BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 43 of 2021
Date of Institution : 19.02.2021
Date of Decision : 06.11.2024
Dikshit Bansal son of Shri Sharwan Bansal, resident of House No. 160, DC Colony, Near Barnala Road, Sirsa, Tehsil and District Sirsa.
……Complainant.
Versus.
1. Star Health and Allied Insurance Company Limited., Opposite Maruti Car Show Room, Dabawali Road, Sirsa through its Incharge/ Manager.
2. M/S Star Health and Allied Insurance Company Limited., No.15, Sri Balaji Complex, 1st Floor, Whites Lane, Royapettah, Chennai- 600014 through its Managing Director.
…….Opposite Parties.
Complaint under Section 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
SMT. SUKHDEEP KAUR……………MEMBER.
SH. OM PARKASH TUTEJA………..MEMBER
Present: Sh. R.D. Bishnoi, 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 complainant purchased a Corona Rakshak policy bearing No. P/211121/01/2021/007853 from ops for the period 02.10.2020 to 15.04.2021 for the diagnosis of COVID-19 Pneumonia for the sum insured amount of Rs.2,00,000/- for which complainant paid premium amount of Rs.4356/ to the ops. As per insurance policy, insured shall be given the benefits if during the period of insurance, the insured is diagnosed with covid positive requiring hospitalization for minimum continuous period of 72 hours then the company will pay the lump sum benefit equal to 100% of sum insured amount. That in the month of October, 2020 the complainant suffered serious attack of breathing and chest pain and he immediately visited Civil Hospital, Sirsa for his treatment where the doctors advised him for Corona test. His Corona test was conducted and found positive vide serial no.512 dated 27.10.2020 and doctors of Civil Hospital, Sirsa referred him to Shah Satnamji Specialty Hospital, Sirsa i.e. a Govt. Covid Center. It is further averred that thereafter complainant was admitted in the above said center on 28.10.2020 and was discharged on 01.11.2020 and during this period he was treated for above said disease of Covid-19. That thereafter complainant approached and requested the ops for disbursement of Rs.2,00,000/- to him as per said policy and all the requisite documents were also sent to the ops but the officials of the ops postponed the matter with one pretext or the other without any rhyme or reason. It is further averred that now vide letter dated 15.12.2020 the ops have declined/ repudiated the genuine request of complainant by mentioning false fact to the effect that “in discharge card, tampering is noted in the date of discharge, thus there is discrepancy in the records which amounts to misrepresentation of facts”. That due to this reason the ops have repudiated the claim of complainant wrongly and illegally because the record submitted to the ops was issued by the hospital and even from the summary and diagnose/ treatment charge already sent to the ops it is clear that complainant remained admitted in the above said center and there is no cutting in it and even there is no tampering by complainant, so on this ground the genuine claim of complainant cannot be repudiated. That complainant again sent a letter of Covid Center in this regard to the ops but to no effect and the ops intentionally and malafidely have repudiated his claim and have caused deficiency in service and unnecessary harassment to the complainant and have adopted unfair trade practice. The complainant also got served a legal notice to the ops on 11.01.2021 but to no effect. Hence, this complaint.
3. On notice, ops appeared and filed written version raising certain preliminary objections. It is submitted that complainant availed Corona Rakshak Insurance Policy commencing from 02.10.2020 to 15.04.2021 covering the risk of Rs. two lacs only. The insured Dikshit bansal admitted in Civil Hospital, Sirsa on 27.10.2020, thereafter from 28.10.2020 to 01.11.2020 in Shah Satnam Ji Multispecialty Hospital, Sirsa for treatment of Covid-19. The insured submitted claim documents for availing lumpsum benefit. On perusal of the claim documents, it is observed that as per submitted discharge summary the patient was hospitalized from 28.10.2020 to 01.11.2020, the SPO2 on arrival is 97% at room air and the insured patient vital signs are stable and general condition is normal throughout the period of hospitalization. So, as per the guidelines from All India Institute of Medical Science, New Delhi and Ministry of Health and Family Welfare, Govt. of India regarding Covid-19, the patient only required self isolation by home quarantine based and not required to admit in hospital for treatment, since the SPO2 is normal, hence the claim was repudiated and communicated to the insured through letter dated 15.12.2020. It is further submitted that moreover there is apparent tampering in the discharge summary and on account of discrepancy and misrepresentation the claim has rightly been repudiated. The complainant has travelled beyond the terms and conditions of the policy and repudiation of claim is justified and therefore, no deficiency in service can be attributed to the ops and complaint is liable to be dismissed on this very score. The letter of repudiation dated 15.12.2020 has been issued with speaking orders and on the basis of documents, treatment record furnished by the complainant. Moreover, the claim of complainant has rightly been repudiated on the basis of guidelines of Govt. of India etc. and on account of sheer violation of terms and conditions of the policy. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
4. The complainant in evidence has tendered his affidavit Ex. CW1/A and documents Ex.C1 to Ex.C13.
5. On the other hand, ops have tendered affidavit of Sh. Sumit Kumar Sharma, Senior Manager as Ex. RW1/A and documents Ex.R1 to Ex.R10.
6. We have heard learned counsel for the parties and have gone through the case file.
7. There is no dispute of the fact that complainant availed Corona Rakshak Insurance Plan from the ops for the period 02.10.2020 to 15.04.2021 for the sum insured amount of Rs. two lacs and said fact is also proved from certificate of insurance Ex.R2 placed on file by ops themselves. From the RTPCR test report of Civil Hospital, Sirsa Ex.C5 and Ex.C6, it is evident that said test of complainant was conducted in Civil Hospital, Sirsa on 26.10.2020 and on 27.10.2020 the complainant was found COVID-19 positive and thereafter on 28.10.2020 the complainant was referred by Civil Hospital, Sirsa to the above said Govt. authorized Covid Center where he remained admitted from 28.10.2020 to 01.11.2020 for the treatment of corona disease as is evident from treatment record placed on file by complainant as Ex.C9 to Ex.C13. So, it is proved on record that complainant remained admitted in the said hospital for more than 72 hours. As per clause 4.1 of the policy, the 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 and the positive diagnosis shall be from government authorized diagnostic centre. It is further made clear under the head “Note” that payment will be made only on Hospitalization for a minimum continuous period of 72 hours following positive diagnosis for COVID and this is onetime benefit applicable for the entire tenure of the policy and shall terminate upon payment of this benefit. Since it is proved on record that complainant was found Corona positive through RTPCR test report of Civil Hospital and thereafter he remained admitted in the Govt. authorized Covid Center from 28.10.2020 to 01.11.2020 i.e. more than 72 hours as is evident from record, so as per terms and conditions of the policy, the complainant is entitled to 100% of the sum insured amount i.e. Rs.2,00,000/- from ops as per terms and conditions of the policy. The complainant was admitted in the hospital due to his health condition and emergent situation and he remained admitted in the hospital under the supervision of a qualified doctor as per need and not as per his own choice and when the said doctor found that after treatment complainant health is stable, then complainant was discharged from the hospital. So, it cannot be said that patient only required self isolation by home quarantine based and was not required to be admitted in hospital for treatment. The other plea of ops that there is tampering in the discharge summary has also no substance because besides discharge summary, the other record of said Covid Centre in the shape of progress notes from 28.10.2020 to 01.11.2020 are on file which clearly prove the fact that complainant remained admitted in the said hospital from 28.10.2020 to 01.11.2020 and therefore ops cannot take advantage of any cutting in the discharge summary which is only due to inadvertent mistake and not due to any other intention. In this regard Dr. Sandeep Bhadu, Medical Officer of Shah Satnam Ji Specialty Hospital, Sirsa has also given his certificate Ex.C2 that complainant remained admitted from 28.10.2020 to 01.11.2020 in the said hospital. So, the repudiation of the claim of complainant on the above said lame excuses and on false and baseless ground is not justified. The complainant is entitled to sum insured amount of Rs.2,00,000/- from ops.
8. In view of our above discussion, we allow the present complaint and direct the opposite parties to make payment of claim amount of Rs.2,00,000/- to the complainant alongwith interest at the rate of @6% per annum from the date of filing of present complaint i.e. 19.02.2021 till actual realization within a period of 45 days from the date of receipt of copy of this order. 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 Member President,
Dt. 06.11.2024. District Consumer Disputes
Redressal Commission, Sirsa.
