BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 260 of 2022
Date of Institution : 08.04.2022
Date of Decision : 06.09.2024
Surjeet Kumar aged about 29 years son of Shri Krishan, resident of village Natar, Tehsil and District Sirsa.
……Complainant.
Versus.
1. Star Health and Allied Insurance Company Ltd., First Floor, Satya Sales (Samsung Showroom), RC Regency, Surkhab Chowk, Sirsa through its Branch Manager.
2. Star Health and Allied Insurance Company Ltd., No. 15, Sri Balaji Complex, 1st Floor, Whites Lane, Royapettah, Chennai- 600014, through its authorized person.
…….Opposite Parties.
Complaint under Section 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
SH. OM PARKASH TUTEJA………MEMBER
Present: Sh. U.P. 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 had purchased a policy namely “Corona Rakshak Policy” from the ops vide policy certificate No. P/700001/01/2022/001370 dated 05.04.2021 against payment of premium of Rs.4538/-. The said policy was valid w.e.f. 05.04.2021 to 18.07.2021 and sum assured was Rs.2,50,000/-. That in the same manner, the complainant had also purchased another policy namely “Corona Kavach Policy” from ops vide policy certificate No. P/700001/01/2022/002319 dated 14.04.2021 and said policy was valid w.e.f. 14.04.2021 to 27.07.2021 and sum assured was Rs.1,00,000/-. It is further averred that as per terms of the policy, in case after 15 days of the issuance of the policy i.e. waiting period, the complainant is found to be infected with COVID-19 and that he remains under treatment/ hospitalized at least for a period of 72 hours, in that eventuality he shall be entitled to a sum of Rs.2,50,000/- from the insurance company i.e. the sum assured under the said policy. That unfortunately complainant was infected with the pandemic COVID-19 disease vide report of Civil Hospital, Sirsa dated 23.05.2021 and immediately he supplied information in this regard to ops. Thereafter he got himself admitted in Civil Hospital, Sirsa on 02.06.2021 and remained admitted there up to 06.06.2021 i.e. more than 72 hours. It is further averred that after being discharged from said hospital, he lodged his claim with the ops under the aforesaid policies and he was asked to submit additional relevant documents/ information which was immediately supplied by him. The claim under policy namely Corona Kavach was indemnified by the ops by paying a sum of Rs.9298/- to the complainant but to the surprise of complainant, the claim lodged by him under the policy namely Corona Rakshak Policy was repudiated by ops vide repudiation letter dated 09.11.2021 without assigning any cogent and reliable reason on the basis of false and lame excuses in order to escape from its legal liability and due to act and conduct of ops, the complainant has suffered unnecessary harassment and mental tension. That complainant contacted the ops a number of times and requested to admit his genuine claim but ops raised their hands in providing any assistance in this regard to him. The complainant also got issued a legal notice to the ops but to no effect. Hence, this complaint.
3. On notice, ops appeared and filed written statement raising certain preliminary objections. It is submitted that complainant availed Corona Rakshak Insurance Policy w.e.f. 05.04.2021 to 18.07.2021 covering the risk of Rs.2.50 lacs. That insured Surjeet Kumar was admitted in Civil Hospital, Sirsa from 02.06.2021 to 06.06.2021 for the alleged treatment of Covid-19. The insured submitted claim documents for availing lump sum benefit and on perusal of claim documents, it is observed that insured has been hospitalized at Talwar Hospital on 02.06.2021 for treatment of COVID-19 and submitted pre authorization request and it was noted that as per indoor case papers the insured SPO2 level is 98% and 97% which is within normal limit, on 23.05.2021 the insured RTPCR shows positive, as per the CT report dated 02.06.2021, the insured CT score is 5/25 (mild infection). Hence, the pre authorization request was initially rejected. Subsequently, the insured submitted claim documents for reimbursement of Rs.9298/- towards investigation and medicine. The insured was admitted only for one day in Talwar Hospital, which may be evident from the vital chart of the hospital. Considering the same as domiciliary hospitalization, the ops have settled the full amount vide claim number CIR/2022/700001/2691716 in Corona Kavach Policy. It is further submitted that in the present alleged hospitalization, the insured submitted patient healthy card of Civil Hospital, Sirsa, in which there was only findings of 06.06.2021. Thus, the ops called for ICP and vital charts and ICP shows that the insured SPO2 level is above 96% which is normal and within limit throughout the hospitalization. It is further submitted that as per guidelines from All India Institute of Medical Sciences, New Delhi and 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 but instead the patient is admitted and treated, which is not warranted. As per operative clause of the policy, if during the policy period the insured person is diagnosed with COVID and hospitalized for more than seventy-two hours following medical Advice of a duly qualified Medical Practitioners 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. Hence, the guidelines from All India Institute of Medical Sciences, New Delhi and Ministry of Health and Family Welfare, Government of India is justified. Further 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 and in this case hospitalization was not at all required. As such claim was repudiated and same was communicated to the insured through letter dated 26.07.2021. The complainant has travelled beyond the terms and conditions of the policy and repudiation of the claim is justified. 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.C18.
5. On the other hand, ops have tendered affidavit of Sh. P.C. Tripathi, Zonal 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. The complainant is seeking sum assured amount of Rs.2,50,000/- from ops under “Corona Rakshak Policy” as he remained admitted in the Civil Hospital, Sirsa from 02.06.2021 to 06.06.2021 i.e. more than 72 hours. From the certificate of insurance Ex.C1, it is evident that complainant purchased Corona Rakshan Policy from ops for the period 05.04.2021 to 18.07.2021 for sum assured amount of Rs.2,50,000/- and as per COVID cover 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. In this regard complainant has also placed on file RT PCR Lab Civil Hospital, Sirsa COVID-19 SPL report dated 23.05.201 as Ex.C5 vide which complainant was found to be Positive from disease of COVID-19 and said report is from Government diagnostic centre. Further more, from bed head ticket of Civil Hospital, Sirsa placed on file by ops as Ex.R5, it is evident that on 02.06.2021 complainant was complaining difficulty in breathing and as such he was admitted in Civil Hospital on 02.06.2021 and he remained admitted there up to 06.06.2021 and thereafter he was advised Home Isolation for 10 days as is evident from record produced on record by the parties. So complainant was admitted in Civil Hospital, Sirsa for above said disease of COVID-19 as per medical Advice of a duly qualified Medical Practitioner. So, it is proved on record that complainant remained admitted in Civil Hospital, Sirsa from 02.06.2021 to 06.06.2021 i.e. for more than 72 hours as he was found COVID-19 positive. During his hospitalization, his SPO2 level also decreased to 92% and even came to 86%. Even as per guidelines of AIIMS New Delhi produced on record by ops as Ex.R10 even in mild disease cases, admission is required when there is difficulty in breathing and when it is advised by treating medical officer. In the present case, also the complainant was feeling difficulty in breathing and his admission was advised by treating medical officer. So, it cannot be said that his admission in the hospital was not required at all and only home isolation was required. The complainant was admitted in the Hospital due to his severe medical condition and not as per his choice. Therefore, as per terms and conditions of the policy, the complainant was entitled to the sum insured amount of Rs.2,50,000/- from the ops but however, ops wrongly and illegally repudiated the claim of the complainant vide their letter dated 26.07.2021 and the repudiation of the claim of the complainant is totally unfair act of the ops.
8. In view of our above discussion, we allow the present complaint and direct the opposite parties to pay claim amount of Rs.2,50,000/- to the complainant within a period of 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/- 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 Member President,
Dated: 06.09.2024. District Consumer Disputes
Redressal Commission, Sirsa.
