BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.              

                                                          Consumer Complaint no. 147 of 2021                                                               

                                                             Date of Institution :    26.07.2021

                                                          Date of Decision   :    10.05.2023

Amandeep Singh, aged about 33 years, son of Shri Mangal Singh, resident of Gali Jandi Wali, Khairpur Colony, Sirsa, District Sirsa.

                      ……Complainant.

                             Versus.

1. The Manager/ Authorized Officer, Star Health & Allied Insurance Company Limited Office at upstairs Samsung Showroom near RC Hotel, Surkhab Chowk, Sirsa.

2. Star Health & Allied Insurance Company Limited Office at New Tank Street, Valluvar Kottam High Road, Nungabakam, Chennai- 600034.

…….Opposite Parties.

            Complaint under Section 12 of the Consumer Protection Act,1986.

Before:       SH. PADAM SINGH THAKUR……. PRESIDENT

                   MRS.SUKHDEEP KAUR……………MEMBER.

Present:       Sh. Sandeep Kamboj,  Advocate for the complainant.

                   Sh. Ravinder Monga, Advocate for opposite parties.

ORDER

                   The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred as Ops).

2.       In brief, the case of complainant is that after horrible situation of pandemic disease of Covid-19, the complainant in order to secure himself and believing on the name and goodwill of the ops’ company purchased Covid-19 protection health insurance policy namely “Corona Raksha Policy” from the ops. That before issuance of the said policy, the ops through its authorized agent collected all the required information and documents from complainant and after being satisfied about the health declaration made by complainant offered the said policy to him. Accordingly, the complainant was issued Corona Raksha Policy bearing No. P/211121/01/2021/007930 against the annual premium of Rs.6126/- paid in advance by complainant and policy was operative w.e.f. 5.10.2020 till 17.07.2021 against the lumpsum insured amount of Rs.2,50,000/-. It is further averred that complainant became Covid-19 positive as confirmed by RTPCR test done in Govt. Hospital, Sirsa on 09.03.2021 and certificate to this effect was issued by Civil Hospital, Sirsa. The complainant got treatment from best Multispecialty Hospital, Sirsa being authorized Covid-19 recognized Centre for the treatment of Corona patients. He was admitted in Astha Multispecialty Hospital, Sirsa on 10.03.2021 and he remained there admitted till 16.03.2021.

3.       It is further averred that during admission period, the complainant has undergone multiple blood sampling, scanning and other respective diagnose/ treatment regarding the covid-19 as complainant was suffering from the problem of breathless, cough, fever and body-ache. That complainant has incurred a huge amount against the medical bill of hospital dated 16.3.2021. After discharge from the hospital, complainant being fully covered by the said policy submitted his claim for reimbursement of medical bills incurred by complainant which were covered under the sum assured of Rs.2,50,000/- and also supplied all the relevant papers, medical bills, testing reports of the hospital. It is further averred that ops’ company acting in an arbitrary manner causing great mental shock and harassment have rejected the genuine claim of complainant simply reporting therein “As per the documents and details available with us, the OPD register dated 8.3.2021 Serial No.08, the patient name is mentioned as Amandeep Singh, gender is female and also address is different. Thus there are discrepancies in the records which amounts to misrepresentation of facts. We are therefore unable to consider the representation of the complainant favourably and would inform that repudiation of claim is in order”. It is further averred that Investigator of the ops verified about the name and gender of Amandeep from the Hospital and same is not related to the complainant as same is not of complainant and pertains to the patient named as Amandeep, aged 25 years, resident of Meerpur Khurd and as such record obtained by the Investigator of ops do not concerns with the complainant in any manner. That the repudiation of claim by ops’ company is totally unwarranted as first of all as per the record of discharge, the IPID number of the complainant is mentioned as “75” and further all the treatment record of complainant clarifies the admission and treatment of complainant but despite this, the ops acting in any illegal manner have repudiated the claim of complainant and have caused unnecessary harassment to the complainant. The complainant also got served a legal notice to the ops on 8.6.2021 but to no effect. Hence, this complaint seeking an amount of Rs.2,50,000/- alongwith interest besides compensation for harassment and litigation expenses from the ops .

4.       On notice, opposite parties appeared and filed written version raising certain preliminary objections regarding maintainability, locus standi, cause of action, suppression of material facts, estoppal etc. On merits, it is submitted that on scrutiny of the claim documents for availing lump-sum benefit, it is observed that the complainant record maintained in stereo type handwriting. As per the documents and details available in the OPD register dated 08.03.2021 at Sr. No.08 the name is mentioned as Amandeep Singh but gender is mentioned as female and also with the different address. Thus, there is a discrepancy in the record which amounts to misrepresentation of the facts. It is further submitted that as per the terms and conditions of the policy, in case if there is any misrepresentative whether by the insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of the claim, hence, the claim is rejected vide letter dated 02.05.2021. The insured represented the case for review alongwith hospital certificate dated 10.05.2021 in response to letter dated 02.05.2021 and the medical team after perusing the representation and reexamining the claim record observed that the submitted medical record and indoor case record of the hospital are in stereo type writing and there is discrepancy in the record prepared by the hospital which amounts to misrepresentation. It is further submitted that reasoned and speaking order through repudiation letter dated 25.05.2021 was duly informed to the complainant. The complainant is a guilty of violation of the policy and had traveled beyond the terms and conditions of the policy and the repudiation of claim is justified. It is also submitted that an insurance policy is a legal contract between policy holder and insurance company and parties are strictly bound by its terms and conditions. Remaining contents of complainant are also denied to be wrong and prayer for dismissal of complaint made.      

5.       The complainant in evidence has tendered his affidavit Ex. CW1/A and copies of documents Ex.C1 to Ex.C8.

6.       On the other hand, ops have tendered in evidence affidavit of Sh. Sumit Kumar Sharma, Senior Manager as Ex. RW1/A and copies of documents Ex.R1 to Ex.R8.

7.       We have heard learned counsel for the parties and have gone through the case file.

8.       Admittedly the complainant purchased the health insurance policy named as Corona Rakshak Policy bearing No. P/211121/01/2021/007930 from the ops for the period 05.10.2020 to 17.07.2021 and sum insured in the policy is Rs.2,50,000/-. According to the complainant on 09.03.2021 i.e. during the period of policy complainant became COVID-19 positive as per RTPCR test conducted in Civil Hospital, Sirsa and was admitted in Astha Multi Specialty Hospital, Sirsa on 10.03.2021 vide IPID No.75 dated 10.03.2021 and remained admitted there till 16.03.2021 and spent huge amount on his treatment. According to the complainant claim lodged by him with the ops has been repudiated by the ops on the flimsy and illogical ground that there is a discrepancy in the hospital record because in the OPD register dated 08.03.2021 at Sr. No.08, the name of the patient is Amandeep but gender is mentioned as Female and also with the different address. The record available on file also supports the version of the complainant and it is proved on record that ops in a very casual and unethical manner have repudiated the genuine claim of the complainant. The complainant has produced on record the hospital record regarding his admission and treatment in Astha Multispecialty Hospital, Sirsa and has also produced on record other supporting evidence in the shape of his test reports conducted in Dr. Soni Path Labs, Sirsa. The ops have alleged that in the OPD register dated 08.03.2021 at Sr. No.08, the name of patient is mentioned as Amandeep but gender is mentioned as Female and also with the different address. But it is the specific case of the complainant that he was admitted in the Astha Multi Specialty Hospital on 10.03.2021 and not on 08.03.2021. Further the complainant has also produced on record copy of the relevant page of register of In-door patients of Astha Multi Specialty Hospital which reveals that complainant Amandeep Singh was admitted in the said hospital on 10.03.2021 against Sr./ IPID No.75 as mentioned in the said register and his address is also not different in the said register and he is shown as resident of Khaipur Colony, Sirsa wherein the complainant actually resides. The ops have not proved on record through cogent and convincing evidence that complainant was not admitted in the hospital for treatment of COVID-19 and has not availed any treatment from the said hospital. The ops have not placed on file any affidavit of the Doctor or any staff member of the hospital to prove the said fact that complainant Amandeep Singh was never treated in their hospital for the symptoms of COVID-19. Rather complainant has also placed on record a certificate Ex.C2 issued by Medical Officer Covid-19 Control Room Civil Hospital, Sirsa in which it has been certified by the Medical Officer that patient Amandeep Singh son of Mangal Singh, aged 32 years, Male, resident of Khairpur Sirsa (i.e. complainant) has been found positive for COVID-19 by RTPCR test done by RTPCR Lab, Civil Hospital, Sirsa. The ops in order to prove their above said plea have also placed on file a photostat copy of the page of the register allegedly pertaining to Astha Hospital, Sirsa but same is not helpful to the ops because from the said document (though not exhibited or marked) itself it is proved on record that the patient Amandeep whose gender has been mentioned as Female and whose residence has been shown as Mirpur was admitted vide Sr. No.8 on 08.03.2021 whereas complainant Amandeep Singh whose address has been mentioned in the hospital record as resident of Khairpur was admitted in the above said hospital on 10.03.2021 vide IPID No.75 and not on 08.03.2021. Moreover, said document produced by ops is also not counter signed by any authorized person of the hospital. So, the ops have failed to prove their plea by any cogent and convincing evidence rather it is proved on record that complainant who was insured with the ops under Corona Rakshak Policy suffered with Corona during the period of the policy and accordingly he took treatment in the Astha Multi Specialty Hospital and therefore, ops have wrongly and illegally repudiated the genuine claim of the complainant on flimsy grounds.

9.       The complainant has claimed sum insured amount of Rs.2,50,000/- from the ops. The sum insured in the policy is Rs.2,50,000/- and clause 4.1 of the coverage clause clearly stipulates that Lump sum 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. Further a Note has also been given under this clause that (i) Payment will be made only on Hospitalization for a minimum continuous period of 72 hours following positive diagnosis for COVID, (ii) This is onetime benefit applicable for the entire tenure of the Policy and shall terminate upon payment of this benefit. Since the complainant was found positive for Covid-19 by Civil Hospital, Sirsa and thereafter he remained admitted in the Astha Multi Specialty Hospital, Sirsa for the period 10.03.2021 to 16.03.2021 i.e. much more than 72 hours, therefore, complainant is entitled to sum insured amount of Rs.2,50,000/- from the ops. Accordingly repudiation of the claim of the complainant is hereby set aside.

10.     In view of our above discussion, we allow the present complaint and direct the opposite parties to pay the sum insured amount of Rs.2,50,000/- to the complainant within 45 days from the date of receipt of copy of this order, failing which complainant will be entitled to receive the said amount of Rs.2,50,000/- from ops alongwith interest @6% per annum from the date of this order till actual payment. We also direct the ops to further pay a sum of Rs.10,000/- as composite compensation for harassment and litigation expenses to the complainant within above said stipulated period.  A copy of this order be supplied to the parties as per rules. File be consigned to the record room.     

Announced.                             Member                                   President,

Dated: 10.05.2023.                                                        District Consumer Disputes

                                                                                        Redressal Commission, Sirsa.

JK