By Smt. PREETHI SIVARAMAN.C, MEMBER
1.The complaint in short is as follows:-
Complainant had taken Corona Rakshak policy for the period from 04/09/2020 to 16/06/2021 for a sum insured of Rs. 1,50,000/- and he had paid premium of Rs. 3,706/- vide policy No. P/18 1312/01/2021/004207. Complainant is diagnosed with Covid -19 on 15/05/2021 and as per the advice of doctor , he had given the sample for test and he got the result on 17/05/2021 which stated that complainant was infected with Covid-19. Thereafter complainant was admitted at Community Health Centre, Vengara on 20/05/2021 due to heavy cough suffocation and body pain as per IP No.538 and he was discharged on 27/05/2021 . Thereafter he was under strict home isolation till 05/06/2021 and doctor prescribed medicines during the home isolation period.
2. Complainant informed the opposite party when he became Covid positive as per claim No.CIR/2022/181312/2668001 on 28/05/2021. Complainant stated that he had taken the Corona Rakshak policy due to the assurance given by opposite party to him that when he insured through this policy he will get the benefit, if he got infected with Covid -19 , he should submit the positive report of Covid -19 from a government lab and there must be a hospitalisation for more than 72 hours following medical advice of a duly qualified medical practitioner. Moreover the documents given by opposite party regarding this policy also stated the above directions.
3. When he was infected with Covid -19 he send the documents regarding the infection of Covid -19 to opposite party in the proper time and complainant got the acknowledgment after receiving the documents by opposite party. But on 13/08/2021 complainant got a phone call that the claim of complainant repudiated by opposite party and they stated the reason that” as per the terms and conditions of the policy issued, lumpsum benefit shall be available on positive Covid requiring hospitalisation and not institutional quarantine’’. Thereafter on 17/08/2021 an email got to complainant dated 13/08/2021 stated that “Repudiation of claim as per terms and conditions of the policy issued to you lumpsum benefit shall be payable on positive diagnosis of Covid Requiring hospitalisation and not for institutional quarantine’’. It is a clear deficiency in service and unfair trade practice from their part of opposite party.
4. Complainant again stated that there is a positive Covid test result from a Government authorised lab and there is hospitalisation from 20/05/2021 to 27/05/2021 that means 7 days hospitalisation at Government Community Health centre, Vengara under the Government Health and Family Welfare Department. Moreover complainant had submitted all documents at the proper time for getting the insurance benefit. Complainant is now also suffering the after effects of Covid -19 and he is treating at Aster MIMS, Kottakkal. Complainant filed petition before the Insurance Ombudsman Ernakulum against opposite party for the repudiation of claim of complainant by opposite party, but that was dismissed by Insurance Ombudsman vide award dated 30/06/2022. But there is clear deficiency in service and unfair trade practice from the side of opposite party. Hence this complaint.
5. The prayer of the complainant is that, he is entitled to get the insurance amount of Rs. 1,50,000/-, Rs.1,00,000/- as compensation on account of deficiency in service and unfair trade practice on the part of opposite party and thereby caused mental agony, physical hardships and sufferings to the complainant and Rs. 20,000/-as cost of the proceedings.
6. On admission of the complaint notice was issued to the opposite party and notice served on them and they appeared before the Commission through their counsel and filed version.
7. In their version, they denied all the allegations levelled by complainant against them except those which are admitted there under. They admitted that complainant had taken Corona Rakshak Policy for the period from 04/09/2020 to 16/06/2021 for a sum insured of Rs.1,50,000/- vide policy No. P/181312/01/2021/004207. At the time of availing the policy complainant was supplied with the terms and conditions of the policy and the conditions were explained to the complainant. Moreover it is clearly stated in the policy schedule that “ the insurance under this policy is subject to conditions, clauses, warranties, exclusions etc attached’’. In the operative clause No.2 of the policy , if during the policy period the insured person is diagnosed with Covid and hospitalised with more than 72 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.
8. The complainant was admitted at Community Health Centre, Vengara on 20/05/2021 for the treatment of Covid -19 category C and discharged on 27/05/2021. The discharge summary issued by CHC Vengara was silent about the patient’s clinical parameters like temperature, pulse rate, SP O2 level, RR etc were not monitored and mentioned in the discharge card. After receiving the claim documents, opposite party had conducted an insurance investigation and collected the details of the above said centre and they had known that CHC Vengara is a Covid -19 Second line treatment centre (CSLTC). CSLTC is only an institutional quarantine facility not a hospital. On 08/10/2021 the Medical office, CHC Vengara certified that the patient (Complainant) has undertaken treatment at this institution for Covid -19 and all treatments including Covid -19 in this institution are free of cost.
9. They again stated that as per the terms and conditions of the policy ‘’ the claim shall be payable on positive diagnosis of Covid -19 requiring hospitalisation for a minimum period of 72 hours’’. Here Covid positive had been diagnosed hospitalisation was not warranted and hence referred to CSLTC for observation. Moreover in this case hospital has not monitored SP O2 value of the insured. As per the policy lumpsum benefit equal to 100% if the sum insured shall be payable on positive diagnosis of Covid, requiring hospitalisation of 72 hours. Here hospitalisation means admission in a hospital designated for Covid -19 treatment by Government for the minimum period of 72 consecutive inpatient care hours. Inpatient care means insured person has to stay in a hospital continuously for more than 72 hours for Covid treatment. But in this case no treatment provided to the patient. Hence stay in the hospital is not at all essential. In the insured person was admitted at CSLTC is only an institutional quarantine facility not a hospital. Any CSLTC provide institutionalised care and treatment to mild or asymptomatic Covid positive patient. This level provides essential Covid care as well as specialised care via telemedicine facility linked to the Covid hospital. It is only for observation. CSLTC in a hospital and lack the infrastructure of a hospital as per policy clause. The purpose of quarantine during the current outbreak is to reduce transmission by separating contact of Covid -19 patients from community , monitoring the developments of sign and symptoms of Covid -19 etc. This policy is designed to meet the huge expenses of hospitalised care/ treatment to a symptomatic patient only. If there is severe symptom of Covid, then such patients are to be referred to Covid hospital for impatient care. CSLTC is not a regular hospital under the policy. Hence the opposite party had repudiated that claim and the same was insured on 13/08/2021.
10. Thereafter complainant approached insurance Ombudsman against the opposite party and that petition had dismissed. They again submitted that there is no deficiency of service and unfair trade practice from their side. They had acted as per the terms and conditions of the policy. Complainant has absolutely no cause of action. Hence complaint may be dismissed.
11. In order to substantiate the case of the complainant, he filed an affidavit in lieu of Chief examination and the documents he produced were marked as Ext. A1 to A7. Ext.A1 is the copy of the complainant’s Certificate of insurance of Corona Rakshak Policy. Ext.A2 is the copy of Covid -19 test report of complainant issued by District Public Health Lab, Malappuram, Ext.A3 is the copy of Lab report issued by CHC, Vengara regarding the treatment of complainant. Ext.A4 is the copy of discharge card received from CHC, Vengara. Ext. A5 is the copy of customer identity card issued by opposite party to complainant. Ext. A6 is the acknowledgement received by complainant which is issued by opposite party after receiving the documents sent by complainant to them. Ext. A7 is the copy of repudiation of claim received by complainant from opposite party on 13/08/2021. Thereafter opposite party also filed affidavit and the documents marked as Ext. B1 to B9. Ext. B1 is the copy of condition of Corona Rakshak Policy. Ext. B2 is the Photostat copy of photographs of CSLTC. Ext. B3 is the copy of Certificate dated 08/10/2021 issued by Medical officer CHC , Vengara. Ext. B4 is the copy of guidelines issued by Government of Kerala dated 28/03/2020. Ext. B5 is the copy of clinical management protocol Covid -19 issued by Government of India dated 13/06/2020. Ext. B6 is the copy of repudiation letter dated 13/08/2021. Ext. B7 is the copy of complaint filed by the complainant before the Insurance Ombudsman. Ext. B8 is the copy of Self Contained Note submitted by the opposite party before the Insurance Ombudsman. Ext. B9 is the copy of Award dated 30/06/2022 passed by Insurance Ombudsman , Kerala.
12. Heard complainant and opposite party Perused affidavit and documents. The following points arise for consideration:-
- Whether there is any deficiency of service and unfair trade practice on the part of opposite party
- If so, reliefs and cost.
13.Point No.1 and 2:-
Case of the complainant is that he was a policy holder of Corona Rakshak policy vide No. P/181312/01/2021/004207 issued by opposite party and he had undergone treatment at Community Health Centre, Vengara due to Covid-19 positive while the policy was in force. Complainant produced ExtA2 document issued by District Public Health Lab, Malappuram which shows that he had given the sample on 15/05/2021 and he became Covid -19 positive on 17/05/2021. Ext.A3 document, the Lab reports shows that patient clinical parameters and platelets count etc. As per Ext.A4 it is seen that complainant was admitted at CHC, Vengara on 20/05/2021 and discharged on 27/05/2021. Hence as per the terms and conditions of the insurance policy the complainant is entitled to the insurance benefit which the opposite party stands denied.
14. In the version and affidavit of opposite party, they opposed the claim of the complainant. The contention of opposite party is that the repudiation of the insurance claim is strictly according to the terms and conditions of the policy. They again stated that in the operative clause No.2 of the policy, if during the policy period the insured person is diagnosed with Covid and hospitalised with more than 72 hours following medical advice of a duly qualified medical practitioner as per the norms specified by the Ministry of Health family welfare, Government of India. They again stated that complainant does not require hospitalisation for the Covid -19 which complainant sustained.
15. On perusal of documents there was a policy admitted by the opposite party in favour of the complainant to cover insurance while the insured undergoes 72 hours hospitalisation due to Covid -19 positive. As per Ext A2 document the covid -19 positive result and ExtA4 the discharge card given from CHC, Vengara shows that complainant was Covid positive and he was hospitalised from 20/05/2021 to 27/05/2021, nearly 7 days he was in CHC Vengara due to Covid -19. Hence the case of the complainant stands proved through the documents and affidavit. It is evident that complainant was infected with Covid -19 positive and was hospitalised for 7 days in a Government Health Centre . As per Ext. B3 produced by opposite party also reveals that complainant was admitted in hospital on 20/05/2021 and discharged on 27/05/2021. Opposite party repudiated the claim of complainant by stating the reason that “ as per the terms and conditions of the policy issued to you, lumpsum benefit shall be payable on positive diagnosis of Covid requiring hospitalisation and not for institutional quarantine”. But in Ext. B3 submitted by opposite party, the certificate issued by Medical officer CHC Vengara stated that complainant was admitted on 20/05/2021 and discharged on 27/05/2021 due to Covid. Nothing mentioned in that certificate about the institutional quarantine of complainant.
16. The admitted case of the opposite party is that they are liable to pay insured amount in case of hospitalisation for a minimum period of 72 hours on diagnosis of Covid -19. So there is absolutely no justification for repudiation of insurance claim of the complainant. In Ext.B6 dated 13/08/2021, the claim repudiation certificate opposite party clearly stated the name of the hospital and location as Community Health Centre, Vengara. As per Ext.A3 the Lab reports submitted by complainant clearly shows the clinical parameters of complainant. The right to determine the medicine and hospitalisation is vest with the doctor and not with the insurance company. The insurance company cannot dictate the mode of Covid treatment and hospitalisation. Hence the insurance company is liable to pay the insured sum to complainant.
17. It appears that opposite party repudiated the claim without sufficient reason. The contention of opposite party is absolutely without any merit. The denial of insurance to the right claimant amounts unfair trade practice and deficiency in service. ‘The insurance policy called Corona Rakhsak Policy was introduced as part of social Welfare measure to provide protection to the interest of public at large. But opposite party cut the very root of the intention contenting unsustainable reason for denying the genuine claim. As per Ext. A6 it is clear that complainant sent all the documents regarding his treatment to opposite party and they admitted that they have received the documents on 21/07/2021. Complainant filed this complaint on 03/08/2022. Complainant herein met with Covid -19 on 2021, Opposite party received the relevant documents on 2021 itself. But after this long period claim of the complaint stands not settled. As per the terms and conditions of the policy, lumpsum benefit equal to 100% of the sum insured shall be payable on positive diagnosis of Covid, requiring hospitalisation for a minimum continuous period of 72 hours. Here all the terms and conditions of the policy are satisfied. Hence complainant is entitled for the insured sum and the interest for the insured sum from the date of claim to till date of payment. In addition to that the complainant entitled reasonable amount of compensation and he is also entitled the cost of the proceedings.
18. Hence the Commission finds that there is deficiency in service on the part of the opposite party as alleged in the complaint. Hence we allow this complaint holding that opposite party is deficient in service.
19. We allow this complaint as follows:-
- The opposite party is directed to pay the lump sum amount of policy Rs.1,50,000/- (Rupees One lakh and fifty thousand only) to the complainant with interest at the rate of 9% per annum from the date of complaint to till date of payment.
- The opposite party is directed to pay compensation of Rs. 50,000/-(Rupees Fifty thousand only) to the complainant on account of deficiency in service on the part of opposite party and thereby caused mental agony, physical hardships and sufferings to the complainant.
- The opposite party is also directed to pay Rs. 5,000/- (Rupees Five thousand only) as cost of the proceedings.
If the above said amount is not paid to the complainant within 30 days from the date of receipt of copy of this order, the opposite party is liable to pay the interest at the rate of 12% per annum on the said amount from the date of receipt of the copy of this order till realisation.
Dated this 14th day of July, 2023.
MOHANDASAN K., PRESIDENT
PREETHI SIVARAMAN C., MEMBER
MOHAMED ISMAYIL C.V., MEMBER
APPENDIX
Witness examined on the side of the complainant : Nil
Documents marked on the side of the complainant : Ext.A1to A7
Ext.A1 : Copy of the complainant’s Certificate of insurance of Corona Rakshak Policy. Ext.A2 : Copy of Covid -19 test report of complainant issued by District Public Health
Lab , Malappuram.
Ext.A3 : Copy of Lab report issued by CHC , Vengara regarding the treatment of
complainant.
Ext.A4 : Copy of discharge card received from CHC, Vengara.
Ext.A5 : Copy of customer identity card issued by opposite party to complainant . Ext.A6 : Acknowledgement received by complainant which is issued by opposite
party after receiving the documents sent by complainant to them.
Ext.A7: Copy of repudiation of claim received by complainant from opposite party on
13/08/2021.
Witness examined on the side of the opposite party : Nil
Documents marked on the side of the opposite party : Ext. B1 to B9
Ext.B1 : Copy of condition of Corona Rakshak policy .
Ext.B2 : Photostat copy of photographs of CSLTC.
Ext.B3 : Copy of Certificate dated 08/10/2021 issued by Medical officer CHC ,
Vengara.
Ext. B4 : Copy of guidelines issued by Government of Kerala dated 28/03/2020.
Ext. B5 : Copy of Clinical Management Protocol Covid -19 issued by Government of
India dated 13/06/2020.
Ext. B6 : Copy of repudiation letter dated 13/08/2021.
Ext. B7 : Copy of complaint filed by the complainant before the Insurance
Ombudsman.
Ext. B8 : Copy of self contained Note submitted by the opposite party before the
Insurance Ombudsman.
Ext. B9 : Copy of Award dated 30/06/2022 passed by Insurance Ombudsman, Kerala.
MOHANDASAN K., PRESIDENT
PREETHI SIVARAMAN C., MEMBER
MOHAMED ISMAYIL C.V., MEMBER
