4. The complainant in evidence has tendered his affidavit Ex. CW1/A and documents Ex.C1 to Ex.C20.
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.R15.
6. We have heard learned counsel for the parties and have gone through the case file carefully.
7. There is no dispute of the fact that complainant purchased Corona Rakshak Insurance Policy from the ops for the period 30.08.2020 to 11.06.2021 for the sum insured amount of Rs.2,50,000/- and paid premium amount of Rs.6126/- to the ops and said fact is also provide from certificate of insurance Ex.C1. From the record available on file i.e. Covid-19 test report of Civil Hospital, Sirsa, it is also proved on record that on 31.10.2020 complainant was found to be Corona positive and name of the complainant finds mention at Sr. No.1018 in the list Ex.C9. The complainant has also placed on file certificate of Medical Officer, Covid Control Room (Health) Sirsa dated 16.12.2020 Ex.C8 to prove the fact that he was found positive for Covid-19 through test of RT PCR. Firstly the complainant was referred to JCD Covid Centre by the Civil Hospital, Sirsa on 01.11.2020 where he remained admitted from 01.11.2020 to 04.11.2020 and then he was shifted to Shah Satnam Ji Specialty Hospital, Sirsa where he remained admitted from 04.11.2020 to 06.11.2020. So, it is proved on record that complainant remained admitted for more than 72 hours even more than 100 hours as he was found COVID-19 positive and 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 06.02.2021 on the ground that as the vital signs of the complainant insured were stable and normal, therefore, hospitalization was not required and only home isolation was required. The repudiation of the claim of the complainant is totally unfair act of the ops because the doctors of Civil Hospital, Sirsa referred the complainant to JCD Covide Center and from there he was shifted to Shah Satnam Ji Specialty Hospital, Sirsa and doctors of two hospitals got admitted the complainant for treatment of Covid-19.
8. During the course of arguments, learned counsel for ops has also drawn our attention towards prescription slip Ex.R8 in which it is mentioned that patient is stable and also drawn our attention towards vitals chart Ex.R13 to show that respiratory level of the complainant during hospitalization all time remained from 97 to 99 and as such learned counsel for complainant contended that as per guidelines of AIIMS, New Delhi dated 08.09.2020 Ex.R15 it was mild disease of Covid-19 to the complainant and complainant needed only home isolation. But however, we do not agree with the contentions of learned counsel for ops because in the admission note dated 04.11.2020 Ex.R12 as well as in emergency slip of Shah Satnam Ji Specialty Hospital, Sirsa Ex.R6, it is mentioned by the doctors of two hospitals that there was difficulty in breathing to the complainant and as his condition was severe at the time when he suffered from Covid-19 disease and besides the said disease he was also having chest pain, palpitation, nausea, breathlessness and was in need of hospitalization and oxygen etc. he was referred to the hospital for admission by the Medical Officer, Civil Hospital Sirsa which fact is evident from referral slip Ex.R9. Moreover, it cannot be said that complainant was admitted in the hospitals as per his choice and joy rather he was shifted to the hospitals due to his severe and horrible condition.
9. Further more, the ops have only talked about the things which are in their favourable only in the guidelines of AIIMS New Delhi whereas it is also clearly mentioned in the same that home isolation is needed when there is no shortness in breath whereas in the present case it is proved on record that complainant was having difficulty in breathing. In these circumstances, it is proved on record from all points of view that ops have wrongly and illegally repudiated the genuine claim of the complainant and as such repudiation of the claim of complainant is hereby set aside. Therefore, complainant is entitled to the sum insured amount of Rs.2,50,000/- from the ops as per clause 4.1 of Covid Cover of the policy which provides that 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 of COVID shall be from a government authorized diagnostic centre.
10. 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: 09.06.2023. District Consumer Disputes
Redressal Commission, Sirsa.
JK
