IN THE CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM
Dated this the 29th day of December, 2022
Present: Sri.Manulal.V.S, President
Smt.Bindhu.R, Member
Sri.K.M. Anto, Member
CC No. 95/2021 (Filed on 25/06/2021)
Complainant : Prince Bhaskar, S/o Bhaskaran
Aged 44 years, Sulochanasadanam
Karikkodu P.O, Peruva, Kottayam- 686610
Mob- 9447057682.
(Adv.T.R.Sathian)
Vs
Opposite party : Reliance General Insurance Company
Represented by the Branch Manager
3rdFloor ,Urumbil Signature Tower
Behind K R Bakery, Kanjikuzhy
Kottayam- 686 004.
(Adv. Agi Joseph)
O R D E R
Smt.Bindhu.R, Member
The Complaint is filed under section 12 of the Consumer Protection Act 1986.
The complainant’s case is that he and his brother took covid 19 policies from the opposite party and when his brother was covid positive, he got his policy settled. While residing with his brother who was the primary contact and thereafter the complainant was tested positive and underwent home quarantine. But when he submitted the claim for insurance after 14 days quarantine, the same was neither repudiated nor settled. This is a deficiency of service on the part of the opposite party. On 04-01-2021 the opposite party emailed that the claim of the complainant is under progress. As per the then situation the Government of Kerala was promoting home quarantine for primary contact cases. From the Covid 19 quarantine release certificate produced by the complainant issued by the competent authority dated 04-12-2020 which was submitted to the opposite party, it is clear that the complainant had to undergo quarantine for 14 days as per the rules. Hence the non action of the opposite party on the claim of the complainant is a deficiency of service and unfair trade practice.
The opposite party appeared on receipt of notice and filed version through itslegal manager contending that the opposite party had not compelled the complainant or his brother to take their policy. As per the terms and conditions of the policy the petitioner is not entitled to get any benefit. No claim shall be payable where the insured person was living with and sharing the same addressas that of persons who were diagnosed with Covid 19. Further the complainant underwent self quarantine which is not covered under the policy. The opposite party is not liable to pay insurance claim on the basis if the petitioner or his brother honoured any claim from any other insurance company. The petitioner has not taken any medicine or any treatment from any of the hospital as definedin the policy. Hence the opposite party is not liable to pay any insurance claim.
There is no cause of action for this complaint and the complainant has not suffered any mental agony. Hence the complaint is liable to be dismissed.
The complainant filed affidavit in lieu of chief examination and documents which were marked as Exhibit A1 to A3 and the opposite party filed Exhibit B1 along with proof affidavit.
The complainant paid premium for the policy issued by the opposite party for the coverage of the covid 19 issues, the opposite party issued policy certificate in which the Benefits column contains two types of cover –diagnose cover and quarantine cover. The quarantine cover clearly statesthat “if this cover is opted, the company pays an amount of 50% of sum insured if insured person is quarantined for covid-19 for at least 14 consecutive days. The opposite party has now here in the version or affidavit stated that the complainant did not opt for the quarantine cover.
So it is evident that the policy included the quarantine cover also. Now herein the policy it is stated that the complainant has opted for the 1st benefit only. Moreover, the opposite party has not challenged the benefits under the policy given to the complainant.
The policy certificate given to the complainant does not bear the terms and conditions along with it. The two benefits are highlighted in the policy. The policy details are available only in the website. Even then in the policy conditions Exhibit B1, S.3 Scope of cover and S.3.2 is Quarantine cover in which it is stated that: In the event of opting plan B or Plan C as defined under section 7, Schedule of benefits and payment of applicable premiums, the company will pay insured person, 50% of sum insured specified in the policy schedule provided that.. “a. The insured person is quarantined due to covid 19, for at least 14 consecutive days”. Further it is stipulated that “S.4.vthat self-quarantine is not covered”.
The policy terms and conditions are accepted, on condition that self-quarantine is excluded. As per the Covid 19 contact tracing and quarantine guidelines No. 31/F2/2020, a person detected with corona positive could either go for home quarantine or institutional quarantine according to the isolation facility in home. So the contention of the opposite party that self-quarantine could not be awarded with is not admissible. Moreover, the complainant has produced Exhibit A3, which isthe quarantine release certificate issued by the Medical officer, Primary Health Centre, Peruva in Kottayam district. The accepted practices in the pandemic days was if one is detected corona positive, immediately aperson from the nearby CFLTC would visit or take report from the patient and ensure that the patient was under quarantine for 14 days either at home or at any concerned institution. So Exhibit A3 is an admissible document to prove that the complainant had undergone quarantine under the supervision of a medical practitioner.
Another contention of the opposite party is that the complainant had shared the house with his brother who was detected covid positive and this was in eligibility for the claim. But as per the averment in the complaint, the complainant had been sharing the same house with the family of his brother even before the corona period. While so his brother got affected with the decease and in the then situation nobody could go out from a home where one person was detected covid positive. Thus he was compelled to share the house further. Moreover, a person affected with corona positive would show symptoms only after 3-5 days. By the time the persons in contact could get contracted by the decease. So if persons incontact get affected with the virus, the acquaintances of the person could not escape. So this condition that the insured must not share a dwelling place with a covid positive person also cannot be admitted. Moreover, the opposite party after receiving the claim from the complainant issued a reply on 04.01.2021 Exhibit A2, informing that the claim would be processed shortly. But they did not do anything till the filing of the complaint.
Thus in the light of above discussion we find that the opposite party insurance company is willfully evading from the payment of 50% of the sum insured to the complainant which is a deficiency of service and an unfairtrade practice. Hence we allow the complaint and pass the following order:
1. The opposite party is directed to pay Rs.1,00,000/- from (04.12.20) with an interest @ 9% pa.
2. The opposite party is further directed to give Rs.10,000/- towards compensation to the complainant. The order shall be complied within 30 days of date of receipt of this order failing which the award amount shall carry 12% interest till realization.
Pronounced in the Open Commission on this the 29th day of December, 2022.
Smt.Bindhu.R, Member sd/-
Sri.Manulal.V.S, President sd/-
Sri. K.M. Anto, Member sd/-
Appendix
Exhibits marked from the side of complainant.
A1- Copy of the insurance certificate
A2- Copy of e-mail dated 04/01/2021
A3- Copy of Covid-19, quarantine release certificate
Exhibits marked from the side of opposite party.
B1- Copy of policy details of Reliance General Insurance Company.
By Order
sd/-
Assistant Registrar
