DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

PATIALA.

                                      Consumer Complaint No. 510 of 1.11.2021

                                      Decided on:         16.9.2024

Mehak aged about 23 years daughter of Sh.Bir Bhan, resident of village Sidhuwal, District Patiala.

Aadhar No.3392 2061 9789  M.No.964676258 .

                                                                   …………...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 Mehak  (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/211115/01/2021/008157 dated 20.2.2021 for the period 20.2.2021 to 2.9.2021 from the OP for the sum insured of Rs.2,50,000/-.The complainant paid premium of Rs.5445/-. 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 as per the terms and conditions of the policy Covid is covered lump sum benefit of equal to 100% of the sum insured which shall be payable POSITIVE diagnosis from a Govt. authorized diagnostic centre and requiring hospitalization  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 27.3.2021 complainant conducted RT PCR test  from Govt. Medical College, Patiala and as per test report dated 28.3.2021, he was diagnosed Covid Positive case and as such admitted himself in Govt. Rajindra Hospital Patiala on 30.3.2021 and remained admitted  under Corona treatment till 7.4.2021. 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/2022/211115/2959521. The complainant also submitted all the requisite documents with the OP. It is averred that the complainant received a letter dated 18.9.2021 regarding repudiation of the claim by the OP. That thereafter complainant served legal notice dated 29.9.2021 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 having raised preliminary objections that  the complainant proposed to get himself insured under the Corona Rakshak  Policy  which was issued vide policy No.P/211115/01/2021/008157 for the period of 20.2.2021 to 2.9.2021,strictly subject to the terms and conditions of the policy, issued to the complainant. 
5. It is pleaded that the complainant intimated one claim under the aforesaid policy with regard to her admission in the hospital. However, it was observed that the complainant  had not submitted the required documents i.e. discharge summary, investigation reports with X-rays films, scan report etc., main hospital bills, payment receipts with break-up, prescriptions, medical bills, investigations bills, receipts etc. earlier treatments records, if any. It is averred that the complainant failed to submit the documents and as such reminder dated 3.9.2021 was issued but the complainant failed to fulfill the requirements and the claim of the complainant was rejected vide letter dated 18.9.2021.
6. 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 .After denying all other averments OP has prayed for dismissal of the complaint.
7. 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.
8. 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 online proposal form, Ex.OP2 copy of policy schedule, Ex.OP3 copy of terms and conditions of policy, Ex.OP4 copy of letter dated 19.8.2021, Ex.OP5 copy of letter dated 3.9.2021,Ex.OP6 copy of repudiation letter and closed the evidence.
9. 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.
10. 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 20.2.2021 to 2.9.2021 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 for admission in hospital for a minimum continuous period of 72 hours provided that positive diagnosis of covid shall be 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.
11. The complainant got conducted RT PCR test  from SRL Diagnostic centre, Patiala and as per test report dated 28.3.2021,Ex.C3, complainant was diagnosed Covid Positive. The complainant was admitted in Govt. Rajindra Hospital Patiala on 30.3.2021 as covid positive case and was discharged on 7.4.2021, as per discharge summary,Ex.C4 i.e. after seven days of the admission .   
12. 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/2022/211115/2959521, as per Ex.C5. The complainant has alleged that all the documents were submitted by her at the time of submission of the claim. However, the claim was repudiated vide letter dated 18.9.2021, Ex.C6/OP6 on the ground of non submission of documents. 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. Even the documents demanded by the OP at the time of repudiation of the claim namely discharge summary,Ex.C4, investigation reports, Ex.C3 have been produced by the complainant.
13. 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”.

14. The complainant was diagnosed as covid positive as per the test report Ex.C3, and the complainant was then hospitalized from 30.3.2021 to 7.4.2021, as per discharge summary, Ex.C4 i.e. for a period of more than 72 hours and fulfills all the conditions for the coverage of Covid Cover and benefits admissible thereof under the said policy.
15. 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.            
16.           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.
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                                              G.S.Nagi                           PUSHVINDER SINGH

                                              Member                          President