Orissa

Cuttak

CC/53/2022

Kailash Chandra Mishra - Complainant(s)

Versus

The Divisional Manager,M/s Oriental Insurance Company Ltd - Opp.Party(s)

S Sen & associates

27 Oct 2022

ORDER

IN THE COURT OF THE DIST. CONSUMER DISPUTES REDRESSAL COMMISSION,CUTTACK.

                                                                C.C.No.53/2022

Kailash Chandra Mishra,

S/O:Ram Chandra Mishra,

Residing At/PO:Rajendra Nagar,

P.S:Madhupatna,Town/Dist:Cuttack,

Pin-753010.                                                                                  ... Complainant.

 

                                                Vrs.

             The Divisional Manager,

M/s. Oriental Insurance Co.Ltd.,

At:Mangalam Nivas(2^nd Floor),

Bajrakabati Road,Cuttack.                                        ... Opp. Party.

 

 

Present:               Sri Debasish Nayak,President.

                                Sri Sibananda Mohanty,Member.

 

Date of filing:    29.03.2022

Date of Order:   27.10.2022

 

For the complainant:          Mr. Sujit Sen,Adv. & Associates.

For the O.Ps               :          Mr. S.Ray,Adv. & Associates.

 

Sri Debasish Nayak,President.                                                                            

            Case of the complainant as made out from the complaint petition in short is that he had taken one Corona Rakshak Policy during Covid-19 pandemic period vide Insurance Policy no. 345100/48/2021/551 in order to safeguard his health which was valid from 31.10.20 till 11.8.21.  The complainant had fallen ill on 20.7.21 as per the testing report of Gurudijhatia Health Centre.  Thereafter, the complainant took admission at Sanjeevani Medicare Multi-speciality Hospital at Bhubaneswar on 23.7.21 and was treated there for Covid-19.  He was discharged in the evening of 26.7.21 and had applied for claim of his insurance on 1.8.21 by furnishing all the required documents.  On 28.10.21 the complainant had sent a letter to the O.P for settling his claim as reminder but on 22.11.21 the O.P had sent a letter to the complainant thereby repudiating his claim since because condition no.3.7 of the policy was not fulfilled.  The complainant had again sent a request letter to the O.P on 26.11.21 in order to reconsider his claim but when the complainant did not respond, the complainant had to file this case claiming the assured amount of Rs.2,50,000/- alongwith interest thereon and a compensation amount of Rs.50,000/- towards his mental agony.  He has further claimed costs from the O.Ps.

            The complainant has filed copies of series of documents in order to prove his case.

2.         The O.P has contested this case and has filed his written version wherein he has stated that the case of the complainant is not maintainable for which it is liable to be dismissed with cost.  Ofcourse the O.P admits about the “Corona Rakshak Policy” as undertaken by the complainant which was valid with effect from 31.10.20 till 11.8.21.  He also has admitted about the claim form as deposited by the complainant from Sanjeevani Medicare Multi-speciality Hospital at Bhubaneswar on 1.8.21 but has urged through his written version that clause-3.7 of the terms and conditions of the said policy was not fulfilled for which the policy claim of the complainant was repudiated.  According to clause-3.7 of the terms and conditions of the said policy, hospitalisation means admission in a hospital designated for Covid-19 treatment by Govt. for a minimum period of 72 consecutive In patient care hours.  The complainant was admitted to the Sanjeevani Medicare Multi-speciality Hospital of Bhubaneswar at 7.35 P.M. on 23.7.21 and had remained there upto 7.10 P.M. of 26.7.21.  Thus, the period of hospitalisation of the complainant is less than 72 hours and do not satisfy the norms as required under clause-3.7 of the terms and conditions of the said policy.  It is for this, the claim of the complainant was repudiated and as such the O.P has prayed to dismiss the complaint petition which, according to him is not maintainable and is liable to be dismissed with cost.

3.         Keeping in mind the averments as made in the complaint petition and the contents of the written version, this Commission is of a view to settle the following issues in order to arrive at a proper conclusion here in this case.

i.          Whether the case of the complainant is maintainable ?

ii.         Whether there was any deficiency in service on the part of the O.P. ?

            iii.        Whether the complainant is entitled to the reliefs as claimed ?

Issues no. i & ii.

            Out of three issues as framed here in this case, Issues no.i & ii being two pertinent issues are taken up first for consideration.

            Admittedly, the complainant had entered into one “Corona Rakshak Policy” which was valid with effect from 31.10.20 till 11.8.21 and the said policy was obtained from the O.P vide policy no.345100/48/2021/551.  It is also not in dispute that the complainant was treated as an indoor patient at Sanjeevani Medicare Multi-speciality Hospital at Bhubaneswar with effect from 7.35 P.M. of 23.7.21 till 7.10 P.M. of 26.7.21 as he was suffering from Corona.  The complainant had made his insurance claim before the O.P on 1.8.21 after being discharged from the hospital.

            As it appears from the facts and circumstances of this case, technically if it is to be calculated, there is indeed a shortage of 25 minutes from the required period of hospitalisation of 72 hours as envisaged at clause-3.7 of the terms and conditions of the Corona Rakshak Policy as undertaken by the complainant from the O.P.  The said clause 3.7 signifies “hospitalisation means admission in a hospital designating for Covid-19 treatment by Govt. for a minimum period of 72 consecutive In patient care hours”.  While probing into the annexures as affixed to the written version of the O.Ps here in this case, it is noticed that as per Annexure-A it is the Corona Rakshak Policy as undertaken by the complainant from the O.P company and Annexure-B is the Corona Rakshak Policy document of the O.P company.  The complainant had undertaken such policy during the Covid-19 pandemic period in order to safeguard his health.  When after suffering from Covid-19, being hospitalised for three days when his claim was repudiated by the O.P, he has taken shelter before this Commission seeking redressal.  This Commission is guided and followed by the Consumer Protection Act,2019 which is squarely applicable to this case in hand.  The very moto of constructing such an Act is to safeguard and protect the benefit of the consumers.  It is also made clear in the said Act therein that it is not necessary always to adhere to the strict principles of law under the Cr.PC  or CPC but the principles of natural justice should always be taken into account while considering and evaluating the facts and circumstances of each and every case.  Here in this case, there is no dispute as regards to the insurance policy, hospitalisation of the complainant due to Covid-19 suffering and about the claim made by him for getting the insurance amount after he being discharged from the Sanjeevani Medicare Multi-speciality Hospital, Bhubaneswar where he was treated for Ciovid-19.  While evaluating the present circumstances of this case, technicality should not be an embargo and rather should not stand as a hurdle and the poor patient/complainant should not suffer simply because there was shortage of 25 minutes in his hospitalisation as it conflicts with the provision of clause-3.7 of the insurance policy.  There is only shortage of 25 minutes as noticed since because the complainant was admitted as a Covid-19 patient to the Sanjeevani Medicare Multi-speciality Hospital at Bhubaneswar  at 7.35 P.M. on 23.7.21 but was discharged at 7.10 P.M. on 26.7.21 thereby scissoring his claim due to the shortage of 25 minutes of hospitalisation.  When the objectivity of Consumer Protection Act,2019 is to  safeguard and protect the consumers from the ruthless pangs of technicalities of law, and it is to be constructively approached with a holistic view, this shortage of 25 minutes thereby disentitling the Covid-19 patient who has undertaken a policy for protecting himself during the pandemic Covid-19 situation should be liberally thought of.  In such scenario, this Commission without going to the strict technicalities as per terms and conditions, feels it proper with a generous heart and broadness in mind that the complainant here in this case should definitely get the benefits of the policy as undertaken by him during the pandemic situation and the barriers raised to this effect by the O.P as regards to the shortage of only 25 minutes towards his hospitalisation thereby disentitling the complainant in order to get his insurance claim is to be cast aside.  Thus, here in this case by disallowing the claim of the complainant there was deficiency in service on the part of the O.P who has become more technical and had turned down the approach of humanity thereby repudiating the claim of the complainant with a sheer technical approach of shortage of 25 minutes which appears to be quite whimsical and arbitrary.  Accordingly, this issue is answered in favour of the complainant.

Issue no. iii.

            From the discussions as made above, it can never be said that the case of the complainant is not maintainable.  Accordingly, the complainant is entitled to the reliefs as claimed by him, ofcourse to a reasonable extent.  Hence it is so ordered;

 

                                                ORDER

            Case is decreed on contest against the O.P.  The O.P is directed to settle the claim as made by the complainant to the tune of Rs.2,50,000/- forthwith within a period of 30 days from the date of receipt of copy of this order.

Order pronounced in the open court on the 27^th day of   October,2022 under the seal and signature of this Commission.           

                                                                                                                                Sri Debasish Nayak

                                                                                                                                            President

                       

                                                                                                                                                              Sri Sibananda Mohanty

                                                                                                                                           Member