PRESIDENT DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

                             CONSUMER COMPLAINT NO. 59/2021

Present-Dr. Ramakanta Satapathy, President,

  Sri. Sadananda Tripathy, Member,

Mr. Dinesh Kumar Yadav,  

S/O- Kuldeep Singh Yadav

R/O- Flat No.-A-010, Ashiyana Apartment, Kachery Road,

PS/Dist- Jharsuguda-768201.                                           ...………..Complainant

Versus

The Branch Manager, Star Health and Allied insurance Co. Ltd.

Office at-2dn floor Quality mansion, Nayapara, Sambalpur,

Dist-Sambalpur-768001, Odisha.                                      …………...Opp.Party

Counsels:-

1. For the Complainant            :-      Sri. B.K.Shroff & Associates
2. For the O.P.                          :-      Sri. B.K. Purohit, Advocate

Date of Filing:29.01.2021,Date of Hearing :24.07.2023,Date of Judgement : 11.09.2023

  Presented by Dr. Ramakanta Satapathy, PRESIDENT

1. The case of the Complainant is that the Complainant insured his family under family Health Opima Plan vide policy No. P/191214/01/2021/001867 for the period 17.08.2020 to 16.08.2021. Rs. 35,896/- renewal policy premium was paid. On 05.04.2021 the Complainant consulted Dr. P.C. Adwani, Raipur for check up as he was sick due to cough, cold ,body ache during covid-19 pandemic. On 10.04.2021 after several medical test Dr. Adwani detected Covid-19 infection Complainant spent Rs. 53,570/- pre-hospitalisation expenses. After admission in hospital Rs. 3,27,515.14P payment made. Rs. 13,757.23P post-hospitalisation expenses made.

The Complainant on 22.07.2021. Claimed Rs. 3,94,842.44P. On 01.09.2021the insurer repudiated the claim. The Complainant alleged unfair trade practice and deficiency in service of the O.P.

2. The O.P. in its version admitted the policy covering Complainant, his wife bhagesh Yadav, dependant child Kritika Yadav and Keshavdeep Yadav. The policy was renewed from 17.08.2020 to 16.08.2021 vide renewal policy No. P/191214/01/2021/001867 and from 17.08.2021 to 16.08.2022 vide policy No. P/191214/01/2021/001867. In the second year the Complainant was hospitalised on 12.04.2021. The O.P. admitted the receipt of claim form but reminded to submit documents on 09.05.2021 and 24.05.2021 letter dated 08.06.2021 was sent that claim was rejected. On 22.07.2021 the Complainant sent documents received by the O.P. After examination the O.P. repudiated the claim on the ground “this patient needs only home isolation and care. Instead the patient is hospitalised. This is hence not payable as per the medically necessary clause of the Policy”.

The details of treatment history are as follows:-

10.04.2021            :V.Y. Hospital recorded Complainants of fever, cold with cough and history of Diabetes mellitus and advised RTPCR test for Covid-19.

11.04.2021.           :- Dr. Omkar Miry, Goutam Multipurpose Hospital, Raipur recorded Complainants of breathlessness, fever, tastless K/C/O/ DM/HTN and regular medication.

12.04.2021            :- Admitted in Shri Balaji Institute of medical sciences, Raipur and discharged on 28.04.2021. Atipical Viral Pneumonia with Covid-19 +ve, HNN and DM-II noted.

                                    The patient was having fever and cough for 4-5 days. First dose. Covid vaccination made on 18.03.2021 and taking other symptoms like multifocal ground glass opacity and lung lobe percentage it was suggested classic Covid-19 infection(Viral extent of disease moderate). The Complainant on 12.04.2021. On the first day of hospitalisation SPO₂ was 97% temperature 99.4 and CT score 6/25 and  on 25.04.2021 CT severity score was 15/25. On 21.04.2021 when antigen negative found the complainant was discharged.

                                    Ganga Diagnostic & Medical Research Centre(P) Ltd. On 07.05.2021 conducted HRCT SCAN OF CHEST after discharge hospitalisation. The Complainant diagnosed Atypical Viral Pneumonia, high possibility of moderate Covid-19 Pneumonia(CORAD6-Resolving stage) CT severity index 13/25. The O.P. submitted that the HRCT SCAN OF CHEST conducted by Ganga Diagnostic Medical Research Centre are fake and /Or the hospitalisation in Shri Balaji Hospital and Pathological Investigation report are questionable. The Complainant suppressed pre-existing disease. Type-2 diabetes Mallitus. The Clinical picture and vital Charts indicate that the patient falls under category A AIIMS protocol. The patient could have been managed under home isolation.

          The O.P. cited oriental Insurance Co. Ltd. Vs Mahendra Construction Civil Appeal Case No. 3359/2019, Satwant Civil Appeal No. 2776/2002, L.I.C. of India V. Smt. Asha Goel & another. Civil Appeal 4186-87/1988 & LIC V Smt. G.M. Channa-basemma, AIR 1997 SC 392 cases for non-disclosure of facts and repudiation of policy found proper.

The O.P. submitted the AIIMS/ICMR COVID-19 National Task force clinical guidance for management of adult-19 patients dated 17.05.2021. As the Complainant violated the terms and conditions of the policy the repudiations is proper.

3. Perused the documents filed by both the parties. The renewal policy No. P/191214/01/2021/001867 was valid from 17.08.2020 to 16.08.2021. The policy is continuing since 2017. The O.P. after proper verification issued the policy from year to year and in this respect also received premium from the Complainant. At the time of renewal of the policy the O.P. has never raised any objection on the point of Diabets Meddlitus and after detection in the medical report has taken the plea that the Complainant has not disclosed the information at the time of taking policy or renewal. The O.P. as had taken premium from 2017 after words every year on the point of pre-existing disease, repudiation of the claim is not proper. The pre-existing disease is no way related with the Covid-19 +ve treatment of the Complainant. Accordingly, the repudiation of the claim made by the O.P. is not proper.

Secondly, after examination of all documents the O.P. came to the conclusion that the clinical picture of the patient and vital chats indicate that the patient falls under category A AIIMs protocol and the patient only needed home isolation. Hence the O.P. is not liable to indemnify the insured Complainant. Only in tablet form medicines were given to the Complainant and not in injection form. Further contention of the O.P. is that HRCT report dated 10.04.2021 of Y.V. Hospital on viral extent of disease was moderate. As per MDCT SCAN THORAX and CORADA of Balaji Hospital dated 12.04.2021 the finding suggestive of COVID infection was CORADs-5 and CT Severity Score 15/25. Balaji Hospital from their report indicated that Clinical and vital of the patient was stable. On the first day of hospitalisation dated 12.04.2021 SPO₂ was 97% with temperature 99.4 and city score 6/25 and on 25.04.2021 the CT Severity was 15/25. On 21.04.2021 Antigen was negative, After discharge from hospital on 07.05.2021 the treatment shows suggestive of Covid-19 pneumonia and Ct Severity index in 13/25. After 12 days treatment also condition of the patient deteriorated. The report of Ganga Diagnostic & Medical research Centre creates doubt. Heard the contention of the O.P.

It is a general tendency of human being that when the patient suffers consult the doctors and act as per advice of the doctors. When the entire world was under psychological impact treatment of the Complainant can not be ignored and the Complainant acted as per advise of the doctor, spent huge money in the treatment. The O.P. has not submitted any medical expert opinion to disregard the treatment details of the Complainant made by experts. In the name of AIIMS Covid-19 guidelines the O.P. can not escape from liability. The Complainant incurred expenditure of Rs. 53,570 during pre-hospitalisation stage, spent Rs. 3,27,515.14P during the hospitalisation stage and Rs. 13,757.23P during post hospitalisation stage Rs. 13,757.23P totalling Rs. 3,94,842.44P. The insurance coverage is up to Rs. 25.00 lakhs. The policy covers the all the three stages for covid-19 treatment of the Complainant. Accordingly, the repudiation made by the O.P. is not proper.

Taking into consideration the circumstances of the case, it is ordered:

ORDER

The Complainant is allowed against the O.P. The O.P. is directed to pay the medical expenses of the Rs. 3,94,842.44P to the Complainant within 30 days of this order. In case of non-payment the amount will carry 6% interest P.A. w.e.f. 05.08.2021 till realisation and litigation expenses of Rs. 10,000/-.

Order pronounced in the open Court today on 11^th day of September, 2023.

Free copies of this order to the parties are supplied.