IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM

Dated, the 28^th day of June, 2024

Present: Sri. Manulal V.S. President

          Sri. K.M. Anto, Member

C C No. 191/2023  (Filed on 17/06/2023)

                                                                                                    O R D E R

Sri. Manulal V.S. President

          Filed under section 35 of the Consumer Protection Act 1973.

The complainants insured themselves for COVID-19, having policy number 220692028521000129 in the name of the 1st complainant, policy number 220692028521000132 in the name of the 2nd complainant, and policy number 220692028521000482 in the name of the 3rd complainant. As per the said insurance, the opposite party promised that if the complainants contract Covid-19, they shall be compensated with an insured sum of Rs 5,00,000/- each.

The complainants were infected due to Covid-19 on 3/11/2020 and were taken to First Line treatment center Nattakom. On 12/11/2020, they all were tested negative and released to home. Thus, the complainants became eligible and rightful to obtain the Insurance amount.

Soon, the complainants contacted the respondent's office and provided all the documents to realize the insured amounts. The documents included the original treatment certificate and a copy of the policy. On submission of the said documents, the officials of the respondent logged their claim into the opposite party website and requested one month to fulfill the claim and its payment.

The complainants were waiting for their claim to get ripened and for the realization of the insurance amount.  Throughout 2021 and 2022, the officers of the respondent deferred the payment to the complainants, stating one reason or another. When the first complainant, who was fed up with the deceitful approach of the opposite party, demanded to either pay the sum assured or return the documents, they denied and dared the 1^st complainant to seek legal recourse.

The opposite party is duty-bound to pay the sum assured to the complainants. The opposite party is deliberately keeping aloof to cheat and defraud the complainants.

The act of the opposite party is aimed to deceive the customer and enrich illegally. The conduct of the opposite party amounts to unfair trade practices. The acts of the opposite party's have caused irreparable injury to the complainant.

Hence, this complaint is filed by the complainants praying for an order to direct the Opposite Party to pay the sum assured in policy number 220692028521000129, in the name of the first complainant, policy number 220692028521000132 in the name of the second complainant, and policy number 220692028521000482 in the name of the third complainant and to direct the Opposite Party to pay Rs.75000/- towards mental, monetary and physical damages to the complainant.

Upon notice from this commission, the opposite party appeared before the commission filed version contending as follows:

          The complaint is not maintainable either in law or on facts. The claim of the second complainant was repudiated on 30/1/2021. The complaint was filed only on 17/5/2023. Hence, this complaint is barred by limitation.

The complainants are not affected by Covid-19 as alleged in the complaint. One Susan Aby filed a claim application for COVID-19 along with a document in the name of Krupa Aby as supporting evidence affecting COVID-19. The insurance company demanded document for evidencing Susan Aby affected Covid-19. But she has not produced the said document. In the above-mentioned circumstances, the insurance company repudiated the claim, stating that "as per the available details, the insured has not provided any such documentary evidence that confirms that Krupa Aby and Susan Aby are the names of the same person and clearly there is a misrepresentation of names. Hence, as per clause, section 6: general exclusions viii, nondisclosure or misrepresentation, the claim stands rejected."

The complainants, Aby Jacob, and  Neha Susan Aby, have not submitted any claim application before the opposite party. The complainants have not submitted proper documents to the claim as alleged in this complaint. The opposite party repudiated Susan Aby's claim on 30/6/2021. Without appropriate documents, the opposite party cannot evaluate the claim of the complainants, which will come within the purview of the terms and conditions of the policy. The opposite party is not liable to pay any amount as alleged in the complaint. Without submitting proper claims or documents, this opposite party is unable to process the claim. There is no cause of action for filing this complaint.

As per the document produced before this commission, the claim of the complainants is not payable as per the terms and conditions of the policy. Self-quarantine will not come within the purview of the terms and conditions of the policy. Quarantine in a home will not be considered for the purpose of this policy. Hence, the complainant is not entitled to any insurance benefit.

The reason for repudiation of the claim is true and correct. The complainant has not suffered any mental agony and loss as claimed in the complaint. The insurance company is not liable to pay any amount to the complainant. The complainant approached the commission with unclean hands without mentioning the correct details in his complaint. There is no deficiency of service on the part of the opposite party.

The complainant filed proof affidavit in lieu of chief examination and marked exhibit A1 to A7. Sujith Krishna S K, who is the manager of legal claims of the opposite party, filed proof affidavit in lieu of chief examination and marked exhibit B1 to B8 from the side of the opposite parties.

We would like to consider the following points in evaluating the complaint, version, and the evidence on record.

1. Whether the complaint is barred by limitation?
2. Whether the complainant had succeeded to prove deficiency in service or unfair trade practice on the part of the opposite parties? 
3. If so, what are the reliefs and costs?

POINTS 1,2 &3

There is no dispute on the fact that the complainants availed Reliance  Covid- 19  Protection insurance policy from the opposite party for a period from 26-4-2020 to 25-4-2021.  It is proved by exhibit A1, which is the Policy issued in the name of the first complainant, that the sum assured was 50,000. Exhibit A2, the health insurance policy issued in the name of the second complaint, proves that the sum assured was 50,000 and the coverage was from 26-4-2020 to 25-4-2021. Exhibit A3 is the health policy issued by the opposite party in the name of the 3rd complainant, and the sum assured by the said policy was Rs. 25,000.

Exhibits A4 and A5 are the  Antigen Test reports of the first and third complainant, respectively, issued by the District Medical Officer Kottayam on            20-11- 2020. Ongoing through exhibits A4 and A5, we can see that the first and third complainants were infected with COVID-19 on 3-11- 2020. Exhibit A6, which is Covid- 19 test report issued from the FHC Nattakom, proves that One  Kripa Aby, Keerikattuputhenparambil, Moolavattom P.O. was found to be COVID-19 positive on antigen test conducted on 3-11- 2020.

According to the complainant, though they submitted a claim form with all relevant documents with the opposite party, they have not processed the claim.

The opposite party resisted the complaint, contending that the second complainant filed a claim application for COVID-19 along with a document in the name of Kripa Aby as supporting evidence for COVID-19. It is proved by exhibit B4, Which is an outpatient ticket issued from the family health center, Nattakom, on 3-11- 2020, that one Kripa, aged 37, residing at Keerikkavu  Puthanparamil, Moollaedam, had consulted the medical officer in outpatient departments with a complaint of headache GBP and advised to undergo antigen test. Exhibit A7 is the one and same certificate issued by the Panachikad village officer on 24-2- 2024. On going through exhibit A7, we can see that the village officer certified that the person who is known as Susan Aby Keerikattu Puthenparambil, Moollavattam P.o. Kottayam as per Aadhar card and Susan B Grace, Keerikattu Puthenparambil, Molabattan, PO, Kottayam as per ration card and Kripa Keerikattu Puttenparambil, Moollavattam P.o. Kottayam as per hospital record are the one and same person.

On going through the exhibitsA1 to A3 insurance policies, we can see that the master policyholder was Global Assure, Private Limited, 3rd-floor AHP Horizon 445, phase 5, Udyog Vihar, Gurgaon, Haryana, and the complainants are the beneficiaries of the policies.

It is further proved by exhibit B 5 that on 4-12-2020, the opposite party issued a letter to the second complainant requesting to provide the COVID-19 positive certificate of the beneficiary, who is the second complaint herein. It is pertinent to note that neither in the complaint nor in the proof affidavit did the complainants disclose the date on which they produced the documents to the opposite parties. Moreover, they did not disclose the date the claim form was duly lodged with the opposite party. According to the opposite parties, the first and third complainants did not file any claim form with them requesting the repayment of the insurance amount. Though the complainant in the complaint alleged that the opposite party issued the receipt for the receipt of the claim form on 24-11- 2020 and 3-12- 2020, they did not produce the same before this commission.

Exhibit B-1 proves that the opposite party repudiated the claim of the second complaint on 30-1- 2021 for the reason that the insured has not provided any such documentary evidence that confirms that the second complainant and the Kripa are the one and the same person. The claim was repudiated as per section 6 of the general exclusion clause of the policy for nondisclosure or misrepresentation.

Ongoing through the records, it can be seen that this complaint was filed on            17-6- 2023. The second complainant ought to have filed this complaint within two years of the production of the claim by the opposite party. Therefore, this complaint should have been filed on or before 3-1- 2023, i.e., before the expiry of two years from the date of repudiation. Therefore, this complaint is barred by a limitation of 5 months. The complainants did not file any petition to condone the delay of 5 months caused in filing this complaint. On close scrutiny of the evidence, we are of the opinion that the complainants failed to prove any deficiency on the part of the opposite party, and the complaint is liable to be dismissed. In the result the complaint is dismissed.        

Pronounced in the Open Commission on this the 28^th day of June, 2024

            Sri. Manulal V.S. President    Sd/-

           Sri. K.M. Anto, Member         Sd/-

APPENDIX :

Exhibits from the side of the Complainant :

A1  -  Copy of Policy No. 220692028521000129

A2  -  Copy of Policy No. 220692008521000132

A3  -  Copy of Policy No. 220692028521000482

A4  -  Copy of Covid 19 Test Report of Aby Jacob

A5  - Copy of Covid 19 Test Report of Neha Susan Aby

A6  - Copy of Covid 19 Test Report of Krupa Aby

A7  - Copy of One and same Certificate dtd. 24/02/2024

Exhibits from the side of Opposite parties :

B1 – Copy of repudiation letter dtd. 30/01/2021

B2 – Copy of claim form filed by Susan Aby

B3 - Copy of Covid 19 Test Report given by Second Complainant

B4 - Copy of OP ticket produced by Second complainant

B5 - Copy of Policy issued to second complainant Susan Aby

B6 - Copy of proposal form given by second complainant Susan Aby.

B7 - Copy of the proposal form given by Aby Jacob.

B8 - Copy of the proposal form given by Neha Susan Aby

                                                                                                         By Order,

                                                                                                                Sd/-

ASSISTANT REGISTRAR