DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

PATIALA.

                                      Consumer Complaint No. 110 of 3.4.2023

                                      Decided on: 4.11.2024

Bhupinder Sharma son of Shashi Bhushan Sharma, resident of H.No.492, Ward No.2, Street No.2, Khalifa Bagh Dhuri Road, Sangrur.

Aadhar No.401548476098.

                                                                   …………...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 Bhupinder Shama (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/211115/01/2022/004085 which was valid for the period 14.8.2021 to 25.5.2022 from the OP and paid Rs.13648/- as premium, for the sum insured of Rs.2,50,000/-. It is averred that the policy covered only Covid-19/Corona Virus and there was 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 with the company. It is averred that the complainant also took covid vaccination.
3. It is further averred that as per the terms and conditions of the policy Covid is covered with lump sum benefit equal to 100% of the sum insured which shall be payable on POSITIVE diagnosis of Covid from a Govt. authorized diagnostic centre and requiring hospitalization  for a minimum continuous  period of 72 hours. This is one time benefit applicable for the entire tenure of the policy and shall terminate upon payment of this benefit.
4.  It averred that on 18.2.2022 complainant fell ill and sample for RT PCR test  was taken at Max Lab Patiala (Ex.C4)  and the test report of the same was issued by the said lab on 19.2.2022 whereby the complainant was found Covid positive . That thereafter complainant was admitted in Sahara Multispecialty Hospital, near Ragho Majra, Patiala on 19.2.2022 and remained admitted there till 22.2.2022. It is averred that complainant paid hospital bill of Rs.37547/-for his treatment.
5. It is further averred that after discharge from the hospital complainant gave intimation to the OP for getting claim under the said policy which was duly registered by the OP  vide acknowledgment ID CIR/2022/211115/3941987 dated 10.5.2022 and also submitted all the required documents but the OP illegally repudiated the claim of the complainant on 10.5.2022. That thereafter complainant served legal notice dated 6.2.2023 upon the OP through speed post which was duly served but the OP did not pay any heed, which amounts to deficiency in service and unfair trade practice on the part of the OP. Hence this complaint with the prayer to accept the same by giving direction to the OP to pay the 100%  sum insured of Rs.2,50,000/- alongwith compensation of Rs.1,00,000/- for causing mental agony and harassment.
6. Upon notice, OP appeared through counsel and filed written statement having contested the claim by raising preliminary objections that the present complaint is not maintainable; that the case of the complainant is not covered under the policy of the company. It is admitted  that the complainant proposed to get himself insured under the Corona Rakshak  Insurance Policy  and upon good faith and based on his declaration policy bearing No.P/211115/01/2022/004085 was issued which was valid  for the period 14.8.2021 to 25.5.2022, strictly subject to the terms and conditions of the policy. 
7. It is further averred that the complainant lodged claim No.CIR/2022/211115/3941987 against the aforesaid policy with regard to the treatment/hospitalization from 19.2.2022 to 22.2.2022, which was duly processed under the terms and conditions of the policy and from the submitted documents it was observed that there was discrepancy in the records which amounted to misrepresentation of facts, under which the insurance company is not liable to make any payment in respect of any claim and the claim was repudiated vide letter dated 10.5.2022 under the terms and conditions of the policy.
8. It is further submitted that the complainant was admitted in Sahara Multispecialty Hospital, Patiala, which was found involved in mal practices as a result of which the said hospital was marked as excluded provider by the insurance company. It is further averred that the complainant has filed vexatious and frivolous complaint for the sole purpose of getting unlawful claim from the OP.
9. On merits, it is admitted to the extent that complainant has proposed to get himself insured under the Corona Rakshak Policy.  It is also admitted that positive diagnosis of covid is covered lump sum benefit equal to 100% of the sum insured but strictly subject to the terms and conditions of the policy. It is also admitted that the complainant was diagnosed as covid positive. Further the OP has reiterated the facts taken in the preliminary objections the contents of which are not repeated for the sake of brevity.  All other averments of the complainant have been denied by the OP and prayer has been made to dismiss the complaint.
10. In evidence, ld. counsel for the complainant has tendered in evidence Ex.CA affidavit of the complainant alongwith documents Exs.C1 to C14 and closed the evidence.
11. On the other hand, ld. counsel for the OP has tendered in evidence Ex.OPA affidavit of Sh.Sumit Kumar Sharma,Sr.Manager, alongwith documents Ex.OP1 to Ex.OP12 and closed the evidence.
12. We have heard the ld. counsel for the parties and have also gone through the record of the case, carefully. 
13. It is the admitted fact that the complainant purchased CORONA RAKSHAK insurance policy, as per Ex.C2, for a consideration of Rs.11566/-. The policy was valid for the period 14.8.2021 to 25.5.2022  i.e. for 285 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 subject to admission in hospital for a minimum continuous period of 72 hours and 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.
14. The complainant submitted sample for RT PCR test  to Max Lab on 18.2.2022 and as per test report dated 19.2.2022, Ex.C4,complainant was diagnosed Covid Positive. Thereafter, the complainant was admitted in Sahara Multi Specialty Hospital, Patiala on 19.2.2022 as a case of covid positive and was discharged on 22.2.2022, as per discharge summary Ex.C7 i.e. after 72 hours of admission.
15. The complainant then applied for claim as per the policy, which was registered vide claim intimation No. CIR/2022/211115/3941987. However, the claim was repudiated vide letter dated 10.5.2022, Ex.C12, on the ground that from the submitted medical records discrepancies were observed which amounted to misrepresentation of facts, and as per the terms and conditions of the policy issued to the complainant, if there is any misrepresentation whether by the insured person or any other person acting on his behalf, the Company will not liable to make any payment in respect of any claim. It is also argued by the ld. counsel for the OP that an amount of Rs.37547/- only as per payment receipt,Ex.C8 was spent by the complainant for his treatment and settlement of the claim, if any, should be made only for Rs.37547/- i.e. amount spent on treatment. The legal notice, Ex.C14 was subsequently served upon the OP by the complainant. However, no response was received by the complainant against the said legal notice.
16. 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”.

17. The complainant was diagnosed as covid positive as per the test report Ex.C4, and the complainant was then hospitalized from 19.2.2022 to 22.2.2022, as per discharge summary, Ex.C7 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. No malpractices as alleged by the OPs against Sahara Multispecialty Hospital could be proved by any convincing evidence and merely stating the same does not serve any purpose.
18. 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 per terms and conditions of the policy 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.
19. Certified copies of this order be sent to the parties under the rules and thereafter  file be consigned to the record room.   
20. 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

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