is from three and half months, six and Half months, nine and half months as per different premium for different age groups. The Covid cover offered is the 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 and the positive diagnosis of Covid shall be from a government authorized diagnostic Centre. Ext A7 Discharge bill issued by Caritas Hospital proves that the complainant was admitted on 30/01/2021 at 13.11 hours in COVID Care ward and treated by Dr. Covid Care Team. The complainant was discharged on 03/02/2021 at 17.38 hours with a total bill of Rs.31,914/-.
Ext A6 is the claim repudiation letter dated 27/03/2021 issued by the opposite party to the complainant stating that the insured was diagnosed as covid positive category A patient and was admitted for the same. As per the provided documents at the time of admission vitals were stable, insured was managed with oral medications. The claim is not admissible as per the exclusion 6. The company shall not be liable to make payment under the policy in respect of any expenses incurred in connection with or respect of (6.1 ). Investigation and evaluation, ( i) Expenses related to any admission primarily for diagnosis and evaluation purposes. (ii) Any diagnosis expenses which are not related or not incidental to the current diagnosis and treatment. (3.8) In-patient care means the treatment for which the insured person has to stay in hospital continuously for more than 72 hours for treatment of covid.
On the basis of the above discussed evidence it is evident that the complainant was tested Covid -19 Positive in the test conducted at SARS- COV2 PCR lab, Department of Microbiology, Government Medical College, Kottayam on 29/01/2021 and the complainant had undergone in-patient treatment in Covid Care ward of Caritas Hospital form 30/01/2021 to 03/02/2021, a period of more than 72 Hours. The act of the opposite party in repudiating the genuine claim of the complainant is deficiency in service on their part. Hence point No.1 is found in favor of the complainant. The complaint is allowed and we pass the following orders.
- The opposite party is directed to pay Rs.31,934/- with 9% interest from 24/11/2022 to the complainant till realization.
- The opposite party is directed to give Rs.10,000/- as compensation for the mental agony, hardships and sufferings with cost Rs.3,000/-
The order shall be complied within 30 days from the date of receipt of the copy of this order.
Pronounced in the Open Commission on this the 27th day of April, 2023.
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- Letter dated 06.12.2020 from Universal Sampo General Insurance Co.Ltd.
A2- Copy of the outpatient record issued from Govt.Medical College Hospital Kottayam.
A3- Copy of the covid -19 test report issued by Dept. of Microbiology, Govt.Medical College Kottayam
A4- Copy of the discharge summary issued by Caritas Hospital Thellakom
A5- Policy details of Universal Sompo General Insurance Co.Ltd
A6- Copy of the claim repudiation letter dated 27.03.2021 issued from Universal Sompo General Insurance Company Ltd.
A7- Discharge bill of Caritas Hospital Thellakom
Exhibits marked from the side of opposite party
Nil
By order
Sd/-
Assistant Registrar
