Orissa

Cuttak

CC/220/2021

Anil Pradhan - Complainant(s)

Versus

Oriental Insurance Co Ltd - Opp.Party(s)

B Bhol & associates

21 Sep 2022

ORDER

IN THE COURT OF THE DIST. CONSUMER DISPUTES REDRESSAL COMMISSION,CUTTACK.

                                                                                   C.C.No.220/2021

Anil Pradhan,

S/O:Akshay Pradhan,

Permanent resident of Sanakanjeni,PO:Balasingha,

Dist:Angul,

At present C/o:Biswaranjan Pradhan,

At:munda Sahi,near Jagannath Temple,

P.S:Bidanasi,Cuttack.                                                                      ... Complainant.

 

                                                Vrs.

1.        Senior Divisional Manager,

Oriental Insurance Co. Ltd.,Raja Jagdev Singh Road,

Near Bus Stand,Dist:Angul,Pin-759122.

 

2.        Oriental Insurance Co Ltd.,

Represented by its Divisional Manager,

At:Bajrakabati Road,Cuttack.                                              ... Opp. Parties.

                       

Present:               Sri Debasish Nayak,President.

                                Sri Sibananda Mohanty,Member.

 

Date of filing:    23.12.2021

Date of Order:  21.09.2022

 

For the complainant:          Mr. B.N.Bhol,Adv. & Associates.

For the O.Ps   1 & 2  :          Miss J.P.Tripathy,Adv. & Associates.

 

Sri Debasish Nayak,President                                      

            Case of the complainant as made out from the complaint petition in short is that during the pandemic Covid-19 period, the complainant had opted for ‘Corona Rakshak Policy’ from the O.Ps bearing policy no.345900/48/2021/581 with insured value of Rs.2,50,000/- and had paid the premium of Rs.2438/- which was valid from 6.10.20 to 17.7.21.  During the validity of the said insurance policy, the complainant had fallen ill and on Covid test he was found to be positive with effect from 3/ 4 of June,2021 for which he was admitted at the Covid Care Centre(Adarsha Vidyalaya) of Talcher on 5.6.21 and was discharged after being treated on 10.6.21.  Thereafter, he had remained on isolation for 7 days obeying the Covid-19 guidelines and advice of the doctors.  Thus on 24.6.21 he had made the insurance claim of the policy as obtained by him but to his dismay, on 25.10.21 his claim was repudiated by the O.Ps.  According to the complainant, as per the condition no.3.6(vi) for the purpose of this policy any other set up designated by the Govt. as hospital for treatment of Covid-19 shall also considered as hospital.  Ultimately, having no other way out, the complainant has filed this case claiming the insured sum of Rs.2,50,000/- alongwith interest thereon @ 10%  with effect from 25.10.21 together with a sum of Rs.30,000/- towards his mental agony and harassment and further has claimed a sum of Rs.10,000/- towards his litigation expenses.  The complainant has also prayed for any other relief as deemed fit and proper.

            He has filed copies of all the documents regarding to his Covid test and treatment and also the policy documents as obtained from the O.Ps.

2.         The O.Ps have contested this case and have filed their written version wherein they admit about the ‘Corona Rakshak Policy’ as obtained by the policy holder/complainant which was effective from 6.10.20 till the midnight of 17.7.21.  They also admit to have received the Covid intimation from the insured/complainant on 24.6.21 who was admitted at Covid Care Centre(Adarsha Vidyalaya) of Talcher.  They have also received the connecting documents together with the discharge certificate of the complainant as a patient suffered from Covid.  According to the O.Ps, the claim should have been lodged within 15 days and since because the complainant, who was detected to be Covid positive on 4.6.21, without making his claim by 19.6.21 had lodged his claim on 24.6.21.  So according to them, the claim of the complainant is beyond the stipulated time of claim.  The O.Ps in their written version have also stated that the place where the complainant was being treated for his Covid lacks certain provisions in order to justify it to be a Covid-19 hospital.  As such, they have prayed to dismiss the complaint petition with cost. 

            They have also filed the copies of documents and the copy of the application of the complainant in order to prove their case.

3.         Keeping in mind the averments as made in the complaint petition and the contents of the written version, this Commission is of a view to settle the following issues in order to arrive at a proper conclusion here in this case.

i.          Whether the case of the complainant is maintainable?

ii.         Whether the case is barred by law of limitation?

            ii.         Whether there was deficiency in service on the part of O.Ps?

            iii.        Whether the complainant is entitled to the reliefs as claimed?

Issue no.iii.

            Out of the four issues, issue no.iii being the pertinent issue is taken up first for consideration here in this case.

            Admittedly the complainant had taken a policy called ‘Corona Rakshak Policy’ from the O.Ps and had paid the premium thereto and thus the said policy was effective during the period when the complainant fell ill and was found to be Covid positive and had undergone treatment at Covid Care Centre(Adarsha Vidyalaya) of Talcher.  The contention of the O.Ps is that the said place where the complainant was being treated for his Covid lacks certain provisions in order to justify the same as a proper Covid Care Centre for which they had mainly repudiated the claim.  During the pandemic situation which was quite grave, the Govt. had announced certain places to be Covid Care Centres by providing the minimum required facilities for the treatment of the Covid patients and one of them so specified and notified by the Govt. was the Covid Care Centre (Adarsha Vidyalaya) of Talcher.  The O.Ps do not dispute that the said Covid Care Centre at Adarsha Vidyalaya of Talcher, was not specified and notified to be a Covid Care Centre for the Covid patients.   Thus, when the Govt. has specified the same to be a Covid Care Centre by disputing the same and repudiating the claim of the complainant, by saying that the said Covid Care Centre lacks certain facilities, the O.Ps had undoubtedly found to be deficient in their service towards the insured policy holder: the complainant of this case.  Thus, this issue is answered in favour of the complainant.

Issues no.i & ii.

            When the claim of the complainant was repudiated, the complainant was forced to file this case is definitely maintainable.  As per the evidence available, the complainant had made his claim before the O.Ps on 24.6.21 for getting his insurance claim of his policy.  The contention of the O.Ps is that the complainant should have made his claim by 19.6.21, but the complainant had made his claim on 24.6.21 i.e., after a delay of 4 to 5 days.  Admittedly, the complainant was suffering from Covid and was being treated at the Covid Care Centre which is not in dispute.  The complainant remaining on isolation is also not in dispute.  Thus, the Covid patient after being discharged from the hospital and after undergoing the isolation period when felt capable had made his claim before the O.Ps for his insurance amount and the delay in this score for 4 to 5 days cannot be considered strictly to be a delay being intentionally made so as to repudiate the claim for insurance.  Thus, it cannot be said here that the case of the complainant is barred by law of limitation.  Accordingly, these two issues are answered.

Issue No.iv.

            From the discussions as made above, this Commission comes to a conclusion that infact the complainant has rightly filed this case when his valid claim was repudiated by the O.Ps and thus he is entitled to the reliefs as claimed by him.  Hence it is so ordered;

                                                      ORDER

            The case is decreed on contest against the O.Ps.  Both the O.Ps are found jointly and severally liable here in this case.  The O.Ps are hereby directed to pay the complainant his insurance amount of Rs.2,50,000/- with effect from 24.6.21 alongwith interest @ 9% per annum thereon till the total amount is quantified.  The O.Ps are further directed to pay a sum of Rs.30,000/- towards his mental agony and harassment as caused by them.  The O.Ps are also to bear the litigation expenses of the complainant to the tune of Rs.10,000/-.  This order is to be carried out within a period of 30 days from the date of receipt of copy of this order.

Order pronounced in the open court on the 21^st day of   September,2022 under the seal and signature of this Commission.           

                                                                                                                                Sri Debasish Nayak

                                                                                                                                            President

                                                                                                                                                             Sri Sibananda Mohanty

                                                                                                                                Member