BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 74 of 2022
Date of Institution : 21.01.2022
Date of Decision : 08.10.2024
Raj Kumar son of Shri Mohan Lal, resident of Ward No. 13, Jangeer Singh Colony, Kalanwali, Sirsa, District Sirsa.
……Complainant.
Versus.
1. Star Health and Allied Insurance Company Ltd., Ist and IInd Floor Satya Sales, Samsung Plaza, Showroom Building adjoining R.C. Regency Hotel, Hisar Road, Sirsa.
2. Star Health and Allied Insurance Company Ltd., through its Branch authorized person/ signatory Regd. & Corporate office at No. 15, Sri Balaji Complex, Ist Floor, Whites Lane, Royapettah Chennai- 600014.
…….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. Kapil Dev, 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/211121/01/2021/006938 from ops for the period 18.09.2020 to 30.06.2021 i.e. for 285 days against the premium amount of Rs.6126/- and it has been specifically mentioned in the policy that if the patient is diagnosed with COVID-19 and undergo treatment of COVID-19 from any medical institution which has been empanelled with ops, then the company will pay the lump sum benefit equal to 100% of sum insured. That on 18.06.2021, the complainant found symptoms of COVID-19 i.e. fever and cough etc., hence he got himself checked up and gone done the test of RTPCR from Civil Hospital, Sirsa and he was found positive and got treatment from Civil Hospital, Sirsa. That as per prescription of the doctor, the complainant got himself home isolated but as there was no improvement in his health, hence he was got admitted in Lalgaria Hospital, Sirsa and remained admitted there from 20.06.2021 to 23.06.2021 for treatment. It is further averred that on date of his admission, he duly intimated the ops as per guidelines of IRDA and after discharge from hospital, he lodged claim with ops and also completed all the formalities required by ops but ops after lingering on the matter with one pretext or other now have repudiated his claim on 06.09.2021 on false grounds that there is tampering with the treatment record. That complainant also got served a legal notice to the ops on 09.12.2021 but to no effect and as such ops have caused financial loss, deficiency in service and unnecessary harassment to the complainant and have adopted unfair trade practice. Hence, this complaint seeking direction to the ops to pay claim amount of Rs.2,50,000/- alongwith interest and also to pay compensation of Rs.1,00,000/- for unnecessary harassment and also to pay litigation expenses.
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 18.09.2020 to 30.06.2021 covering the risk of Rs.2,50,000/-. The insured Raj Kumar was admitted in Lal Gadia Hospital, Sirsa from 20.06.2021 to 23.06.2021 for treatment of Covid-19 and on perusal of claim documents it is observed that as per indoor case papers, the insured patient vital signs are stable after two days of hospitalization, the clinical investigation reports are within normal limits and there are numerous tampering in the SPO2 noting. It is further submitted that from the above findings, the ops are of the opinion that the insured patient could have been managed under Home Quarantine. 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, hence the claim was repudiated and communicated to the insured through letter dated 06.09.2021. It is further submitted that as per condition of policy vide 4.1 coverage lump sum benefit equal to 100% of the sum insured shall be payable on positive diagnosis of COVID requiring hospitalization for the minimum continuous period of 72 hours. In this case hospitalization is warranted only for two days and the insured was stable after the same. Hence, the lump sum benefit is not payable. It is further submitted that complainant has travelled beyond the terms and conditions of the policy and repudiation of the 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. 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.C32.
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. R11.
6. We have heard learned counsel for the parties and have gone through the case file.
7. From the certificate of insurance Ex.C4, it is evident that complainant purchased Corona Rakshak Policy from ops vide which complainant was insured with the ops for the period 18.09.2020 to 30.06.2021 for the sum insured amount of Rs.2,50,000/-. From the RTPCR test report of Civil Hospital, Sirsa Ex.C11, it is evident that said test of complainant was conducted in Civil Hospital, Sirsa on 18.06.2021 and on 19.06.2021 the complainant was found COVID-19 positive and thereafter he remained admitted in Lalgaria Hospital, Sirsa for the treatment of corona disease from 20.06.2021 to 23.06.2021 as is evident from treatment record placed on file by complainant as Ex.C13 to Ex.C30. 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 said hospital from 20.06.2021 at 2.00 p.m. till 23.06.2021 up to 8.00 p.m. 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.2,50,000/- from ops. 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 after two days the hospitalization of the complainant was not necessary. The other plea of ops that there are numerous tampering in the SPO2 noting has also no substance because in the treatment record produced by complainant there is no over writing/ tampering and only there is over writing/ tampering in the photostat copies of treatment record produced on record by ops themselves and the possibility that ops themselves made cuttings in one copy and thereafter got another copy through photostat cannot be ruled out because ops have not proved on record through any cogent and convincing evidence that there was actually tampering in the record of the hospital and that tampering was made knowingly and was intentional one. The complainant cannot be blamed in this regard and his genuine claim cannot be withheld by ops on mere technicalities and on lame excuses. The ops have failed to prove on record any exact reason of tampering, if any or any collusion between complainant and 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.2,50,000/- 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.2,50,000/- to the complainant alongwith interest at the rate of @6% per annum from the date of filing of present complaint i.e. 21.01.2022 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 Member President,
Dt. 08.10.2024. District Consumer Disputes
Redressal Commission, Sirsa.
