By Sri. A.S. Subhagan,  Member:

          This is a complaint filed under Section 35 of the Consumer Protection Act 2019.

          2. Facts of the case:-   This  Complainant  had obtained  a Corona Rakshak Policy No.P/181318/01/2021/001934 for the period  starting  from  13.07.2020 to 24.04.2021 covering  285 days, from the Opposite Party.  As per the Policy, the sum insured was Rs.1,00,000/- .  The Opposite Party has provided only  the Policy Schedule.  Terms and conditions of the policy were not given by the Opposite party  to the Complainant.  The Opposite Party deliberately suppressed the terms and conditions with  malafide intention for exploitation.  During the policy period, the Complainant was admitted in Max Smart Super Speciality  Hospital,  Sakett,  New Delhi on 24.09.2020 and discharged on 16.10.2020  due to Covid 19 Pneumonia with mild severity.  The Complainant was admitted in the hospital with Throat Pain, body pain,  head ache etc  since 2 days.  As per the policy, the Complainant is entitled  to get lump sum benefits equal to 100% of sum insured  which shall be payable on positive diagnosis of Covid requiring hospitalization for minimum continuous period of 72 hours.  After the completion of treatment,  Complainant submitted the claim form to the Opposite Party.  But the Opposite party did not settled the claim.  So this Complainant issued  Registered Lawyer Notice to the Opposite party on 18.10.2021.  After receiving  the notice, the Opposite Party replied that the vitals of the Complainant were stable throughout admission,  investigations were  within  normal limit and could have been managed under home isolation.  Hence,  the claim was repudiated by the Opposite  Party.  In fact at the time of discharge, the Doctor advised strict Home Isolation for seven days with proper medication and advised to use nasal spray 2 putts thrice daily for  7 days.  Betadine gargles four times a day etc.  And  advised to stay in a separate room and away from other people in home.  The claim repudiation of the Opposite Party is baseless and it amounts to deficiency in service and unfair trade practice.  The Complainant is entitled to get the claim amount of Rs.1,00,000/-  with 12% interest from 06.10.2020 and  Rs.25,000/-   towards compensation and Rs.10,000/-   towards cost of this proceedings from the Opposite Party. 

3. Hence,  this complaint with the following  prayers.

1.  To pay a sum of Rs.1,00,000/-   with 12% interest  from 06.10.2020 till  

  the date of payment.

2.   To pay a sum of Rs.25,000/-  towards compensation.
3.   To pay a sum of Rs.10,000/- towards cost of this proceedings to this  

  Complainant and

4.   Any other relief as deems fit and proper for the disposal of this case.

4. Opposite Party appeared and  filed detailed version before the Commission, 

the contents of which are as follows:-  It is admitted  that the Complainant had taken a Corona Rakshak Policy from the Opposite Party for the period from 13.07.2020 to 24.04.2021 for a sum insured of Rs.1,00,000/-  vide policy No. P/181318/01/2021/ 001934.  At the time of  availing the  policy, the Complainant was supplied with the terms and conditions of the policy.  The terms and conditions of the policy were explained to the Complainant at the time of  proposing policy and the same was served to the Complainant along with the policy schedule.  It is submitted that  as per  Operative clause No.2 of the policy,  if during the policy period the insured person is diagnosed with Covid and hospitalized for more than seventy two hours following medical advice of a duly qualified medical  practitioner as per the norms specified by Ministry of Health and Family Welfare, Government of India,  the company shall pay the agreed sum insured towards the coverage mentioned in the policy schedule.  Moreover,  as per terms and conditions of the policy, 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. This  is onetime benefit applicable for the entire tenure of the policy and shall terminate upon payment of this benefit.   The positive diagnosis of covid shall be from  a government  authorized diagnostic centre.  The policy is designed to mitigate the huge expenses incurred for the prolonged treatment. During the aforesaid policy period,  the Complainant was admitted in Max Health Care  Hospital,  Saket,  New Delhi on 24.09.2020 for  the treatment of Covid 19 and  after the treatment, she was  discharged on 06.10.2020.  After being discharged from  hospital,  the Complainant had submitted claim  form along with discharge summary and Lab reports.  It is submitted that in the discharge summary issued by Max Health Care Hospital,  Saket, New Delhi,  the clinical parameters and  the vitals were mentioned as follows:-

1.  Temperature:  95
2. Pulse rate:  98/Mt (Normal Range: 60-100 beats per minute)
3. Respiration: 20/MIN
4. Blood pressure: 100/68 MM HG

The Opposite Party  submitted  that  as  per  the discharge  summary  and  the  case  sheet,  the Complainant’s vitals were stable & minor symptoms were only noted.    As per the terms and conditions of the policy it was clearly mentioned that “the claim shall be payable on positive diagnosis of covid 19  requiring  hospitalization for a minimum period for 72 hours” as per  the norms specified by Ministry of Health and Family Welfare,  Government of India.  Here Covid positive has been  diagnosed but the patient’s vitals were stable,  Respiration rates,  SPO2,  Pulse rate etc seemed normal,  hospitalization was not warranted and she was under  observation.  SPO2 is oxygen saturation, is a measure of the amount of oxygen-carrying haemoglobin in the blood relative to the amount of haemoglobin  not carrying oxygen.  The body needs certain  level of oxygen in the blood or it would not  function as efficiently.  In fact,  very low levels of SPO2 can  result in very serious respiratory symptoms.  The normal oxygen level which is measured by a pulse oximeter usually range from 95% to 100%.  The  Blood oxygen levels below 90% are considered low (hypoxemia) and hence oxygen support is mandatory in such cases.  But in this case the SPO2 is well within normal range only.  Based on  the available  medical  records, it is clear that the Complainant’s  vitals were stable through out admission.  Investigations were within normal and could have been managed under home isolation and it did not require admission in a hospital.  Hence,  the Opposite Party had repudiated the claim and the same was informed to the Complainant on 26.03.2021.  After repudiation,  the Complainant had issued a notice  through her advocate and the Opposite Party had duly replied  to the same denying all the  allegations made in the notice.  It is  submitted that the Complainant had taken the policy after fully understanding the terms and conditions of the policy and it was clearly explained  to the Complainant that “Lump sum benefit equal to 100% of the sum insured should be payable on positive diagnosis of Covid,  requiring hospitalization”.  Also the terms  and conditions were served to the Complainant along with the Policy schedule.  Here, in this case, the Complainant’s vitals were stable throughout admission.  Investigations were within normal limit and could have been managed under home  isolation, which was not payable.  The allegation of the Complainant in paragraph 4 of the complaint are not fully correct. It is submitted that from the treatment records,  it is clear that the Complainant’s vitals were stable and it doesn’t require admission in a hospital.  The treatment of the Complainant was not within the conditions stipulated in the policy as the general condition of the Complainant was normal and could have been managed under home isolation.  It is submitted that from the treatment records it is clear that no specific treatment was given to the Complainant for covid and was treated with oral  medications.  It is  the Complainant, in order to get the claim unlawfully, had admitted in the hospital showing that  she  was hospitalized and is eligible for the claim.   It is  submitted that the Opposite party had repudiated the claim of the Complainant based on the treatment records and  as per the terms and conditions of the policy.  There is no deficiency of service and unfair trade practice from the part of the Opposite Party.  The Complainant is not entitled for any amount as per the terms and conditions of the policy. All other allegations are false. The Complainant is not entitled for compensation and cost of the proceedings. The Complainant  has filed this complaint frivolously for the  sole purpose of harassing the Opposite Party with intention for getting unlawful enrichment from  these Opposite Parties who are dealing with public money and are functioning under the guidelines of IRDA controlled by the Government of India.  As public money is held in trust,  the company must exercise abundant caution in dealing with claim by applying  all conditions correctly.

5. Chief affidavit was filed by the Complainant, Exts.A1 to A5 and X1 were

marked from her side and she was examined as PW1.  Chief affidavit was also filed by the Opposite Party.  Exts B1  to B4 were marked from their side and the Assistant Manager (Legal) was examined as OPW1 and the complaint was finally heard  on 27.05.2023.

          6. Based on the complaint,  version,  affidavits,  documents marked,  oral depositions of the parties to the complaint and the arguments of the counsels  for the Complainant and the Opposite Party,  Commission raised the following points for consideration.

1.  Whether there has been any deficiency in service/unfair trade practice from the part of the Opposite Parties?
2. Relief and cost....?

7. Point No.1:-  The case of the  Complainant  is  that  the   insurance claim

submitted by him was repudiated by the Opposite Party though he had a  valid Corona Rakshak Health Insurance policy,  with the Opposite Party after undergoing   hospitalisation and treatment from 24.09.2020 to 06.10.2020,  which is deficiency in service and unfair trade practice from the part of the Opposite Party.  Hence,  this complaint with prayer to get insurance claim,  compensation and cost.  The Opposite Party admitted the policy of the Complainant but contented that even though Covid-19 was diagnosed to the Complainant,  her vitals were seen normal as per hospital records. So,  hospitalisation was not needed and hence as the Complainant was not entitled for the claim as per the policy,  the Opposite Party repudiated his claim.  The Opposite Party in version has admitted that “as per the terms and conditions of the policy, lump sum benefit equal  to 100% of the sum insured shall be payable on positive diagnosis of Covid,  requiring hospitalisation for a minimum continuous period of 72 hours”.  In the version itself,  the Opposite Party state that “The Complainant was admitted at  Max Health Care Hospital,  Saket, New Delhi on 24.09.2020  for the treatment of COVID-19 and after the treatment she was discharged on 06.10.2020.  For the repudiation of the claim,  the Opposite Party  depended  on the Discharge Summary issued by the hospital in which the temperature pulse rate,  Respiration,  blood pressure etc  were seen noted to be in the normal range.  In the complaint,  the Complainant has stated that she was admitted in the hospital with throat pain,  body pain,  head ache since two days etc which are also evident from the  history of present illness stated  in the discharge summary,  the disease diagnosed was  “COVID-19 pneumonia with mild severity”.  It is quite natural that  a patient with the above symptoms shall be usually admitted in hospital,  especially in Covid-19  pandemic  situation and after diagnosis of Covid-19 pneumonia with mild severity,  temperature,  pulse rate,  respiration rate, blood pressure  etc  shall also be examined.  On examination,  if the  vitals are seen normal,  it does not mean that hospitalisation was not required in such cases.  Moreover,  it is  the doctors who  have to decide that hospitalisation is required or not to a particular patient.  So the contention of the Opposite Party that hospitalisation of the Complainant was not needed since the vitals of the Complainant were normal cannot be accepted by this Commission as a reason for repudiation of the claim under the policy.  Here,  in this case,  the Complainant was admitted in hospital on 24.09.2020 and after diagnosing Covid-19 pneumonia with mild severity, she was discharged on 06.10.2020. That is, she was in hospital for about 14 days.  As per the conditions of the policy,  the Complainant is eligible for 100% of the policy amount as one time payment for admission in hospital for a minimum period of 72 hours.  But without considering this truthful fact,  the Opposite Party repudiated the lawful claim of the Complainant without any good faith or bonafide.  This is deficiency in service/unfair trade practice from the part of the Opposite Party for which they are liable to compensate the Complainant.  So,  point No.1 is proved against the Opposite Party.

          8. Point No.2:-  As point No.1 is  proved against the Opposite Party,  the Complainant has the right to get the  claim amount,  compensation and cost as prayed for.

          In the result,  the complaint is allowed and the Opposite Party is directed to

1.  Pay Rs.1,00,000/-  (Rupees One Lakh only)  being the claim under the Corona Rakshak Health Insurance Policy.
2. Pay Rs.25,000/-  (Rupees Twenty Five thousand only) towards compensation and
3. Pay Rs.10,000/-  (Rupees Ten thousand only) towards cost of this complaint.

  The above amounts shall be paid by the Opposite Party to the Complainant

within one month from the date of  receipt of this order,  failing which the amount will carry interest at the rate of 8% per annum from the date of this order.

          Dictated to the Confidential Assistant, transcribed by him and corrected   by   me   and  pronounced  in  the  Open  Commission on this the   21^st   day of June  2023.

          Date of filing:22.03.2022.

                                                                             PRESIDENT:   Sd/-

                                                                             MEMBER    :   Sd/-

                                                                             MEMBER    :   Sd/-

APPENDIX.

Witness for the Complainant:

PW1.           Helen Abraham.                       Complainant.                 

Witness for the Opposite Party:

OPW1.        Balan. M                                  Assistant Manager – Legal.

Exhibits for the Complainant:

A1.       Copy of Policy Schedule.              

A2.      Copy of Laboratory Investigation Report.

A3.      Copy of Discharge Summary.

A4.      Copy of Lawyer Notice.                                      dt:07.10.2021.

A5.      Reply Notice.                                            dt:16.12.2021

X1 Series    Copy of Documents produced by  the  Opposite Party.

Exhibit for the Opposite Party:

B1.        Copy of Insurance Certificate.

B2.        Copy of  Discharge summary.

B3.        Copy of Medical Records.

B4.        Copy of Letter.                                        dt:26.03.2021.

                                                                                                PRESIDENT:  Sd/-

                                                                             MEMBER    :  Sd/-

                                                                             MEMBER    :  Sd/-