Kerala

Idukki

CC/154/2021

Siby Joseph - Complainant(s)

Versus

Star Health and Allied Insurance Company Ltd - Opp.Party(s)

Adv: Tibin Nadackal

11 Oct 2022

ORDER

DATE OF FILING :8.11.2021

IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, IDUKKI

Dated this the  11^th  day of October,  2022

Present :

                    SRI. C. SURESHKUMAR                   PRESIDENT

SMT. ASAMOL P.                               MEMBER

SRI. AMPADY K.S.                            MEMBER

CC NO.154/2021

     Between

Complainant                                        :   Siby Joseph,

                                                                Nadackal House,

                                                                Paloorkavu P.O.,

                                                                Peruvanthanam, Peermade.

   (By Adv: Tibin Nadackal)

        And

Opposite Party                                     :  Star Health and Allied Insurance Company Ltd,

                                                                Represented by the Branch Manager,

                                                                Branch Office, Bhavani Trade Centre,

                                                                1^st Floor, H.S. Junction, Karunagappally,

                                                                Kollam

   (By Adv: K. Pradeedkumar)

O R D E R

SRI. C. SURESHKUMAR, PRESIDENT

 

1. This is a complaint filed under Section 35 of the Consumer Protection Act of 2019 (the Act, for short).  Complainant’s case as disclosed from the complaint is briefly discussed here under :

 

          On 6.8.2020, complainant had taken a medical insurance policy known as Corona Kavach from Karunagappally branch of opposite party Insurance Company, after paying Rs.3,425/- as premium.  Policy period was from 6.8.2020 till 18.5.2021.  Complainant, his wife and his 3 children were covered under the policy.  On 21.4.2021, eldest daughter of the complainant, namely, Maria Sibi was tested positive for Covid and admitted for inpatient treatment in Mary Queens Hospital, Kanjirappally from 23.4.2021 till 29.4.2021.  After treatment, complainant had submitted a claim along with requisite documents in first week of June, 2021 seeking reimbursement of treatment expenses, which came to Rs.44,025/-.  However, claim was not honoured.  On 5.8.2021, complainant had caused a lawyer notice to be issued against opposite party for reimbursement of medical expenses.  On 6.8.2021, he had received a reply whereby                                                                                                                      (cont….2)

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more records were requested by opposite party.  On 22.8.2021, a communication was received from opposite party to the effect that treatment records were not forwarded to them and thereafter on 29.9.2021, those records were forwarded to opposite party, by complainant.  Finally on 29.9.2021, complainant had received a repudiation letter from opposite party.  According to them, since the treatment did not require any hospitalization, claim for hospital expenses cannot be honoured.  Complainant submits that he had duly insured himself and his family members with opposite party.  Despite this, his claim was dishonoured in connection with his daughter’s treatment for Covid without any valid or cogent reason.  This amounts to deficiency in service on the part of opposite party.  Complainant prays for reimbursement of treatment expenses amounting to Rs.44,025/-, compensation of Rs.1 lakh and litigation expenses of Rs.25,000/- from opposite party.

 

          2. Opposite party had entered appearance and filed written version.  It’s contentions are briefly discussed here under :

 

          Opposite party admits that complainant had taken a Corona Kavach policy which was live from 6.8.2020 till 18.5.2021.  Sum assured was Rs.1 lakh.  Complainant and his family members were covered under the policy.  At the time when proposal was submitted terms and conditions of the policy were fully explained to complainant.  All the claims are subject to the terms and conditions of  policy.  Complainant’s daughter Maria Sibi was admitted in Mary Queens Mission Hospital, Kanjirappally, on 23.4.2021, as she was tested positive for Covid 19.  She was discharged on 29.4.2021.  However, discharge summary issued from the hospital did not reveal what were the complainant’s clinical parameters like temperature, pulse rate and SPO2 level.  Moreover, the doctor who had treated her had noted in the discharge summary that upon clinical examination, Cardio Vascular System / Respiratory System of the patient is within normal limits.  Upon receipt of claim document, opposite party had requested the complainant, vide letter dated 7.8.2021, to forward RTPCR Covid test report, CT Scan of chest, CRP, D Dimer, IL 6 test reports for further processing.  However, complainant had not sent any reply or forwarded the requested documents. Instead a lawyer notice dated 5.8.2021 issued on his behalf was received by opposite party on 12.8.2021.  A detailed reply was sent to lawyer notice on 16.8.2021.  After receipt of reply notice, complainant had produced lab report and X-ray report.  Upon verification, it was found that those lab reports revealed normal parameters.  Opposite parties had, as  part of claim processing arranged an investigation and collected hospital records from Mary Queen’s Mission Hospital.  Those records revealed the following clinical parameters :

                                                                                                             

Dated 23.4.2021

 

Blood Pressure : 110/70 mm of HG                                                       (cont….3)

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Pulse Rate  :  82 / Mt. (normal range : 58 – 100 beats per minute)

Respiratory Rate  : 20 / Mt. (normal range : 12-22 breath per minute)

SPO2 : 99% (normal range : 94% to 100%)

 

Dated 24.4.2021

 

Blood Pressure : 110/70 mm of HG

Pulse Rate  :  82 / Mt. (normal range : 58 – 100 beats per minute)

Respiratory Rate  : 20 / Mt. (normal range : 12-22 breath per minute)

SPO2 : 98% (normal range : 94% to 100%)

 

Dated 25.4.2021

 

Blood Pressure : 130/80 mm of HG

Pulse Rate  :  78 / Mt. (normal range : 58 – 100 beats per minute)

Respiratory Rate  : 20 / Mt. (normal range : 12-22 breath per minute)

SPO2 : 98% (normal range : 94% to 100%)

 

Dated 26.4.2021

 

Blood Pressure : 110/80 mm of HG

Pulse Rate  :  80 / Mt. (normal range : 58 – 100 beats per minute)

Respiratory Rate  : 20 / Mt. (normal range : 12-22 breath per minute)

SPO2 : 98% (normal range : 94% to 100%)

 

It is clear from the hospital records that patient’s vitals were stable.  There was no evidence to prove that she required hospitalization.  Though diagnosed to be Covid positive, her vitals were stable and within normal limits.  She was only given oral medicines.  Therefore hospitalization was not necessary.  It is clearly mentioned in the conditions of policy that claim shall be honoured only on positive diagnosis of Covid 19 requiring hospitalization for a minimum period of 72 hours.  Patient did not have any symptoms requiring inpatient care / treatment in a hospital.  She did not have any Corona symptoms like fever, head ache, chills, loss of smell or taste, congestion or runny nose, nausea or vomiting, diarrhea or breathing difficulties.  Hence there was no requirement for hospitalization.  No specific treatment was given to her.  Her SPO2 (Oxygen Saturation Value) was 98% to 99%  throughout admission time.  Besides, hospital authority had charged for  medicines and consumables which would come to Rs.12,715/-.  As per bills, medicines worth Rs.1000/- were purchased and Rs.11,000/- was spent for PPE kit and consumable items.  As no hospitalization was required, claim was repudiated and insured was informed about this on 22.9.2021.  It is further asserted                                                                                                        (cont….4)

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in the written version that rights and obligations are covered by the contract of insurance.  In this context, decision of Hon’ble Supreme Court in Surajmal Ram Niwas Oil Mills (P) Ltd. Vs. United India Insurance Co. Ltd. and another (2010 10 SCC 567) is relevant.  On these premises, opposite party contends that there was no deficiency in service.  Complaint is filed for obtaining unlawful gains.  It is to be dismissed with compensatory costs.

 

          3. After filing of written version, case was posted for evidence after affording sufficient opportunity to both sides to take steps.  It is seen from the proceedings that neither the complainant, nor the opposite party representative were present  to give evidence as such.  However, we notice that an affidavit has already been filed along with complaint by the complainant in proof of complaint averments.  Similarly opposite party has also filed an affidavit supporting the contentions mentioned in written version.  As there was no representation from the side of complainant, we have not formally marked documents produced by him in evidence.  However, upon representation by learned counsel for opposite party, documents produced by opposite party were admitted as Exts.R1 to R5.  Evidence was closed.  Since counsel for opposite party alone was present, we have heard him.  There was no representation for the complainant and neither was the complainant present when the matter was being heard after closing of evidence.  Now the points which arise for consideration are :

1)  Whether complainant was entitled to get his treatment expenses reimbursed in accordance with terms of Ext.R1 ?

2)  Whether repudiation of the claim by opposite party would amount deficiency in service ?

3)  Reliefs and costs ?

 

4. Point Nos.1 and 2 are  considered together for the sake of convenience :

 

          Learned counsel appearing for opposite party has contended that claim was not in accordance with the terms and conditions of the policy, copy of which is marked as Ext.R1.  Upon reception of claim, complainant was requested to produce RTPCR Covid test report, CT Scan of chest, CRP, D Dimer test and IL 6 report for further processing.  Instead of forwarding these documents, a lawyer notice was received from complainant, for which a detailed reply was given.  After receipt of reply notice, complainant had forwarded lab report and X-ray report.  Opposite party had investigated the claim also.   Hospital records revealed that vitals of the patient were stable at the time of admission.  Her Cardio Vascular System and Respiratory System were within normal limits.  SPO2

level was between 98% and 99%.  Her temperature was also normal.  She was only given oral medication.  Treatment records would reveal that the patient did not require any hospitalization.  As per terms of the policy, claim can be honoured only upon                                                                                                                      (cont…..5)

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positive diagnosis of Covid 19 requiring hospitalization for a minimum period of 72 hours.  In this case, hospitalization was not required.  Therefore claim was repudiated.  Repudiation is in accordance with the terms and conditions of policy.  Therefore, there is no deficiency in service. 

 

          We have gone through the rival pleadings and documents produced by complainant and opposite party respectively.  For the sake of easy reference, we are referring to the documents submitted by the complainant.  These are : 1.  Copy of policy, which is also  marked as Ext.R1 from the side of opposite party. 2^nd document is Covid 19 test report copy.       3. Copy of bill dated 29.4.2021 for Rs.44,025/- issued from Mary Queen’s Mission Hospital, Kanjirappally.  4.  Copy of legal notice issued by Advocate of complainant.  5.  Copy of letter sent by opposite party requesting for additional medical records. 6.  Certificate of posting pertaining to sending of legal notice.  7.  Copy of letter issued by opposite party 22.8.2021 seeking production of additional medical records.  8.  Copy of repudiation letter dated 22.9.2021.

 

          On the side of opposite party, all documents were exhibited.  Ext.R1 is policy copy along with terms and conditions.  Ext.R2 is discharge summary copy.  Ext.R3 is  Copy of B.P. Chart and inpatient case sheet.  Ext.R4.  Copy of letter sent by opposite party requesting for additional medical records.  Ext.R5  is copy of letter pertinent to repudiation of claim dated 22.9.2021.   

 

          Crux of the contentions advanced by learned counsel for opposite party is that, patient who was admittedly covered under Ext.R1 policy did not require hospitalization and therefore claim of insured for reimbursement of her treatment expenses was repudiated vide Ext.R5.  These contentions do not appear to us as forceful.  Ext.R1 is copy of policy along with terms and conditions.  2^nd sheet of Ext.R1 discloses what were the required conditions under which the claim for Corona Kavach policy can be honoured by opposite party.  Those terms and conditions are contained in clauses 4.1, 4.4 and 4.5 of the terms and conditions.  We have gone through the said conditions.  4.1 deals with Covid hospitalization cover.  It states that Company shall indemnify medical expenses incurred for hospitalization of the insured person during the policy period for treatment of Covid on positive diagnosis of Covid in a government authorized diagnostic centre including the expenses incurred on treatment of any comorbidity along with treatment for Covid up to the sum insured specified in the policy schedule.  These are the expenses mentioned under clause 4.1, which have to be reimbursed : 1.  Room rent, boarding, nursing expenses as provided by the hospital.  1.  Intensive Care unit and Intensive Cardiac Care unit expenses.  3.  Surgeon, anesthetist, medical practitioner, consultants, specialist fees whether directly paid to the   doctor or through hospital.  4^th clause is pertaining to anesthesia, blood, oxygen, surgical appliances, ventilator charges,                                                                                                               (cont….6)

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medicines and drugs costs towards diagnostics, PPE kit, gloves, mask and such other similar expenses.  It is mentioned in the note given under the clause that expenses of hospitalization for a minimum period of 24 consecutive hours only shall be admissible.  Clause 4.4 provides that pre hospitalization care is also covered by the policy.  As per clause 4.5, post hospitalization care expenses are also to be reimbursed under the policy.

 

          Opposite party does not have a case that the hospital where daughter of the insured was treated is not a government authorized Covid diagnostic centre.  Medical records, copies of which were produced by opposite party itself would go to show that she was test positive for Covid.  Admittedly, she was hospitalized for the period from 23.4.2021 till 29.4.2021.  Hospitalisation is for more than 24 hours.  Terms and conditions of the policy do not require that any particular type of test should be conducted, to determine whether the patient is Covid positive or not.  Similarly, it is also contended by opposite party that normal symptoms attached with Covid 19 infected person were not found in the case of complainant’s daughter.  Therefore, she did not require any hospitalization. These contentions are not fully correct as could be seen from discharge summary that patient had sore throat and slight cough which are also symptoms of the disease. Evidence tendered in this case would reveal that daughter of the complainant was hospitalized for 6 days as she was tested positive in a recognized private hospital for Covid treatment.  The fact that her vitals were stable and other parameters of the patient were normal, in our view, are not sufficient reasons to hold that she do not require any hospitalization.  If converse were to be true, i.e., if hospitalization was not  necessary, the hospital authorities would have informed the patient accordingly.  Ordinarily, no one stay in  a hospital for a pleasure of it.  It is also to be noted that Covid 19 was a virus induced disease for which  there were no prescribed or recognized methods of treatment.  Disease and patient management were done in accordance with medical protocol set out by the Government for patient management, set or decided on the outbreak of the pandemic.  There is  every possibility of medical condition of the person getting worse. Observation of the patient  was probably necessary.  We do not find any evidence to the contrary from the side of opposite party.  No medical experts were examined by opposite party to prove that as per medical records and despite the fact that the patient was tested positive for Covid, her care and treatment could have been managed without hospitalization.  We notice that there was a further request from the side of opposite party vide Ext.R4 to complainant for submitting RTPCR Covid report, CT chest, CRP, D Dimer, IL 6 report for further processing.  Terms and conditions do not require production of such records for processing of claim.  Terms and conditions only lay down that patient must be tested positive for Covid 19 by any government or government recognized Covid treatment centre.  Opposite party does not have a case that these conditions were not complied with.  Medical records pertaining to the patient, copies of which are marked as Ext.R2 disclose that the patient was tested                                                                                                           (cont…7)

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positive for Covid and therefore hospitalized for treatment from 23.4.2021, till 29.4.2021.  There are detailed reports with regard to investigations carried out.  The course and management of treatment and condition of the patient at the time of discharge and the fact that only oral medicines were administrated will not go against the claim.  We are not aware of any guidelines for treatment methods or course for covid treatment/management requiring/prescribing  surgical intervention except for treatment of comorbities or administration of medicines otherwise than by mouth in all cases. Nore were any such opinions obtained and placed before us of medical experts. Nothing was produced to show that management of disease by administering medicines orally will not classify as treatment for the disease. That apart, yet another reason stated is that the vitals were normal and that her clinical parameters were also within normal limits and therefore the patient did not require hospitalization. This reasoning is not sound, to say the least.  Decision mentioned in the written version will not support the case of opposite party  that repudiation of claim was in accordance with the terms and conditions of Ext.R1 policy. 

 

          Opposite parties do not have a case that the patient was not covered.  In fact they admitted this fact and also that the policy was live at the time when the patient was treated.  The only contention taken is that patient did not require any hospitalization, according to them.  For this, it was incumbent upon opposite parties, to examine an expert and to establish this fact, since initial burden that the patient was given inpatient treatment and that such treatment which was necessary has been discharged by the complainant by production of medical records in this case. Opposite party has not discharged this burden. Hospitalization is admitted.  The only case put forth is that it was not required, which we find is without any basis as such.  Yet another contention advanced is that amount spent for consumables cannot be reimbursed.  This contention is falsified by the terms and conditions submitted along with Ext.R1, by opposite party itself.

 

          To put it shortly, we find that the complainant was entitled to get his claim honoured by opposite party, repudiation of the claim was not in accordance with the terms and conditions of the policy taken by him.  This would certainly amount to deficiency in service.  Point Nos.1 and 2 are answered accordingly. 

 

Point No.3 :

 

          Complainant has claimed Rs.44,025/- towards reimbursement of treatment expenses of his daughter.  A copy of the hospital bill is also produced by him to substantiate this fact.  Complainant is entitled to get this amount from opposite party in view of Ext.R1 policy.  He has further claimed an amount of Rs.1 lakh for mental agony                                                                                                       (cont….8)

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caused due to deficiency in service.  Considering the circumstances, we are of the view that the compensation for deficiency in service could be quantified as Rs.30,000/-.  Similarly, we are of the view that an amount of Rs.5,000/- will suffix towards the head of litigation costs. 

 

          In the result, complaint is allowed in part upon the following terms :

 

1.  Opposite party shall pay Rs.44,025/- to complainant towards reimbursement of his claim for medical expenses of his daughter, covered by Ext.R1 policy.

 

2.  Opposite party shall pay Rs.30,000/- towards compensation to complainant for deficiency in service.

 

3.  The amount ordered as per clause (1) shall carry interest at the rate of 12% per annum from 29.9.2021, the date when claim of complainant was repudiated and amount ordered as per clause (2) shall carry interest at the rate of 12% from the date of this Order, till the date of payment or realization.

 

4.  Opposite party shall pay Rs.5,000/- to complainant towards litigation costs.

 

          Amount ordered above shall be paid within a period of 45 days from the date of this Order.  If not, complainant will  be entitled to realize the same in accordance with the provisions of this Act.  Parties are at liberty to take back extra copies of pleadings, petitions and documents produced by them after the expiry of Appeal Period.

 

                          Pronounced by this Commission on this the  11^th   day of October, 2022

 

 

                                                                                                    Sd/-

   SRI. C. SURESHKUMAR, PRESIDENT

 

                                                                                Sd/-

           SMT. ASAMOL P., MEMBER

 

                                    Sd/-

SRI. AMPADY K.S., MEMBER

 

 

                        (cont....9)

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APPENDIX

 

Depositions :

Nil.

Exhibits :

On the side of the Complainant :

Nil.

On the side of the Opposite Party :

Ext.R1    -  Policy and terms and conditions.

Ext.R2    -copy of discharge summary.

Ext.R3    -  copy of B.P. Chart and case sheet.

Ext.R4    -  letter of requirement of additional documents.

Ext.R5    -  copy of repudiation letter.

 

                                                                                          Forwarded by Order,

 

 

 

                                                                                     ASSISTANT REGISTRAR