DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

PATIALA.

                                      Consumer Complaint No. 507 of 1.11.2021

                                      Decided on:         16.9.2024

Sukhbir Singh aged about 52 years son of Sh.Jora Singh, resident of village Balbera, Tehsil & District Patiala Aadhar card No.856894847333.

                                                                   …………...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

                                      G.S.NAGI, MEMBER

1. The instant complaint is filed by Sukhbir 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  borrowed CORONA RAKSHAK insurance policy bearing No. P/211115/01/2021/006624 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. It is averred that in cases where insured is found COVID-19/CORONA POSITIVE (from authorized Govt. diagnostic centre) and had remained under IN Patient Care of Hospital, then the insured has to file claim within 30 days of discharge from the hospital.
3.  It averred that on 7.6.2021 complainant gave sample for conducting RT PCR test from Govt. Medical College, Patiala and as per test report dated 8.6.2021 complainant was detected Corona/Covid-19 Positive and admitted himself in Amar Hospital, Patiala on 8.6.2021 and remained under Corona treatment till 11.6.2021. 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/2022/211115/2780647.The complainant also submitted all the requisite documents with the OP. It is averred that the complainant received a letter dated 9.9.2021 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/- 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.
4. 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.
5. It is pleaded that the complainant had availed Corona Rakshak Policy vide policy no. P/211115/01/2021/006624 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 further pleaded that the complainant was admitted at Amar Hospital for the period from 8.6.2021 to 11.6.2021 for the treatment of Covid-19 positive. Thereafter complainant submitted claim reimbursement document. That after going through the documents, it was opined that complainant was covid-19 positive, the vital signs of which were stable throughout the period of complainant’s hospitalization and the investigation report were within normal limits. As such the medical team of the company opined that the complainant could have been managed the said disease under home quarantine. Further 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 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 9.9.2021 to the insured.
6. On merits it is admitted by the OP that the complainant was the holder of insurance policy in question. All other contents taken in the preliminary objection have been reiterated which are not repeated for the sake of brevity. The OP has alleged there is no deficiency in service on its part and 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 C6 and closed evidence.
8. 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 OP8 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. 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.
11. The complainant fell ill and reported to Govt. Medical College, Patiala on 7.6.2021 where RT PCR test of the complainant was conducted and the complainant was diagnosed as Covid positive as per the report dated 7.6.2021,Ex.C2. The complainant was admitted in Amar Hospital, Patiala on 8.6.2021 and was discharged on 11.6.2021 i.e. after three days of the admission, as per discharge summary,Ex.C3.The complainant was advised to quarantine for 10 days from the date of covid positive test.
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/2022/211115/2780647.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 9.9.2021 which is Ex.C4 on the grounds that  the vital signs of the complainant were stable before the period of hospitalization and the complainant could have managed under home quarantine. The legal notice, Ex.C5 was subsequently served upon the OP by the complainant. However, no response was received by the complainant against the said legal notice.
13. The OP has relied upon, the guidelines Ex.OP8 issued by the AIIMS for the management of Covid-19 patients and have argued that as the vital signs of the complainant were stable as such he was mildly affected by the Covid-19 and did not need any hospitalization.
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.C2, conveyed by Govt. Rajindra Medical College and Hospital, Patiala and the complainant was then hospitalized from 8.6.2021 to 11.6.2021 i.e. for a period of more than 72 hours and fills all the conditions for the coverage of Covid Cover and benefits admissible thereof under the said policy.
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