Haryana

Bhiwani

CC/30/2022

Hardeep - Complainant(s)

Versus

Star Health Ins. - Opp.Party(s)

P.K Yadav

02 Apr 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BHIWANI.

 

                                                             Consumer Complaint No. :  30 of 2022

                                                        Date of Institution           : 10.02.2022

                                                                  Date of order                  : 02.04.2024

 

Hardeep son of Sh. Jamna Das  R/o Ward No.6 Siwani, Tehsil Siwani District Bhiwani.

  

           ……Complainant.

 

Versus

 

1. Star Health and Allied Insurance Co. Ltd., New Tank Strict Valluvar Kottam High Road, Nungambakkam, Chennai-600034 through its Managing Director/Authorized signatory.

 

2. Star Health and Allied Insurance Co. Ltd., Branch Office: SCF No.47, Panchayat Bhawan Pocket, Bhiwani through its Branch Manager/Authorized signatory.

 

…… Opposite Parties.

 

COMPLAINT U/S 35 OF CONSUMER PROECTION ACT, 2019.

 

BEFORE:       Mrs. Saroj Bala Bohra, Presiding Member.

  Ms. Shashi Kiran Panwar, Member.

 

Present:-       Sh. P.K. Yadav, Advocate for complainant.

                    Sh. Avinash Sardana, Advocate for OPs.

 

ORDER:

 

Saroj Bala Bohra, Presiding Member:

 

1.                 In brief, facts of this case are that complainant taken Corona Rakshak Policy from OPs for a period of 01.09.2020 to 13.06.2021 by paying premium of Rs.6126/- for a sum assured of Rs.2,50,000/-.  It is submitted that complainant was serving as Lab Technician in Sub Divisional Hospital, Tosham and thus was front line corona worker and warrior being a member of checking team of corona positive patient. It has averred that on 09.05.2021, complainant found corona positive and remained admitted there from 09.05.2021 to 13.05.2021 in Sub Divisional Hospital, Tosham.  Thereafter, complainant submitted his treatment bills to the OPs for reimbursement of Rs.2,50,000/- but the OPs repudiated the claim of complainant without any reason. However, complainant approached the OPs but in November 2021, they flatly refused to pay the amount. Hence, the present complaint has been preferred by complainant alleging deficiency in service on the part of OPs resulting into monetary loss besides mental and physical harassment.  In the end, prayer has been made to direct the OPs to pay Rs.2.50 lac alongwith interest @ 18% per annum from 09.05.2021 till realization of the amount. Further to pay Rs.1.00 lac as compensation for harassment besides Rs.25,000/- as litigation expenses.

2.                 Upon notice, OPs appeared through counsel and tendered reply raising preliminary objections qua maintainability of complaint, deficiency in service, locus standi & cause of action and suppression of material facts. On merits, it is admitted that Corona Rakshak Policy was issued to the complainant for the period from 01.09.2020 to 13.06.2021 subject to certain terms and conditions. It has been averred that from the medical record, oxygen saturation was maintained, the insured patient is afebrile and vital signs were stable throughout the period of hospitalization. The medical team of Op opined that the insured patient could have been managed under home quarantine and a false story has been put forth by complainant. As per the indoor Case paper of the treatment, it is noted that no supportive investigations warranting hospitalization, all the vitals were normal. The SPO2 level and other vitals of the insured were, as follows:-

09.05.2021   SPO2- 98%   Temp-98.4         PR-20

10.05.2021   SPO2- 99%   Temp-98            PR-22

11.05.2021   SPO2- 99%   Temp-98.4         RR-22

12.05.2021   SPO2- 98%   Temp-98.4         RR-20

13.05.2021   SPO2- 98%   Temp-98.5         RR-22

As per guidelines of AIIMS, New Delhi, Ministry of Health and Family Welfare, Govt. of India regarding treatment of Covid-19 patients, this patient needs only self-isolation by home quarantine based on submitted claim documents. Further, medical team of OP opined that the insured patient could have been managed under home quarantine. Thus the complainant was not entitled to get reimbursed any amount from the OP and claim was rightly repudiated under intimation to the complainant. In the end, denied for any deficiency in service and prayed for dismissal of the complaint with costs.

3.                 In evidence of complainant, his affidavit Ex.CW1/A alongwith documents Annexure C-1 to Annexure C-8 were tendered and then closed the evidence.

4.                 In evidence of OPs, affidavit of Mr. Sumit Kumar Sharma, Chief Manager of OP company as Ex. RW1/A alongwith documents Ex. R-1 to Ex. R-8 were filed and closed the evidence.

5.                 We have heard learned counsels for the parties and perused the record carefully.

6.                 It is not in dispute that the policy was issued to complainant by OP insurance company for corona protection for the period from 01.09.2020 to 13.06.2021 and sum assured in the policy is Rs.2,50,000/- (Annexure C-1).  As per discharge slip (Annexure C-3) complainant was admitted in the hospital on 09.05.2021 and was discharged on 13.05.2021 after getting treatment of Covid-19.  Learned counsel for complainant has argued that complainant was entitled to the sum insured under the terms and conditions of the policy (Annexure R-3) which says:

4.1 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 center.

Note:

1. Payment will be made only on hospitalization for a minimum continuous period of 72 hours following  positive diagnosis for Covid.
2. This is onetime benefit applicable for the entire tenure of the policy and shall terminate upon payment of this benefit.        

5. Waiting period: The company shall not be liable for any claim arising for Covid within 15 days from the first policy commencement date.

7.                 In support of his case, learned counsel for complainant has relied upon case laws delivered by Hon’ble Consumer Disputes Redressal Commission Gujarat State, Ahmedabad in case titled Future Generali Insurance Co. Ltd. Vs. Ashishbhai Satishchandra Dave, and Future Generali Insurance Co. Ltd. Vs. Prajapati Nilesh Rameshbhai FA No.139 & 140 of 2022 decided on 03.03.2022. We have gone through the above referred case laws.

8.                 On the other side, learned counsel for Ops has argued that as per medical treatment record of complainant, he was having normal oxygen level, temperature and pulse rate etc. thus as per Covid-19 guidelines, he was not entitled to get any claim from OP insurance company and thus the claim was rightly rejected by the OPs.

9.                 After hearing learned counsel for the parties and going through the evidences and case laws relied upon, we have observed that the treatment was taken by complainant after lapse of waiting period of 15 days. Further, the treatment taken was for Covid-19 from Govt. hospital and remained hospitalized for more than 72 hours.  Thus, the terms and conditions of insurance policy mentioned above has not been violated by complainant, in any manner. Thus, in our considered opinion, as per terms and conditions of insurance policy, the complainant is entitled to get the sum assured to the tune of Rs.2,50,000/-. It is further observed that OPs have remained negligent and deficient in providing proper services to the complainant which caused him monetary loss as well mental and physical harassment to him. As such, the complaint is allowed and OPs, jointly and severally, are directed to comply with the following directions with 40 days from the date of passing of this order:-

(i)       To pay a sum of Rs.2,50,000/- (Rs. Two lac fifty thousand) to the complainant.

(ii)      To pay a sum of Rs.10,000/- (Rs. Ten thousand) on account of harassment.

(iii)     Further to pay Rs.5500/- (Rs.Five thousand five hundred) towards litigation expenses.

                    In case of non-compliance, the OPs shall liable to pay simple interest @ 9% per annum on all the aforesaid awarded amounts for the period of default.  If this order is not complied with, then the complainant shall be entitled to the execution petition under section 71 of Consumer Protection Act, 2019 and in that eventuality, the opposite party may also be liable for prosecution under Section 72 of the said Act which envisages punishment of imprisonment, which may extend to three years or fine upto rupees one lac or with both.  Copies of this order be sent to the parties concerned, free of costs, as per rules.  File be consigned to the record room after due compliance. 

Announced.

Dated:02.04.2024.