District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.506/2021.
Date of Institution: 29.09.2021.
Date of Order:29.07.2022.
Rahul Aggarwal s/o Shri Naresh Kumar Aggarwal, resident of House No. 457, sEctor-17, Faridabad (Haryana) 121002.
…….Complainant……..
Versus
1. Reliance General Insurance Company Limited, Claim Servicing Office R care at 1-89/3/B/40 to 42/KS/301, 3rd floor, Krishe Block, krishe Sapphire, Madhapur, Hyderabad – 500 081.
2. Yes Bank Limited, SCO No.4, Ground & Second floor, Sector-16, Faridabad (Haryana) – 121002. (Through its Director/Manager/principal Officer.)
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
PRESENT: Sh. Braham Dutt, counsel for the complainant.
Sh. Rakesh Dabaas, counsel for opposite party N.1.
Sh. Neeraj Kumar Gupta, counsel for opposite party No.2.
ORDER:
The facts in brief of the complaint are that the complainant got insured with opposite party No.1 through intermediary opposite party No.2 vide policy NO. 920292028521000004 covered under COVID 19 protection insurance for sum insured as Rs.1,50,000/- under an agreement, which comes under the purview of Consumer Protection Act, 2019. Opposite party No.2 was the intermediary company for providing insurance to the customers on behalf of opposite party No.1. Opposite party No.2 being a service provider makes proposal before the customers and sale policies under various schemes like in the present case under COVID 19 Protection Insurance Policy on behalf of the opposite party No.1 and was obliged to pay subsequent claim arise under the existing policies taken on behalf of opposite party No.1. The complainant being on advice of the doctor had given sample for RT-PCR Test form the Haryana Government Hospital, Sector-30, Faridabad and as per report of the same had been found as COVID-19 Positive. As per the terms of the policy it was specifically mentioned in the policy certificate under benefits column in the above said policy as “Diagnosis cover-During the policy period, the company pays lumpsum payment of 100% of sum insured if insured persons diagnosis test confirms presence of COVID-19”. After diagnosis as COVID-19 positive, the complainant had submitted his claims amounting to Rs.1,50,000/- under claim reference No. 2211019510 with claim form for COVID-19 Projection Insurance claim alongwith allied required documents to opposite party No.2 for himself under the terms of the policy ibid, but the opposite parties had failed to pay the claim in time. The complainant had been submitted all the requisite documents as and when demanded by the opposite parties from time to time to settle the claim and reminding the opposite parties in person and on telephone as well as through email from time to time requesting him to pay the claim amount alongwith interest but the opposite parties had been avoiding to pay the amount. The complainant requested the opposite parties again and again to pay the amount of his claims, but the opposite parties had failed to pay the same till date, declined/rejected the claim vide letter dated 23.06.2021 stating false excuse as “as per details it had been noticed that as per registered digital registered records inured tested covet negative’ without any cogent proof & any proper documents as evident. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) pay the claim amount of Rs.1,50,000/- and interest @ 18% p.a. upto the actual realization of the payment.
b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment .
c) any other relief as may be deemed fit and proper in the facts and circumstances of the case..
2. Opposite party No.1 put in appearance through counsel and filed written statement wherein Opposite party No.1 refuted claim of the complainant and submitted that the complainant neither had any cause of action n or locus standi in lodging of the present complaint before this Forum, reason being, the complainant had submitted claim form dated 30.04.2021. Thereafter the claim was registered vide claim No. 2211019510 and matter was got investigated by the insurance company and the finding of the said investigation report are being reproduced as under:
- Patient suffering with c/o fever, headache, loose motion and consulted to his family doctor, Shatayu Multi specialty clinic (documents available or the same).
- Patient underwent Covid test at Health Department Faridabad and diagnosed Covid positive on 20.03.2021.
- Patient was home isolated for 18 days.
- N/H/O any chronic illness had been specified by the insured.
- Separately SRF form not collected, SRF ID was mentioned on the covid report and no separate message received by patient on his phone by the Govt.
- Antigen report was also collected dated 11.05.2021 that found to be negative.
- Patient work at Sanmark & Associates as Article Assistant and was on leave from 17.05.2021 to 10.05.2021.
- Covid report from the ICMR portal was tried but no data for Covid positive noted in the ICMR portal for dated 17.04.2021. Only the report found for 12.05.2021 which is negative.
Hence, it was established from the claim documents as well investigation report at the end of the opposite party No.1 that as per registered digital records i.e. ICMR report there was no evidence that insured was tested Covid positive, thus as per clause “Section 6 : General Exclusions: ix. Dishonest or Fraudulent Claims”, the said claim was not payable and the insurance company have treated the subject claim as “No Claim by closing the file in terms of “letter of intimation” dated 23.06.2021, which decision cannot be termed unconscionable at all. Opposite party No.1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Opposite party No.2 put in appearance through counsel and filed written statement wherein Opposite party No.1 refuted claim of the complainant and submitted that the terms and conditions and submission of the claim by the complainant was a matter of record. The claim of the complainant was rejected by the opposite party No.1 on the “Rejection remarks”. As per available details, it had been noticed that as per Digital Registered records insured tested Covid negative. Hence, as per clause, Section 6: General Exclusions: IX: Dishonest or Fraudulent claims, claim stands rejected”. Opposite party No.2 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
4. The parties led evidence in support of their respective versions.
5. We have heard learned counsel for the parties and have gone through the record on the file.
6. In this case the complaint was filed by the complainant against opposite parties – Reliance General Insurance company Ltd. with the prayer to : a) pay the claim amount of Rs.1,50,000/- and interest @ 18% p.a. upto the actual realization of the payment. b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment . c) any other relief as may be deemed fit and proper in the facts and circumstances of the case..
To establish his case the complainant has led in his evidence Ex.CW1/A – affidavit of Rahul Aggarwal,, Ex.C-1 – Proposal Form, Ex.C-2 – Reliance Covid-19 Protection Insurance Certificate of Insurance, Ex.C-3 – Premium certificate, Ex.C-4 – COVID Test Report (FRU-1), Ex.C-5 – Claim Form for Covid-19 Protection Insurance,, Ex.C-6 – Cancelled cheque, ex.C-7 – slip UHID: 425000009341 dated 17.04.2021, Ex.C-8 – email, Ex.C-9 0 Covid Test Report (FRU-1), Ex.C-10 & 11 – emails, Ex.C-12 – letter dated 13.05.2021, Ex.C-12 & 13 – emails, Ex.C-15 – letter dated 12.06.2021, Ex.C-16 – Covid Test Report (FRU-1), Ex.C-17 –letter dated 23.6.2021 regarding assessment letter, Ex.C-18 to 20 - emails
On the other hand counsel for the opposite party No.1strongly agitated and opposed. As per the evidence of the opposite party No.1, Ex.RW1/A – affidavit of Shri Suryadeep Thakur, Area Manager (Legal) M/s. Reliance General Insurance co. ltd., Chandigarh,, Ex.R-1 - Covid-19 Protection Insurance-Certificate of Insurance, Ex.R-11 – Claim Form for Covid -19 Protection Insurance,, Ex.R-III – RCU Final Report, Ex.R-Iv - letter dated 23.6.2021.
As per evidence of opposite party No.2, Ex.RE2/A – affidavit of Rashmi Singh, manager , Yes Bank Ltd., Sector-16,. Faridabad, Ex.RW2/1 – letter dated 23.06.2021, Ex.RW2/2 – Reliance Covid-19 Protection Insurance –Certificate of insurance,, Ex.RW2/3 – premium certificate, Ex.RW2/4 – Reliance covid-19 Protection Insurance Proposal Form.
7. In this case, complainant insured with opposite party No.1 through intermediary opposite party No.2 vide policy NO. 920292028521000004 covered under COVID 19 protection insurance for sum insured as Rs.1,50,000/- under an agreement, which comes under the purview of Consumer Protection Act, 2019. Opposite party No.2 was the intermediary company for providing insurance to the customers on behalf of opposite party No.1. Opposite party No.2 being a service provider makes proposal before the customers and sale policies under various schemes like in the present case under COVID 19 Protection Insurance Policy on behalf of the opposite party No.1 and was obliged to pay subsequent claim arise under the existing policies taken on behalf of opposite party No.1. The complainant being on advice of the doctor had given sample for RT-PCR Test form the Haryana Government Hospital, Sector-30, Faridabad and as per report of the same had been found as COVID-19 Positive. As per the terms of the policy it was specifically mentioned in the policy certificate under benefits column in the above said policy as “Diagnosis cover-During the policy period, the company pays
lumpsum payment of 100% of sum insured if insured persons diagnosis test confirms presence of COVID-19”. After diagnosis as COVID-19 positive, the complainant had submitted his claims amounting to Rs.1,50,000/- under claim reference No. 2211019510 with claim form for COVID-19 Projection Insurance claim alongwith allied required documents to opposite party No.2 for himself under the terms of the policy ibid, but the opposite parties had failed to pay the claim in time. The complainant had been submitted all the requisite documents as and when demanded by the opposite parties from time to time to settle the claim and reminding the opposite parties in person and on telephone as well as through email from time to time requesting him to pay the claim amount alongwith interest but the opposite parties had been avoiding to pay the amount. The complainant requested the opposite parties again and again to pay the amount of his claims, but the opposite parties had failed to pay the same till date, declined/rejected the claim vide letter dated 23.06.2021 stating false excuse as “as per details it had been noticed that as per registered digital registered records insured tested covid negative’. Hence as per Clause, Section 6: General Exclusions: IX. Dishonest or Fraudulent Claims, Claim stands rejected”.
8. After going through the evidence led by the parties, the Commission is of the opinion that the opposite party has repudiated the claim of the complainant due to fraud vide letter dated 23.06.2021 on the ground that “as per details it had been noticed that as per registered digital registered records insured tested covid negative’. Hence as per Clause, Section 6: General Exclusions: IX. Dishonest or Fraudulent Claims, Claim stands rejected.” As per Reliance Covid-19 Protection Insurance –Certificate of Insurance vide Ex.RW2/2 , in which it has been mentioned in Section 6 i.e “In the event of any incorrect representation, the liability shall be upon the policyholder” No other T & C exhibited by the opposite parties. As per Covid Test Report (FRU-I) vide Ex.C4 it shows that Mr. Rahul Aggarwal was positive as per test and the opposite party has failed to establish the fraud of the complainant. Hence, the complaint is allowed. Opposite parties are directed to process the claim of the complainant within 30 days of receipt of the copy of order and pay the due amount to the complainant along with interest @ 6% p.a. from the date of filing of complaint till its realization. The opposite parties are also directed to pay Rs.2200/- as compensation on account of mental tension, agony and harassment alongwith Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 29.07.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
