By: Sri. Mohamed Ismayil C.V., Member
The grievance of the complainant is as follows:-
- On 20/08/2020 the complainant subscribed Corono Rakshak Policy worth
Rs.1,50,000/- issued by the opposite party after making payment of Rs.3,706/ as premium. Policy No.1 P/181312/01/2021/003629 and policy is commenced on 20/08/2020 and valid up to 01/06/2021. It is came to know that after 15 days of subscription of policy, the complainant is eligible for 100% reimbursement of expenses incurred for treatment if he tested positive for covid 19 pandemic and hospitalized for 72 hours. Later on 12/10/2020, complainant approached Government Hospital, Manjeri due to sore throat, headache and other physical discomfort. On 17/10/2020, on the basis of advice given by doctors, RTPCR test was conducted and resulted was covid 19 positive. From 18/10/2020 to 23/10/2020, the complainant was admitted in a CFLTC functioning under Government Hospital, Tirurangadi. On 03/11/2020 the complainant submitted claim application along with required documents before the first opposite party. After one month, on enquiry, the complainant understood that his claim was rejected. Subsequently the complainant received a claim repudiation letter dated 05/12/2020 stating that requiring hospitalization not for institutional quarantine. According to the complainant the reason stated for repudiation is arbitrary and intended to make unlawful gain by the opposite parties. The opposite parties are liable to reimburse the claim of the complainant. So the complainant approached this Commission for an order of direction to the opposite parties to reimburse the claim amount of Rs.1,50,000/- and to pay Rs.1,00,000/- as compensation for mental agony and hardship suffered due to the act of the opposite parties.
2. The complaint is admitted on file and issued notice to the opposite parties. The opposite parties entered appearance and filed version.
3. In the version, it is contended by the opposite parties that the complaint is filed with ulterior motive and intended to make illegal gain. It is admitted by the opposite parties that the complainant subscribed insurance policy as stated in the
complaint and added that terms and conditions the policy also explained to the complainant. It is stated in the version that the complainant had submitted a claim as CIR /2021/181312/0451654 along with the claim form and discharge card from the Government Taluk Hospital, Tirurangadi which states that the complainant had undergone treatment in the hospital from 18/10/2020 to 23/10/2020 for the treatment of covid 19. It is contended by the opposite parties that as per record the patient was asymptomatic, vitamin and oral medicines were only given to him. It is also stated that discharge summary issued from the hospital was silent about patients’ clinical parameters like Temperature, Pulse rate, SPO2 level etc. It is submitted that the patient was asymptomatic & no active line of treatment was given but only vitamins tablets prescribed. As per the terms and conditions of the policy it is clearly mentioned that “the claim shall be payable on positive diagnosis of Covid 19 requiring hospitalization for a minimum period for 72 hours”. Here covid positive has been diagnosed but the patient was symptomatic, hospitalization was not warranted. There were no symptoms requiring inpatient care/ admission in a hospital. Corona symptoms like fever, sore throat, headache, chills, loss of smell or taste, congestion or runny nose, nausea or vomiting, diarrhoea or breathing difficulty were absent and hence it doesn’t require admission in a hospital. No specific treatment given to the patient and no documents submitted other than discharge summary. As per terms and conditions of policy , lump sum benefit equal to 100% of the sum insured shall be paid on positive diagnosis of Covid, requiring hospitalization for a minimum continues period of 72 hours. It is further added that the positive diagnosis shall be from a government authorized diagnostic centre. According to the opposite parties the repudiation letter issued on 05/12/2020 is valid one. It is also stated that the rights and obligations are governed by the terms of contract and provisions of law should be interpreted literally. The terms of the policy have to be construed as it is and the court cannot add or substract something. The opposite parties stated that the complainant has preferred complaint before Insurance Ombudsman KOC–H-044-2021-0870 and the Ombudsman dismissed the same. According to the opposite parties, the complainant was stayed at hospital only for observation. The repudiation of claim by the opposite parties did not cause mental agony to the complainant and there is no deficiency in service on the part of the opposite parties and complainant is not entitled for the lump sum benefit of the policy. It is contended by the opposite parties the complaint is filed to make unlawful enrichment and so prayed for dismissal of complaint with compensatory costs.
4) The complainant and opposite parties filed affidavits. The documents produced by the complainant is marked as Ext. A1 to A9. Ext. A1 document is the insurance policy certificate No. P/181312/01/2021/003629 issued by the opposite parties to the complainant. Ext. A2 document is the copy of insurance policy conditions issued by the opposite parties to the complainant. Ext. A3 document is the copy of one pages of insurance policy conditions issued by the opposite parties to the complainant. Ext. A4 document is the copy of Covid test report dated 17/10/2020 issued from Department of Micro Biology, Government Medical College, Manjeri. Ext. A5 document is the copy of discharge card dated 23/10/2020 issued from Government Taluk Hospital, Tirurangadi . Ext. A6 documents is the casualty ticket dated 12/10/2020 issued from Government Medical College Hospital, Manjeri. Ext. A7 document is the copy of repudiation letter dated 05/12/2020 issued by the opposite parties to the complainant. Ext. A8 document is the copies of print out of the advertisement of the Covid Rakshak Insurance policy published in internet by the opposite parties. Ext. A9 document is the copy of terms and conditions of Corona Kavach Policy issued for Star Health Allied Insurance Co. Ltd. The documents produced by the opposite parties also marked as Ext. B1 to B6. Ext. B1 document is the copy of insurance policy certificate No. P/181312/01/2021/003629 issued by the opposite party to the complainant. Ext. B2 document is the copy of discharge card dated 23/10/2020 issued from Government Taluk Hospital, Tirurangadi. Ext. B3 document is the copy of repudiation letter dated 05/12/2020 issued by the opposite parties to the complainant. Ext. B4 document is the copy of notice dated 15/02/2021 issued by office of the insurance Ombudsman, Kochi. Ext. B5 document is the copy of self contained note filed by the opposite party before the insurance ombudsman. Ext. B6 document is the copy of award dated 26/03/2021 passed by the insurance Ombudsman.
5) Heard both sides in the detail. Perused documents and affidavits produced by both parties. The points arisen for the consideration of the Commission are;
1) Whether the opposite parties committed any kind of deficiency in service towards the complainant?
2) Relief and cost?
6. Point No.1 & 2
According to the complainant he availed an insurance policy known as Corona Rakshak Policy from the opposite parties. The complainant produced insurance certificate before the Commission and marked as Ext. A1 document. The opposite parties also produced same document which is also marked as Ext. B1 document by the Commission. It is contended by the complainant that as per conditions of policy after the initial waiting period of 15 days and during the period of insurance coverage, if the insured person is diagnosed with Covid positive requiring hospitalization for minimum continuous period of 72 hours, then the opposite parties will have to pay the lump sum benefit equal to 100% of sum insured opted. The complainant produced Ext. A2 and A3 document to show the terms and conditions of the insurance policy. It is stated both in the complaint and in affidavit that he was affected with sore throat head ache and other physical discomfort and approached Government Hospital on 12/10/2020. The complainant produced Ext. A6 document to prove this contention. On 17/10/2020 the complainant undergone for RTPCR test which culminated in the result of Covid 19 Positive. The complainant produced Ext. A4 document to show the Covid test result. On the basis of Ext. A4 document he was admitted in Government Taluk Hospital, Tirurangadi and undergone treatment for Covid 19 pandemic from 18/10/2020 to 23/10/2020. The complainant produced Ext. A5 document, which is the discharge card to show that he had hospitalized for more than 72 hours continuously. The opposite parties also produced same document and marked as Ext. B2 document. It is stated in the complaint that when the complainant applied for a claim the same was rejected alleging lump sum Benefit shall be payable on positive diagnosis of Covid, requesting hospitalization and not for institutional quarantine. The repudiation letter dated 05/12/2020 issued by the opposite parties produced before the Commission by the complainant and marked as Ext. A7 documents. The opposite parties also produced same document and marked as Ext. B3 document by the Commission.
7. On the contrary, the opposite parties contended that as per Ext. B2 and Ext. A5 documents (both are same) the complainant was asymptomatic and only vitamin and oral medicines were given to him. According to the opposite parties, the medical record shows that complainant stayed in hospital only for observation i.e. under institutional quarantine. So the complainant is not entitled for reimbursement under Ext. A1 and (Ext. B1) documents.
8. When going through the evidences adduced by the complainant, it can be seen that he was symptomatic at the time of issuance of Ext. A6 document by the hospital authority. Ext. A5 document as well as Ext. A6 document clearly shows that he was admitted and under gone treatment in Government hospital. In the complaint it is categorically stated by the complainant that he approached Government hospital Manjeri on 12/10/2022 due to symptoms of Covid 19. When Covid 19 was detected, then complainant was admitted to the hospital and later discharged on 23/10/2020. So the contention raised by the opposite parties that the complainant had hospitalized only for observation cannot be accepted by the Commission. The opposite parties should have considered the facts that medical science did not find out a given protocol for the treatment of Covid 19 Pandemic by that time. So the opposite parties cannot dictate the treatment protocol to the customers who subscribed Corono Rakshak policy from them. At a time when the world is reeling under the Covid 19 epidemic, the complainant could have been treated only through the means prepared by the Government system. It can be understood from the document that the complainant has used the same drugs that are currently available to prevent the Covid 19 disease. It is contended by the opposite parties that there is violation of definition clauses of policy and so claim of the complainant is rejected. The definition clause 3.7 and clause 3. 8 of Ext.B1 document defines hospitalisation and in – patient care respectively. The term hospitalization means admission is a hospital designated for Covid 19 treatment by Government for a minimum period 72 consecutive as patient care hours and in – patient care means treatment for which the insured person has to stay in a hospital continuously for more than 72 hours for treatment of Covid. The above mentioned contentions raised by the opposite parties is to sustainable and cannot be acceptable by this Commission. Ext. A5 and A6 document clearly proves that the complainant undergone treatment as per the guidelines of policy conditions. Moreover, the Commission need not look in to beyond the reason for repudiation of claim by the opposite parties. The opposite parties also failed to adduce evidences to substantiate the procedure taken for rejection of the claim of the complainant. After introducing Ext. A9 document before public realm and issuing policy like this one during Covid pandemic, it is not fair on the part of the opposite parties to evade from responsibility in considering the legal claim of the complainant. It can be find that there is no error in the procedure of claim made by the complainant. So this Commission finds that the opposite parties committed deficiency in service in considering the claim application. This Commission allow the complaint in the following manner.
1) The opposite parties are directed to pay Rs.1,50,000/- (Rupees one Lakh fifty thousand only ) to the complainant as the amount covered under the insurance policy No. P/181312/01/2021003629.
2) The opposite parties are directed to pay Rs.50,000/- (Rupees fifty thousand only) to the complainant as compensation for sufferings of mental agony and hardship due to the deficiency in service on the part of the opposite parties.
3) The opposite parties are also directed to pay Rs.10,000/- (Rupees ten thousand only) as the cost of the proceedings.
The opposite parties shall comply this order within one month from the date of receipt of copy of this order; otherwise the entire amount shall bear 9% of interest per annum from date of order till realization.
Dated this 23rd day of January, 2023.
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: Ext.A1 to A9
Ext.A1: Insurance policy certificate No. P/181312/01/2021/003629 issued by the
opposite parties to the complainant.
Ext.A2: Copy of insurance policy conditions issued by the opposite parties to the
complainant.
Ext A3: Copy of one pages of insurance policy conditions issued by the opposite
parties to the complainant.
Ext A4: Copy of Covid test report dated 17/10/2020 issued from Department of
Micro Biology, Government Medical College, Manjeri.
Ext A5: Copy of discharge card dated 23/10/2020 issued from Government Taluk
Hospital, Tirurangadi .
Ext A6: Casualty ticket dated 12/10/2020 issued from Government Medical College
Hospital, Manjeri.
Ext A7: Copy of repudiation letter dated 05/12/2020 issued by the opposite parties
to the complainant.
Ext. A8: Print out of the advertisement of the Covid Rakshak Insurance policy
published in internet by the opposite parties.
Ext.A9: Copy of terms and conditions of Corona Kavach Policy issued for Star Health
Allied Insurance Co. Ltd.
Witness examined on the side of the opposite party: Nil
Documents marked on the side of the opposite party: Ext. B1 to B6
Ext.B1: Copy of insurance policy certificate No. P/181312/01/2021/003629 issued by
the opposite party to the complainant.
Ext.B2: Copy of discharge card dated 23/10/2020 issued from Government Taluk
Hospital, Tirurangadi.
Ext.B3: Copy of repudiation letter dated 05/12/2020 issued by the opposite parties to
the complainant.
Ext.B4: Copy of notice dated 15/02/2021 issued by office of the insurance
Ombudsman, Kochi.
Ext.B5: Copy of self contained note filed by the opposite party before the insurance
ombudsman.
Ext.B6: Copy of award dated 26/03/2021 passed by the insurance Ombudsman.
Mohandasan K., President
Preethi Sivaraman C., Member
VPH Mohamed Ismayil C.V., Member
