DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

PATIALA.

                                      Consumer Complaint No. 509 of 1.11.2021

                                      Decided on:         16.9.2024

Kunal Rao aged 34 years s/o KSK Rao, resident of H.No.335, street No.11, Sanouri Adda, Markal Colony, Patiala. Aadhar No.9385 81423785 M.No.98888114338.

                                                                   …………...Complainant

                                      Versus

The Branch Manager, Star Health and Allied Insurance Company Limited, SCO No.17, First Floor, Kandhari Complex, Stadium Road, Patiala.

                                                                   …………Opposite Party

Complaint under the Consumer Protection Act

QUORUM

                                      Sh.Pushvinder Singh, President

                                      Sh.G.S.Nagi, Member   

ARGUED BY

                                      Sh.P.S.Sidhu, counsel for complainant.

                                      Sh.Amit Gupta, counsel for OP.                                            

 ORDER

                                      PUSHVINDER SINGH, PRESIDENT

1. The instant complaint is filed by Kunal Rao (hereinafter referred to as the complainant) against The Branch Manager, Star Health and Allied Insurance Company Limited, (hereinafter referred to as the OP/s) under the Consumer Protection Act (for short the Act).
2. It is averred in the complaint that the complainant purchased CORONA RAKSHAK insurance policy bearing No. P/211115/01/2021/008101 on 19.2.2021 for the period 19.2.2021 to 1.9.2021 from the OP for the sum insured of Rs.2,50,000/-.The complainant paid premium of Rs.5445/-.The policy was effective from 4.3.2021 after expiration of the waiting period for securing himself from CORONA virus. It is averred that policy covered only COVID-19 positive diagnosis and the OP shall not be liable for any claim if the insured detected Covid-19/ Corona positive within 15 days from the date of policy. It is averred that in cases where insured found COVID-19/CORONA POSITIVE (from authorized Govt. diagnostic centre) and had hospitalized for a minimum period of 72 hours then the insured has to file claim within 30 days of discharge from the hospital.
3.  It averred that on 16.4.2021 complainant conducted RT PCR test from Govt. Medical College, Patiala and as per test report dated 17.4.2021, he was diagnosed Covid Positive and admitted himself in Govt. Rajindra Hospital Patiala on 17.4.2021 vide CR No.5602 dated 17.4.2021 remained admitted  under Corona treatment till 20.4.2021. That after discharge from the hospital, complainant intimated the OP for getting claim under the policy in question which was registered under claim bearing No.CIR/2022/211115/2776904.The complainant also submitted all the requisite documents with the OP. It is averred that the complainant received a letter dated 17.9.2021 regarding repudiation of the claim by the OP. That thereafter complainant served legal notice dated 21.9.2021 and also sent requisite documents alongwith the  legal notice to the OP but despite of receipt of legal notice and documents OP did not pay any heed to the request of the complainant. That the repudiation of claim by the OP is illegal, arbitrary and against the principles of natural justice. There is also deficiency in service and unfair trade practice on the part of the OP which caused mental agony and harassment to the complainant. Hence this complaint with the prayer to accept the same by giving directions to the OP to pay 100% amount of sum insured i.e. Rs.2,50,000/- and also to pay Rs.25000/-as compensation for causing mental agony and harassment and costs of litigation expenses.
4. Upon notice, OP appeared through counsel and filed written statement. It is submitted that the complainant proposed to get himself insured under the Corona Rakshak  Policy  which was issued vide policy No.P/211115/01/2021/008101 for the period of 19.2.2021 to 1.9.2021,strictly subject to the terms and conditions of the policy, issued to the complainant.  
5. It is further submitted that the complainant lodged claim against the aforesaid policy with regard to the treatment/hospitalization w.e.f. 17.4.2021 to 20.4.2021 which was duly processed and it was observed from the submitted medical record that the insured patient i.e. complainant was hospitalized at Govt. Medical College and Rajindra Hospital, Patiala from 17.4.2021 to 20.4.2021 for the treatment of Covid-19. The insured/ complainant submitted documents for reimbursement of medical expenses. That after going through the documents, it was observed that the Sp02 rate  and respiration rate  during the period of hospitalization were as follows:

17.4.2021- SPOD-97%; Respiration rate: 20/min

18.4.2021- SPOD-98%; Respiration rate: 20/min

19.4.2021- SPOD-96%; Respiration rate: 20/min

6. From the above it was confirmed that complainant was suffering from covid-19 mild infection only. It is averred that as per the guidelines from all India Institute of Medical Science, New Delhi and Ministry of Health and Family Welfare Govt. of India regarding the treatment of Covid-19 patient, the patient with SpO2 level greater than 94% on room air and respirator rate lesser than 24/min are having only mild infection and the patient having mild infection is prescribed home isolation only. As such there is no need to the complainant to admit in the hospital and take treatment over there. As such the claim of the complainant was repudiated and communicated vide letter dated 17.9.2021 to the insured.
7. On merits OP reiterated the facts taken in the preliminary objections which are not repeated for the sake of brevity. The OP has alleged that there is no deficiency in service on its part and has prayed for dismissal of the complaint.
8. In evidence, ld. counsel for the complainant has tendered in evidence Ex.CA affidavit of the complainant alongwith documents Exs.C1 to C8 and closed evidence.
9. On the other hand, ld. counsel for the OP has tendered in evidence Ex.OPA affidavit of Sh.Sumit Kumar Sharma, Sr. Manager, Star Health alongwith documents i.e. Ex.OP1 copy of proposal form, Ex.OP2 copy of policy, Ex.OP3 copy of terms and conditions of policy, Ex.OP4 copy of claim form, Ex.OP5 copy of discharge summary of Rajindra Hospital dated 20.4.2021, Ex.OP6 copy of indoor case papers, Ex.OP7 copy of repudiation letter, Ex.OP8 copy of AIIMS guidelines and closed the evidence.
10. Written arguments by the complainant have been filed. We have gone through the same, heard the ld. counsel for the parties and have also gone through the record of the case, carefully.
11. It is the admitted fact that the complainant purchased CORONA RAKSHAK insurance policy, as per Ex.C1, for a consideration of Rs.5445/-. The policy was valid for the period 19.2.2021 to 1.9.2021 i.e. for 195 days for the sum insured of Rs.2,50,000/-. As per the terms and conditions of the policy, Ex.OP3, produced by the OP, the COVID COVER, as per clause 4.1 was available to all insured persons and lump sum benefit equal to 100% of the sum insured was payable on positive diagnosis of covid subject to admission in hospital for a minimum continuous period of 72 hours provided that positive diagnosis of covid was from a Govt. authorized diagnostic centre. This was a onetime benefit applicable to the policy holder during the tenure of the policy and was to terminate on payment of the benefit.
12. The complainant got conducted RT PCR test  from Govt. Medical College, Patiala and as per test report dated 17.4.2021,Ex.C2, he was diagnosed Covid Positive. The complainant was admitted himself in Govt. Rajindra Hospital Patiala on 17.4.2021 vide Ex.C6 as a covid positive. The complainant was  discharged on 20.4.2021 in stable condition, as per discharge summary Ex.C4. i.e. after three days of the admission .The complainant was advised to quarantine for 15 days from the date of covid positive test.   
13. The complainant then applied for claim as per the policy with the OP and the claim was duly registered by the OP under claim No.CIR/2022/211115/2776904. The complainant has alleged that all the documents were submitted by him at the time of submission of the claim. However, the claim was repudiated vide letter dated 17.9.2021, Ex.C5 on the grounds that the vital signs of the complainant indicate that the patient need only home isolation and care instead of hospitalization as he  falls under Category A of Covid protocol circulated by AIIMS , Ex.OP8. The legal notice, Ex.C7 was subsequently served upon the OP by the complainant. However, no response was received by the complainant against the said legal notice.
14. The OP has relied upon, the guidelines Ex.OP8 issued by the AIIMS for the management of Covid-19 patients and have argued that that the patient falls under Category A of AIIMS protocol and needs only home isolation and care instead of hospitalization.
15.  We are of the opinion that the claim of the complainant is to be considered strictly as per the terms and conditions of the insurance policy issued by the OP, copy of which is Ex.OP3. Clause 4.1 of the said insurance policy relating to the Covid Cover states that ;

“Lump sum benefit equal to 100% of the sum insured shall be payable on positive diagnosis of covid, requiring hospitalizationfor a minimum continuous period of 72 hours. The positive diagnosis of covid shall be from a Govt. authorized diagnostic centre”.

16. The complainant was diagnosed as covid positive as per the test report Ex.C2, conveyed by Govt. Rajindra Medical College and Hospital, Patiala and the complainant was then hospitalized from 17.4.2021 to 20.4.2021, as per discharge summary, Ex.C4 i.e. for a period of  3 days/ 72 hours and fulfills all the conditions for the coverage of Covid Cover and benefits admissible thereof under the said policy.
17. As such we are of the opinion that the complainant is entitled  for a claim of Rs.2,50,000/- i.e. sum insured as he fulfills all the terms and conditions of the policy. We therefore allow the complaint and direct the OP to settle the claim of Rs.2,50,000/- alongwith interest @6% per annum from the date of rejection of the claim till realization. The OP is also directed to pay Rs.5000/-as compensation for causing mental agony and harassment to the complainant alongwith Rs.5000/-as costs of litigation. Compliance of the order be made by the OP within 45 days from the date of receipt of certified copy of this order.            
18.           The instant complaint could not be disposed of within stipulated period due to heavy rush of work and for want of Quorum from long time.
85109252238716.  
85109252238717.  

                                              G.S.Nagi                           PUSHVINDER SINGH

                                              Member                          President