DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

PATIALA.

                                      Consumer Complaint No. 513 of 1.11.2021

                                      Decided on: 16.9.2024

Pargat Singh aged about 48 years son of Sh.Ajit Singh , resident of village Hari Nagar @ Kherki, Post office Karhali Sahib, Patiala.

Aadhar No.9662 6212 9398 .

                                                                   …………...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

                                      G.S.NAGI, MEMBER

1. The instant complaint is filed by Pargat Singh (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/211115/01/2021/006815 dated 8.1.2021 for the period 8.1.2021 to 21.7.2021 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 on 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 19.2.2021 complainant conducted RT PCR test  from Govt. Medical College, Patiala and as per test report dated 20.2.2021, he was diagnosed Covid Positive case and as such complainant admitted himself in Govt. Rajindra Hospital Patiala on 20.2.2021 and remained admitted  under Corona treatment till 23.2.2021. 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/2022/211115/2855341. The complainant also submitted all the requisite documents with the OP for getting the claim. It is averred that the complainant received a letter dated 22.7.2021 regarding submission of all the original documents then another letter dated 24.9.2021 regarding repudiation of the claim .That thereafter complainant served legal notice dated 21.9.2021 but after receipt of legal notice OP rejected the claim  which 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/211115/01/2021/006813 for the period of 8.1.2021 to 20.7.2021, 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 within one month of the policy which was registered under claim No.CIR/2022/211115/2855341 with regard to the admission in the Rajindra Hospital, Patiala  w.e.f.20.2.2021 to 23.2.2021 for the treatment of Covid-19. It is averred that it was observed from the indoor case sheet from the above hospital that patient is a known case of CAD and had undergone valve replacement in 2018, which was disclosed at the time of inception of policy and hence claim was rejected on 29.10.2021.
6. On merits , it is admitted by the OP that the policy in question was issued to the complainant. Further the OP has 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 C10 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, 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 IRDA guideline for relevant portion,Ex.OP5 copy of filed visit report,Ex.OP6 copy of claim form, Ex.OP7 copy of discharge summary Ex.OP8 copy of indoor case papers, Ex.OP9 copy of repudiation letters dated 24.9.2021 and 29.10.2021 and closed the evidence.
9. We have 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 8.1.2021 to 21.7.2021 i.e. for 195 days, for the sum insured of Rs.2,50,000/-. As per the terms and conditions of the policy, 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 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 submitted his sample for RTPCR test and was diagnosed as covid positive as per report , Ex.C3 of Govt. Medical College, Patiala. The complainant was admitted in Govt. Rajindra Hospital Patiala on 20.2.2021 vide Ex.C5 as a case of covid positive. The complainant was  discharged on 23.2.2021, as per In-Patient Case History Bed Head Ticket, Ex.C5  i.e. after three days of the admission, for home isolation .  An inquiry was also made by the OP from the hospital, as per Ex.C4 and the findings were confirmed. 
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/2022/211115/2855341. 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 24.9.2021, Ex.C8 on the grounds that  the patient is a known case of CAD and had undergone valve replacement in 2018, the same was not disclosed at the time of policy inception and claim was rejected on the grounds of non disclosure. The legal notice, Ex.C9 was subsequently served upon the OP by the complainant. However, no response was received by the complainant against the said legal notice.
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 hospitalization for 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, conveyed by Govt. Rajindra Medical College and Hospital, Patiala and the complainant was then hospitalized from 20.2.2021 to 23.2.2021, as per In Patient Case History,Ex.C5 and discharge summary, OP7 produced by the OP. 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. We are of the opinion that claim was rejected on flimsy grounds i.e. non disclosure of pre-existing disease which has no bearing with the current ailment i.e. suffering from covid 19  pandemic and the same has been admitted by the OP itself in the repudiation letter stating that even though “current ailment is not related to PED”.
16. 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.            
17. 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