DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

PATIALA.

                                      Consumer Complaint No. 511 of 1.11.2021

                                      Decided on: 16.9.2024

Rakesh Kumar aged about 30 years son of Sh.Prem Kumar, resident of H.No.106, Adarsh Nagar-B, Ablowal, Patiala

Aadhar card No.7643 8266 3873.

                                                                   …………...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.Munish Mittal, counsel for OP.            

 ORDER

                                      PUSHVINDER SINGH, PRESIDENT

1. The instant complaint is filed by Rakesh Kumar (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  borrowed CORONA RAKSHAK insurance policy bearing No. P/211115/01/2021/006615 on 2.1.2021 for the period 2.12021 to 15.7.2021 and paid premium of Rs.5445/- for the sum insured of Rs.2,50,000/-.It is averred that policy only covered COVID-19/CORONA VIRUS and there is a waiting period of 15 days as the company shall not be liable for any claim arising under the policy within 15 days from the first policy commencement date.
3. It is averred that as per the terms and conditions of the policy Covid is covered lumpsum benefit of equal to 100% of the sum insured  which 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  Govt. authorized diagnostic centre and the patient/insured remained under IN Patient Care of Hospital, then the insured has to file claim within 30 days of discharge from the hospital.
4.  It averred that on 17.2.2021 complainant gave sample for conducting RT PCR test from Govt. Medical College, Patiala and as per test report dated 18.2.2021 complainant was detected Corona/Covid-19 Positive and got admitted himself in Govt. Rajindra Hospital, Patiala on 19.2.2021 and remained 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/2022/211115/0604225.The complainant also submitted all the requisite documents with the OP. It is averred that the complainant received a letter dated 25.4.2021 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/- the complainant being infected Covid-1 during the period of  insurance policy and also to pay Rs.25000/-as compensation for causing mental agony and harassment and costs of litigation expenses.
5. Upon notice, OP appeared through counsel and filed written statement having raised preliminary objections that the present complaint is not maintainable;  that the case of the complainant is not covered under the policy of the company and as such his case was rejected; that this Hon’ble Commission does not have the jurisdiction to decide the present complaint.
6. It is pleaded that the complainant had availed Corona Rakshak Policy vide policy no.P/211115/01/2021/006615 covering self  for the basic sum insured of Rs.2,50,000/- for the period from 2.1.2021 to 15.7.2021. It is pleaded that the complainant has not submitted the claim form alongwith complete medical record towards reimbursement of medical expenses inspite of repeated reminders dated 26.3.2021 and 10.4.2021, sent  by the OP and the claim of the complainant was rejected vide letter dated 25.4.2021.
7. On merits , it is averred that the complainant has failed to submit any documents with regard to her treatment and her claim was rejected vide letter dated 25.4.2021. There is no deficiency in service on the part of the OP. After denying all other averments, OP has prayed for the dismissal of complaint.
8. In evidence, ld. counsel for the complainant has tendered in evidence Ex.CA affidavit of the complainant alongwith documents Exs.C1 to C7 and closed evidence.
9. On the other hand, ld. counsel for the OP has tendered in evidence Ex.OP1/A affidavit of Sh.Sumit Kumar Sharma, Sr.Manager,Star Health alongwith documents Ex.OP1 to OP6 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. Admittedly, the complainant had purchased Corona Rakshak insurance  Policy, as per Ex.C1 for a consideration of Rs.5445/-. The policy was valid from 2.1.2021 to 15.7.2021 i.e. for 195 days for the sum insured of Rs.2,50,000/-. As per the terms and conditions of the policy, produced by the OP, as per Ex.OP3, 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.
12. The complainant got his RT PCR tests conducted on 17.2.2021 from Dr.Lal Path Labs . As per lab report dated 18.2.2021, Ex.C3, the complainant was diagnosed as covid positive. Accordingly the complainant  reported to Govt. Medical College and Rajindra Hospital, Patiala on 19.2.2021 for treatmentof covid and was discharged on 23.2.2021 i.e. after four days of the admission, as per discharge summary,Ex.C4. The complainant was advised to home quarantine for seven days.
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/2022/211115/0604225 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 25.4.2021, copy of which is Ex.C5 on the grounds that  the complainant has not submitted the documents as demanded by the OP. The legal notice, Ex.C6 was subsequently served by the complainant. However, no response was received by the complainant against the said legal notice.
14. 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”.

15. The complainant was diagnosed as covid positive as per the test report Ex.C3, conveyed by Dr.Lal Path Lab and the complainant was then hospitalized from 19.2.2021 to 23.2.2021 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. Even the documents as demanded by the OP at the time of repudiation, namely discharge summary (Ex.C4), investigation reports (Exs.C2 and C3) have been produced by the complainant.
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