By Sri. MOHAMED ISMAYIL C.V., MEMBER
The averment of the complainant is as follows:-
1. On 23/08/2020, the complainant had availed an insurance policy from the opposite party covering period upto 04/06/2021. The insurance policy number is P/181312/01/2021/003735 and plan title is ‘Corona Rakshak Policy’. At the time of availing policy, the opposite party had made assurance that policy would cover all medical expenses and other reliefs for the treatment of Covid-19 disease. It is pleaded by the complainant that as per policy condition the opposite party would provide sum insured if the complainant was affected by Covid - 19 disease. On 13/01/2021, the complainant was tested positive in RTPCR test conducted at Molecular diagnosis laboratory, Department of Microbiology, Government Medical College, Manjeri. Subsequently the complainant was shifted to CSLTC, Safa Hospital, Kalikkavu, a covid special treatment centre associated with Government Medical College Hospital, Manjeri. Then the complainant was admitted in NIMS Hospital, Vaniyambalam and undergone treatment for Covid-19 disease and he was discharged from the hospital on 23/01/2021.
2. It is averred that the complainant had submitted a claim application before the opposite party to avail benefits of Rs.2,50,000/- (Rupees Two lakh and Fifty thousand only) under Insurance policy coverage. The claim application number is ID CIR/2021/ 181312/2198752. It is averred that the complainant had submitted required documents before the opposite party for getting the sum insured. But the opposite party repudiated claim application of the complainant. The opposite party stated in the repudiation letter that patient’s vitals are stable throughout admission, investigations are within normal limit and could have been managed under home isolation. It is pleaded in the complaint that the repudiation of the claim is violation of policy conditions. The opposite party was liable to pay sum insured to the complainant as per terms and conditions of policy. The act of repudiation is amounted to deficiency in service on the part of the opposite party. The reason stated in repudiation letter is baseless. The act of the opposite party had caused mental agony and inconvenience to the complainant. So the complainant prayed for a direction to the opposite party to pay Rs. 2,50,000/- to the complainant as per policy conditions. The complainant also demanded Rs. 1,00,000/- (Rupees One lakh only) from the opposite party as compensation for the sufferings of mental agony and inconvenience due to the act of the opposite party. The complainant also claimed Rs. 10,000 /-(Rupees Ten thousand only) as cost of the proceedings from the opposite party.
3. The complaint is admitted and issued notice to the opposite party. The opposite party entered appearance and filed version.
4. The opposite party is an insurance company represented by its Assistant General Manager-Legal. The opposite party has denied allegations raised in the complaint. The opposite party had admitted issuance of Corona Rakshak Policy in favour of the complainant. The policy was issued from the branch office in Malappuram and coverage was commenced from 23/08/2020 to 04/06/2021 for a sum of Rs. 2,50,000/- vide policy No. P/181312/01/2021/003736. It is contended that the complainant was fully aware of terms and conditions of the policy. As per operative clause No: 2 of policy, during the policy period if insured person is diagnosed with Covid-19 and hospitalised for more than 72 hours following medical advice of a duly qualified Medical Practitioner as per the norms specified by Ministry of Health and Family Welfare, Government of India, the opposite party shall pay agreed sum insured towards the coverage mentioned in the policy schedule. It is further stated that lumpsum benefit equal to 100% of sum insured shall be payable on positive diagnosis of Covid -19 requiring hospitalisation for minimum continuous period of 72 hours. The positive diagnosis of Covid-19 shall be from a Government recognised diagnostic centre.
5. It is admitted by the opposite party that they had received a claim application along with documents in respect of treatment undergone for covid-19 by the complainant. It is admitted by the opposite party that the complainant was hospitalised between 19/01/2021 and 23/01/2021. It is contended by the opposite party that discharge summary does not disclose condition of the patient and only minor symptom are noted. It is contended that Corona symptoms like Sore throat, chills, Loss of smell or taste, congestion or runny nose, Nausea or vomiting, Diarrhoea or breathing difficulty were absent and all clinical parameters are normal. So the patient was not required hospitalisation. Moreover SPO2 level was very normal. It is alleged that the complainant had colluded with the hospital to get over policy condition of 72 hours continuous treatment for the complainant. The opposite party has repudiated claim on the basis of documents produced by the complainant along with claim application. There is no deficient act on the part of the opposite party hence prayed for dismissal of the complaint.
6. The complainant and the opposite party have filed affidavits in lieu of evidence. The complainant did not produce documents. But the opposite party is produced documents and same are marked as Ext.B1 to Ext. B4 documents. Ext. B1 document is the copy of certificate of insurance along with terms and conditions of policy issued in favour of the complainant by the opposite party. Ext. B2 document is the copy of discharge summary dated 23/01/2021 issued by NIMS Hospital, Vaniyambalam. Ext. B3 document is the copy of case sheet of treatment of the complainant. Ext. B4 is the document is the copy of repudiation letter dated 22/03/2021 issued by the opposite party to the complainant.
7. Heard both sides in detail. Perused documents and affidavits thoroughly. The Commission considered following points to adjudicate the matter:-
- Whether the opposite party has committed deficiency in service towards the complainant?
- Relief and cost?
8. Point No.(i) & (ii):-
The grievance of the complainant is that he had availed an insurance coverage in the name of Corona Rakshak Policy from the opposite party and later he had affected with covid-19 disease and treated for the same and applied for benefits under insurance coverage but opposite party repudiated claim stating baseless reasons. The complainant has alleged deficiency in service against the opposite party. The complainant did not produce documents before the Commission. But the Commission find that the documents produced by the opposite party is conducive for just and proper decision of the matter. The opposite party is admitted issuance of Corona Rakshak Policy to the complainant and copy of insurance certificate and its terms and conditions are produced before Commission by the opposite party and same is marked as Ext.B1 document. The opposite party has also admitted the fact that the complainant had submitted a claim application along with documents on the basis of Ext.B1 policy and same was repudiated after examination of records and repudiation letter is produced and marked as Ext.B4 document. It is argued by the opposite party that the complainant is not entitled for insurance benefit as treatment record would show that disease affected was mild one and was not required for hospitalisation. It is further argued that all vital organs of complainant were normal and disease could have been managed under home isolation. Moreover it is alleged by the opposite party that the complainant had colluded with hospital authority to avail continuous treatment for 72 hours in order to fulfil the condition of policy.
9. It can be find in evidence that two conditions are to be fulfilled for availing benefit of policy issued to the complainant. Firstly, hospitalisation is required for a minimum continuous period of 72 hours. Secondly, the positive diagnosis of covid-19 shall be from a Government authorised diagnostic centre. The opposite party has produced discharge summary related to treatment of the complainant and it is marked as Ext.B2 document. The opposite party also produced case sheet of treatment of the complainant and it is marked as Ext.B3 document. In the examination of discharge summary produced by the opposite party, the Commission find that the complainant was admitted in the hospital on 19/1/2021 and discharged on 23/01/2021. So it can be concluded that the complainant had undergone treatment for covid-19 disease for more than72 hours continuously. The Commission also consider the argument of the complainant that he was tested covid-19 positive from the laboratory, Department of Microbiology, Government Medical College Hospital, Manjeri. The opposite party did not dispute over the diagnosis of covid-19 disease of the complainant. So the Commission find that the complainant had been righteously taken steps to undergo treatment of covid-19 disease and deserving release of sum insured as per Ext.B1 document. Even though the opposite party has alleged collusion between hospital authority and the complainant for securing inpatient treatment to get over hurdles of 72 hours continuous treatment but no evidence was adduced by the opposite party on that effect. So the Commission cannot doubt the sanctity of Ext.B2 and Ext.B3 documents. There is no merit in the argument of the opposite party that the complainant had no usual symptoms of Covid-19 disease as he was affected mild covid and was required only home isolation. The Commission find that the opposite party cannot determine the procedure adopted for treatment of the complainant. It is the treating doctor, who got authority for taking every decision on treatment of the patient. The complainant had adopted treatment on the basis of protocol fixed by the Government of India. The Commission also consider the fact that entire world was facing outbreak of a new disease and there was no established formula for treatment of Covid-19 disease. Moreover, the Commission find that Ext.B2 and Ext.B3 documents are suggestive of Covid-19 related respiratory infection and Vascular Head ache to be the complainant. It can be seen that Ext.B1 document did not put forward any protocol for treatment of Covid-19 patients. In the light of discussion made above, the Commission find that there was no legality in issuing repudiation letter to the complainant and the act of the opposite party is amounted to deficiency in service. The Commission find that the complainant is entitled for the sum insured as per Ext.B1 document. It is also find that the act of opposite party has caused mental agony and inconvenience to the complainant for which the opposite party is liable to pay compensation. The Commission consider that the opposite party should pay Rs.10,000/- as compensation for the act of deficiency in service. Moreover the opposite party is also liable to pay Rs.5000/- as cost of the proceedings to the complainant. In conclusion, the Commission find that evidence brought out before the Commission reveal that the pleadings of the complainant is proved and hence the complaint is
allowed in the following manner:-
- The opposite party is directed to pay Rs.2,50,000/-(Rupees Two lakh fifty thousand only) to the complainant as per Ext. B1 document.
- The opposite party is directed to pay Rs. 10,000/- (Rupees Ten thousand only) as compensation for the sufferings of mental agony and inconvenience caused due to the act of the opposite party.
- The opposite party is also directed to pay Rs. 5000/- (Rupees Five thousand only) to the complainant as the cost of the proceedings.
The opposite party shall comply this order within 30 days from the date of receipt of copy of this order otherwise entire amount shall carry interest at the rate of 9% per annum from the date of the order till date of its realisation.
Dated this 29th day of February, 2024.
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 : Nil
Witness examined on the side of the opposite party : Nil
Documents marked on the side of the opposite party : Ext. B1 to B4
Ext. B1 : Document is the copy of certificate of insurance along with terms and
conditions of policy issued in favour of the complainant by the opposite
party.
Ext. B2 : Document is the copy of discharge summary dated 23/01/2021 issued by
the NIMS Hospital, Vaniyambalam.
Ext. B3 : Document is the copy of case sheet of treatment of the complainant.
Ext. B4 : Document is the copy of repudiation letter dated 22/03/2021 issued by the
opposite party to the complainant.
MOHANDASAN K., PRESIDENT
PREETHI SIVARAMAN C., MEMBER
MOHAMED ISMAYIL C.V., MEMBER
