SRI. SAJEESH.K.P : MEMBER
The complainant has filed this complaint under Sec.35 of the Consumer Protection Act 2019, seeking direction against the OPs to release the eligible insurance amount of Rs.2,50,000/- and to pay Rs.25,000/- as compensation towards the mental agony.
Complaint in brief :-
According to the complainant, during the Covid-19 pandemic the agent of the 1st OP approached the complainant and persuaded the complainant to insure herself with the newly introduced corona Rakshak policy, which covers lump sum benefit equivalent to 100% of sum insured which shall be payable in case of positive diagnosis of covid -19 requiring hospitalization for the period of 72 hours. The positive diagnosis of covid -19 shall be from a government authorized diagnosis center as such the policy was taken in the name of the complainant and the premium was paid. An ID card was issued by the 1st OP. During the policy period the complainant was tested positive for covid-19 and she was advised to be admitted in the isolation ward for covid treatment in Govt. hospital Thalassery. She was discharged from the isolation ward after 10 days. As per the terms and conditions of the policy issued to the complainant, the complainant was entitled to enjoy the benefit of the policy and she is entitled to get the full insurance amount of Rs.1,00,000/-. The OPs refused to honour the claim and the complainant asserted that there is a deficiency in service on the part of the OPs. Hence this complaint.
After filing the complaint, commission sent notice to both OPs and both OPs entered appearance before the commission and filed their version accordingly.
Version of OPs in brief:
The OPs denied the entire averments except those specifically admitted. The OPs admits the policy and its validity took by the complainant. The OPs contended that the claim was denied on the grounds that in discharge card of complainant for the treatment of covid-19 positive at General Hospital,Thalassery, nothing was mentioned ie, condition of complainant level of SPO2, line of treatment etc, which was one of the essential criteria in the claim and it is clearly noted that complainant is asymptomatic and only vitamin tablets were suggested etc. As per the terms and conditions of the policy, lump sum benefit equal to 100% of the sum insured shall be payable on positive diagnosis of covid-19 requiring hospitalization of continuous period of 72 hours not for institutional quarantine. According to the records produced by complainant, OP contended that it is clear that complainant sought a planned admission to the hospital, for a period of 10 days in order to obtain the claims. Moreover, the claim was rejected by OPs stating that the complainant failed to meet the criteria specified in policy and after the rejection complainant referred it to ombudsman and their award passed in favour of OPs. The OPs rejected the claim on the basis that complainant failed under the category of asymptomatic covid which does not make complainant eligible to get the benefit of the policy. Hence OPs prayed to dismiss the complaint.
Due to the rival contentions raised by the OPs to the litigation, the commission decided to cast the issues accordingly.
- Whether there is any deficiency in service from the part of OPs?
- Whether there is any compensation & cost to the complainant?
In order to answer the issues, the commission called evidence from both parties. The complainant produced documents which is marked as Exts.A1 to A10. Ext.A1 is the copy of policy schedule of Star Health & Allied Insurance Company limited, Ext.A2 is the copy of customer ID card issued by OPs, Ext.A3 is the copy of OP ticket issued by General Hospital, Thalassery, Ext.A4 is the true copy o Covid negative test report issued from the Govt. General Hospital Thalassery. Ext.A5 is the Original Discharge summary. Ext.A6 is the policy terms and conditions issued by OPs. Ext.A7 is the letter issued by OPs repudiating the claim, Ext.A8 is the copy of E mail sent to OP clarifying the admission of the complainant at the Covid isolation ward of General Hospital, Thalassery. Ext.A9 is the copy of letter issued from Insurance Ombudsman dismissing the complaint and Ext.A10 is the certified true copy of progress note and Doctors orders issued by General Hospital Thalassery. The complainant adduced evidence through proof affidavit and examined as PW1. The OPs produced documents which is marked as Exts.B1 to B5. Ext.B1 is the certified copy of the policy schedule with condition. Ext.B2 is the copy of Discharge summary of complainant from General Hospital Thalassery from 2/9/2020 to 11/9/2020. Ext.B3 is the copy of Covid -19 Guide lines. Ext.B4 is the copy of repudiation letter dtd.24/11/2020 issued by OPs and Ext.B5 is the original copy of award dtd.16/2/2021 passed by Hon’ble Insurance Ombudsman. 1st OP adduced evidence through proof affidavit and examined as DW1. Complainant filed argument note.
On the perusal of evidences produced by both parties in order to answer the issues raised. No detail discussion is needed with regard to the policy, sum assured, policy duration etc as both parties to the case has no dispute with regard to it. The dispute arises when the OPs refused the claim of complainant stating that she is not eligible to get the benefit of the policy as she is asymptomatic as per Ext.A10 and Ext.A5 and mere stay in hospital will not attract the benefit of policy. In order to resolve the issue, the commission perused Ext.B1, and it is seen that the clause 3.7 specifically mentioned that admission in a hospital for Covid -19 treatment by government for a minimum period of 72 hours consecutive care hours required and the Ext.A5, indicates that complainant DOA is on 2/9/2020 to 11/9/2020 ie complainant is admitted for 10 days at General hospital Thalassery, and the specification of 72 hours mentioned in clause 3.7, Ext.B1 therefore turned in favour of complainant. As per clause 5 of Ext.B1 the complainant is eligible to get the benefit of policy since waiting period of 15 days from the first policy commencement date was over when complainant got admitted. According to Clause 7.3 of Ext.B1, medical history is needed and it is specifically provided through Ext.A5 and Ext.A10. On perusing the Exts(A5&A10) no where it is seen the statement that vital are stable and home quarantine is only required. The complainant took the treatment in a Govt. hospital and it is to the surprise of the commission that in pursuance of covid whether such a government institution keep a person without any reason for 10 days. Here the OPs contended that medical officer in Ext.A5 advised home quarantine which is true but it advised after the discharge of complainant. The OP suspects the genuinity of admission of complainant but no steps taken to cross examine the medical officer to substantiate their claim and nowhere in the case records or discharge summary(Exts.A5&A10) stated that it is an institutional quarantine . Hence the commission is in the view that it is not the OPs to decide that complainant should undergo institutional quarantine rather than hospital admission. If OPs have the doubt that they have fair enough chance to cross examine the witness to prove the genuinity of admission of complainant for 10 days in the General Hospital but they never choose such steps. Further , OPs contended that complainant was supplemented by vitamin tablets and to the knowledge of this commission. The government specified to give vitamin supplements to the patient who underwent corona treatment.
During the cross examination of DW1 he clearly deposed that he is an LLB holder and he is the legal manager to examine the medical records of complainant. He also admits the corona pandemic was in peak at September.
According to Exts.A4,A5 and A10 the complainant took treatment for corona and got admitted in General Hospital Thalassery, for 10 days which OPs contended that the admission was somehow sought by complainant. DW1 specifically admits that the 72 hours of admission is the mandatory period of getting the claim which complainant underwent 10 days admission. Moreover, OPs admit during the cross examination, that the policy clauses never specifies the word symptomatic or asymtamatic.
To conclude , the commission held that opposite parties are liable for the deficiency in service towards complainant and complainant is entitled to get the sum assured specified in Exts.A1 and also entitled to get compensation of Rs.1,00,000/- due to the rejection of policy by opposite parties even after the submission of required documents by complainant. The complainant is also entitled to get compensation for the deficiency in service from the part of OPs by denying the claim which complainant was eligible to claim as per the terms and conditions of Ext.A1 policy.
In the result the complaint is allowed in part. The opposite parties are directed to pay Rs.1,00,000/- as sum assured specified in Ext.A1 and Rs.15,000/- towards the compensation to the complainant for the deficiency in service from the part of opposite parties and also pay Rs.5000/- as cost of litigation within 30 days of receipt of this order. In default, the amount of Rs.1,00,000/- carries interest@ 10% per annum from the date of order till realization , failing which the complainant is at liberty to execute the order as per the provisions of Consumer Protection Act 2019.
Exts:
A1- policy copy
A2-Copy of customer ID card
A3-OP ticket -General hospital
A4-Covid +ve and –ve test report
A5- Original discharge summary
A6- Terms and condition
A7- letter issued by OP
A8- copy of email
A9- Copy of letter issued from insurance Ombudsman dismissing the complaint
A10- progress note and Doctors orders issued by General Hospital Thalassery
B1- Policy schedule
B2- Copy of discharge summary
B3- copy of guide lines
B4- copy of repudiation letter dtd.24/11/2020
B5- Original award dtd. 16/2/2021 passed by Hon’ble insurance Ombudsman.
PW1-Sumaja.C.M-complainant
DW1-Balu.M- witness of OP
Sd/ Sd/ Sd/
PRESIDENT MEMBER MEMBER
Ravi Susha Molykutty Mathew Sajeesh K.P
eva
/Forwarded by Order/
ASSISTANT REGISTRAR
