BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 14 of 2022
Date of Institution : 10.01.2022
Date of Decision : 15.03.2024
Jagjit Singh, aged 36 years son of Shri Sukhdev Singh, resident of village Phulkan, Tehsil and District Sirsa (Haryana).
……Complainant.
Versus.
1. Star Health and Allied Insurance Company Ltd., Branch Office: Ground Floor, Rathore Tower, Dabwali Road, Near Hotel Mehak, Opp. Shakti Motors, Sirsa, Tehsil and District Sirsa, through its Branch Manager.
2. Star Health and Allied Insurance Company Ltd., No. 15, Sri Balaji Complex, 1st Floor, Whites Lane, Royapettah, Chennai- 600 014, through its authorized signatory.
…….Opposite Parties.
Complaint under Section 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
Present: Sh. JBL Garg and Ms. Anita Bansal, Advocates 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 Health Insurance Policy from the ops vide Policy No. P/211121/01/2021/002384 for the period w.e.f. 27.6.2020 to 26.6.2021 and got himself insured after paying premium amount of Rs.9122/- and the sum assured amount of this policy was Rs.1,00,000/-. That on 30.04.2021, complainant was attacked by Covid-19 and he got himself medically examined from Medicare Hospital, Sirsa and it was declared that he is Corona positive. The complainant remained admitted as an indoor patient in the said hospital from 30.04.2021 to 04.05.2021 and a sum of Rs.55,000/- was incurred by complainant on his treatment. The complainant remained hospitalized for more than 88 hours in the hospital under the care and supervision of doctors of Medicare Hospital, Sirsa and therefore, as per above policy he lodged his claim with the ops and supplied all the original documents and informed as required by the ops for settlement of his claim. It is further averred that however very strangely the ops vide their letter dated 21.06.2021 have repudiated the claim of complainant on the ground that as per the guidelines from All India Institute of Medical Sciences, New Delhi and Ministry of Health and Family Welfare, Govt. of India regarding the treatment of Covid-19 patients, this patient needed only self-isolation by home quarantine based on submitted claim documents instead of admission and treatment and same is not payable. That complainant was shocked to know the repudiation of his claim due to above imaginary reason by the ops because he remained admitted in the hospital for more than 88 hours and therefore, it is quite false, baseless and wrong that he required self isolation and the ops by their such act and conduct have indulged themselves in unfair trade practice and have committed gross deficiency in service and have caused unnecessary harassment to him. That complainant approached the ops on many occasions and requested for settlement of his claim but they continued put off the matter with one pretext or the other and complainant also got served a legal notice ups ops on 23.09.2021 but of no use. Hence, this complaint.
3. On notice, ops appeared and filed written statement raising certain preliminary objections. It is submitted that in the first year of the policy, the insured Jagjit Singh was admitted to Medicare Hospital on 30.04.2021 for treatment of Covid-19 Pneumonitis. The insured submitted claim documents for reimbursement of Rs.53,685/-. On perusal of the claim documents, it is observed that as per discharge summary the patient was diagnosed with Covid positive and hospitalized on 30.04.2021 and was discharged on 04.05.2021. After carefully observing the medical treatment records, it is observed that :-
* As per the discharge summary, the insured has complaints of dry cough and was diagnosed with COVID with Pneumonitis.
* As per the indoor case papers, the SPO2 level on 01.05.2021 and 02.05.2021 is 98%, on 03.05.2021 the SPO2 is 96% and on 04.05.2021 the SPO2 is 97% on room air.
* All the vitas are within normal limit.
* As per the CT report dated 30.04.2021, the insured CT severity score is 05/25, CORADS-5.
4. It is further submitted that from the above findings, it is noted that insured had only mild infection and the hospitalization for the same is not warranted. As per the guidelines from AIIMS, New Delhi ad Ministry of Health and Family Welfare, Government of India regarding the treatment of COVID 19 patients, the patients with SpO2 level greater than 94% on room air and respiratory rate lesser than 24/min are having only Mild Infection. The patients with Mild Infections were prescribed Home Isolation only instead of admission and treatment which is not warranted. Hence, the claim was repudiated and communicated to the Insured through letter dated 11.06.2021. The complainant has travelled beyond the terms and conditions of the policy and repudiation of claim is justified. It is further submitted that in case it is found that company is liable to pay the claim in terms of the contract of insurance issued to the claimant, then the maximum quantum of liability under the terms of the policy shall be Rs.48,184/-. All other contents of complaint 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 documents Ex.C1 to Ex.C29.
6. 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.R11.
7. We have heard learned counsel for the parties and have gone through the case file.
8. There is no dispute of the fact that complainant purchased Health Insurance Policy from the ops for the period 27.06.2020 to 26.06.2021. Though complainant has claimed that sum insured under the policy was Rs. one lac whereas from the policy schedule Ex.C1, it is evident that sum insured amount was Rs.10,00,000/- but however, the claim of the complainant is less than Rs. one lac. There is also no dispute about the fact that complainant remained admitted in Medicare Hospital, Sirsa from 30.04.2021 to 04.05.2021 and he was found Corona Positive on 01.05.2021 as is evident from report Ex.C29. According to complainant he has spent an amount of Rs.55,000/- on his treatment and submitted the claim to the ops for reimbursement of his claim but however, ops have wrongly and illegally repudiated the claim of complainant on the above said ground that admission and treatment was not required to the complainant and he needed home isolation only. No doubt, the ops have also placed on file guidelines of AIIMS, New Delhi dated 08th September, 2020 Ex.R11 regarding management of COVID-19 disease of the patients of Mild cases, Moderate Cases and Severe cases and it is mentioned that patient who has Mild disease needs home isolation but however the fact cannot be ignored that well qualified doctor of Medicare Hospital, Sirsa keeping in view the condition of the complainant got admitted him in the hospital. The complainant remained admitted in the hospital from 30.04.2021 to 04.05.2021 under the care and supervision of M.D. Doctor of Medicare Hospital, Sirsa and therefore, it cannot be said at all that admission and treatment of the complainant was not required at all. It is very common known fact that disease also varies from person to person. A person having mild symptom can be treated at home or a person having same symptom needs hospitalization and that depends upon health condition of the patient and also upon various factors like weakness etc. and it only depends upon the qualified treating doctor whether a patient is to be admitted or not and it is not the choice of the patient either to get treatment by admission in the hospital or to get treatment only at home. So, the ops have wrongly and illegally repudiated the genuine claim of the complainant only on baseless ground. The complainant is entitled to reimbursement of total claim amount of Rs.55,000/- and not Rs.48,148/- as worked out by ops in bill assessment sheet Ex.R10 because complainant has duly proved through bills/ receipts Ex.C14 to Ex. C22 that he has incurred above said amount of Rs.55,000/- on his said treatment.
9. In view of our above discussion, we allow the present complaint and direct the opposite parties to pay the claim amount of Rs.55,000/- to the complainant alongwith interest @6% per annum from the date of filing of present complaint i.e. 10.01.2022 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 President,
Dated: 15.03.2024. District Consumer Disputes
Redressal Commission, Sirsa.
