IN THE CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM
Dated this the 30th day of March, 2023
Present: Sri.Manulal.V.S, President
Smt.Bindhu.R, Member
Sri.K.M. Anto, Member
CC No. 28/2022 (Filed on 10.02.2020)
Complainant : Mohandas V.M,
Vazhakkaparambil House
Veloor P.O, Kottayam-686003
(By Adv.Santhosh Thomas Kandamchira)
Vs
Opposite party : Star Health and Allied Insurance Co.
Branch Office, IInd Floor,
Puthenpurackal Complex, M.C.Road
Kodimatha, Kottayam-686013.
(By Adv.Avaneesh V.N)
O R D E R
Sri.Manulal.V.S, President
The complaint is filed under section 35 of the Consumer Protection Act against the opposite parties.
Crux of the complaint is as follows:
The complainant availed Corona Rakshak Health Insurance Policy from the opposite party. As per the policy conditions of the opposite party insured is entitled to lump sum benefit equal to 100 % of the sum assured ie Rs.2,50,000/- if the insured person is hospitalized as covid positive.
On 24-10-2020 the complainant was found to have been covid -19 (category b) at General hospital Kottayam and was admitted at CFLTC Nattakom from 31-10-2020 to 03-11-2020.
The complainant lodged claim to the opposite party along with the documents. But the first opposite party repudiated the claim stating that “Lumpsum Benefits shall be payable on positive diagnosis of covid requiring hospitalization and not for institutional quarantine”.
The opposite party illegally repudiated the genuine claim of the complainant. According to the complainant the act of the opposite party amounts to unfair trade practice and deficiency in service and he had suffered huge mental agony and hardship and financial loss due to the actions of the opposite party. Hence this complaint is filed by the complainant praying for an order to direct the opposite parties to pay Rs. 2.5 lakhs along with interest and to direct the opposite parties to pay compensation of Rs.1,00,000/-.
Upon notice opposite party appeared before the commission and filed version.
Version of the opposite party is as follows: The opposite party issued the policy to the complainant vide policy number P/181113/01/2021/003593 for a period from 27-07-2020 to 09-05-2021. The opposite party received a claim informing the insured was admitted at a Covid first line treatment centre from 31-10-2020 to 03-11-2020 for the treatment of Covid 19. In discharge summary patient’s clinical parameters like temperature, pulse rate, spo2 level etc were not monitored and mentioned in the discharge summary. Moreover it is also noted that the complainant had history of type 2 diabetes mellitus and on insulin. There is no active line of treatment and medication. The hospitalization was not justified. Mild symptoms does not require hospitalization. The complainant was covid 19 positive asymptomatic and was managed conservatively. The opposite party is liable to compensate the complainant only according to the terms and conditions of the policy. According to the opposite party there was no deficiency in service or unfair trade practice on their side.
Complainant filed proof affidavit in lieu of chief examination and marked Exhibit A1 to A7. Padma Prabha , who is the Chief Manager -legal of the opposite party filed proof affidavit and exhibit B1 to B7 marked from the side of the opposite party.
On evaluation of complaint, version and evidence on record we would like to consider the following points.
- Whether there is any deficiency in service or unfair trade practice on the part of the opposite party?
- If so what are the reliefs and costs?
For the sake of convenience we would like to consider the point number 1 and 2 together.
There is no dispute on the facts that the complainant had availed a Corona Rakshak Health Insurance Policy from the opposite party vide policy number P/181113/01/2021/003593 for a period from 27-07-2020 to
08-05-2021. On perusal of exhibit A1 policy we can see that the sum assured was Rs. 2,50,000/-. Exhibit A2 proves that the complainant had underwent for covid -19 RT PCR test by Corona Cell General Hospital Kottayam on
24-10-2020 and was diagnosed as covid positive. It is proved by Exhibit A3 discharge card issued by duty medical officer of CFLTC Nattakom that the complainant was admitted in the CFLTC which is Covid First Line treatment Centre on 31-10-2020 and discharged on 03-11-2020 when he became covid negative. On perusal of Exhibit A3 discharge summary we can see that the complainant was diagnosed with Covid 19 category B and he has the complaint of back pain on admission. And he was treated with injection and other symptomatic supportive care was given. Opposite party vide exhibit a7 repudiated the claim of the complainant stating that as per the terms and conditions of the policy Lumpsum benefit shall be payable on positive diagnosis of Covid, requiring hospitalization and not for institutional quarantine.
Complaint was resisted by the opposite party, stating that as per discharge summary patient’s clinical parameters like temperature, pulse rate, spo2 level etc were not monitored and mentioned in the discharge summary and the complainant had history of type 2 diabetes mellitus on insulin. There is no active line of treatment and medication.
On perusal of Exhibit A3 which is the discharge card issued by the duty Medical Officer we can see that the complainant was treated with injection and symptomatic and other supportive care.
According to the opposite party the hospitalization means admission in a hospital for covid 19 treatment by government, for a minimum period of 72 hours consecutive “in-patient care hours”.
In Star Health and Allied Insurance Company Ltd v. Avinash T. and other decided on 17 January, 2022 Hon’ble High Court of Kerala held that "CFLTCs are Primary Level Health Care Centres set up for providing care to less serious cases and referral of serious cases to COVID hospitals, so as to avoid crowding in COVID Hospitals and avoid wastage of resources. It can therefore be unhesitatingly held that CFLTCs are designated as hospitals for the treatment of COVID-19".
As discussed earlier it is proved by exhibit A3 that the complainant was admitted in CFLTC Nattakom, after being tested positive for covid -19 on
31-10-2020 and was discharged on 03-11-2020. Thus it is clear that the complainant was hospitalized and treated there as inpatient for a continuous period of 72 hours.
Another contention of the opposite party is that in discharge summary wherein it is stated that the complainant has type 2 DM, on date of admission.
The Hon'ble National Commission while dealing with a similar set of facts, in Sunil Kumar Sharma Vs. TATA AIG Life Insurance Company and Ors. bearing case no. RP no. 3557/2013 decided on 01.03.2021 held as under:-
14. Moreover the claim had been repudiated only on the ground that the insured was suffering from diabetes for a long time. So far as life style diseases like diabetes and high blood pressure are concerned, Hon'ble High Court of Delhi in Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., W.P.(C) No. 656 of 2007, decided on 17.09.2007 held as under:
"Insurance-Mediclaim-Reimbursement-Present Petition filed for appropriate directions to respondent to reimburse expenses incurred by him for his medical treatment, in accordance with policy of insurance-Held, there is no dispute that diabetes was a condition at time of submission of proposal, so was hypertension.
Petitioner was advised to undergo ECG, which he did-Insurer accepted proposal and issued cover note. It is universally known that hypertension and diabetes can lead to a host of ailments, such as stroke, cardiac disease, renal failure, liver complications depending upon varied factors-That implies that there is probability of such ailments, equally they can arise in non-diabetics or those without hypertension-It would be apparent that giving a textual effect to Clause 4.1 of policy would in most such cases render mediclaim cover meaningless-Policy would be reduced to a contract with no content, in the event of happening of contingency-Therefore Clause 4.1 of policy cannot be allowed to override insurer's primary liability-Main purpose rule would have to be pressed into service-Insurer renewed policy after petitioner underwent CABG procedure-
Therefore refusal by insurer to process and reimburse petitioner's claim is arbitrary and unreasonable-As a state agency, it has to set standards of model behaviour; its attitude here has displayed a contrary tendency-Therefore direction issued to respondent to process petitioner's claim, and ensure that he is reimbursed for procedure undergone by him according to claim lodged with it, within six weeks and petition allowed."
Though the opposite party contended that the complainant is a known case of diabetes mellitus which is a pre-existing disease they did not produce any previous medical history of the complainant to prove their case. The onus of proving the fact that the insured had prior knowledge that he was suffering from fatal diseases and as such he deliberately suppressed these material facts at the time of filling up the proposal form was on the insurance company.
Further, it was noted that, there was no evidence on record to show that the insured had knowledge that he was suffering from fatal diseases prior to taking the policy and there was inadequate evidence to support that he had deliberately suppressed his medical condition.
On perusal of operative clause of B1 terms and conditions of policy we can see that, If during the policy period the Insured Person is diagnosed with COVID and hospitalized for more than seventy-two 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 Company shall pay the agreed sum insured towards the Coverage mentioned in the policy schedule. On perusal of Exhibit A3 we cannot see that the admission of the complainant was only for the purpose of investigation and for the evaluation of the ailment which he had. It is argued by the counsel for the complainant that he was treated as per the guidelines issued by the Ministry of Health and Family Welfare, Government of India, and Government of Kerala at that time. It is pertinent to note that the opposite party has not produced any evidence to prove that the complainant has not treated with the guidelines and protocol which was issued by the Ministry of Health and Family Welfare, Government of India and Government of Kerala at that time.
As per Clause 4.1 of the terms and conditions of the policy COVID Cover is a Lumpsum benefit equal to 100% of the Sum Insured shall be payable on positive diagnosis of COVID, requiring hospitalization for a minimum continuous period of 72 hours. The positive diagnosis of COVID shall be from a government authorized diagnostic centre. The payment will be made only on Hospitalisation for a minimum continuous period of 72 hours following positive diagnosis for COVID. Under such circumstance, we have to keep in mind very sound and salutary principle of "better protection of the right of the consumer" which is clearly stated in the preamble of Consumer Protection Act, 2019, and even if it is believed for the sake of argument that there was some inconsistency in reports, however, looking to the aforesaid hospital papers as we discussed, we are of the considered opinion that complainant was suffering from Covid-19 positive, hence repudiation is not sustainable. Therefore, we hold that the present complainant is covered under the policy of Corona and 100% of insured amount of Rs.2,50,000/- requires to be given under policy.
Therefore, we hold that letter of repudiation dated 07-12-2020 was passed against the principles of natural justice and fair play and very niggardly and hyper technical approach has been taken, with a myopic view of the opposite party in denying the claim amount. Therefore, we do not accept the ground stated in the letter of repudiations accordingly it cannot be acted upon. Thus, we are of the opinion that the said act of the opposite party amounts to deficiency in service and unfair trade practice. Hence the complaint is allowed.
In the result following final order is passed.
- The complainant is entitled to recover the amount of Rs.2,50,000/-(Rupees Two Lakh Fifty Thousand only)from the opposite party with the interest at the rate of 9% p.a. from the date of the filing of this complaint till realization.
- The complainant is entitled to recover the amount of Rs.25,000/- (Rupees Twenty Five Thousand Only) under the head of mental pain and suffering from the opposite party.
Aforesaid all amount to be paid to the complainant within 30 (thirty) days from the date of receiving the copy of the order, in default the compensation amount will carry further 9% interest from the date of this order till realization.
Pronounced in the open Commission on this the 30th day of March, 2023.
Sri.Manulal.V.S, President sd/-
Smt.Bindhu.R, Member sd/-
Sri. K.M. Anto, Member sd/-
Appendix
Exhibits marked from the side of complainant
A1- Copy of certificate of insurance issued from Star Health and Allied Insurance Co.Ltd.
A2- Copy of covid-19 test report dated 02.11.2020 issued by District Medical Office, Kottayam
A3- Discharge card issued from Covid First Line Treatment Centre, Nattakom, dated 03.11.2020.
A4- Copy of legal notice dated 14.12.2020.
A5- Copy of order of Insurance Ombudsman dated 25.08.2021
A6- Copy of the policy conditions of Star Health and Allied Insurance Co.Ltd.
A7- Copy of claim intimation letter dated 07.12.2020 issued from Star Health and Allied Insurance Co.Ltd.
Exhibits marked from the side of opposite party
B1- Copy of certificate of insurance issued from Star Health and Allied Insurance Co.Ltd.
B2- Copy of customer information sheet – corona rakshak policy issued from Star Health and Allied Insurance Co.Ltd.
B3- Discharge card issued from Covid First Line Treatment Centre, Nattakom, dated 03.11.2020.
B4- Copy of covid-19 test report dated 02.11.2020 issued by District Medical Officer, Kottayam
B5- Copy of claim intimation letter dated 07.12.2020 issued from Star Health and Allied Insurance Co.Ltd.
B6- Copy of addendum to advisory for patient admissions to covid FLTC issued from Health and Family Welfare Department, Government of Kerala.
By order
sd/-
Assistant Registrar
