By Sri. A.S. Subhagan, Member:

            The Complainant has filed this complaint under section 12 of the Consumer Protection Act 1986.

            2.  Facts of the complaint:- The First Opposite Party is a service provider in the General Insurance sector including health insurance. At the beginning of the COVID-19 Pandemic, the company started a medi-claim Policy named Corona Rakshak, by which they accepted premium and issued policy assuring that, the insured would be given policy amount, if the policy holder tested COVID Positive. As per their proposal on 30.11.2020, the petitioner took policy No. 40528602 paying Rs.2,863.50/- and the insured amount is Rs.2,50,000/-.  The term of the policy was 30.11.2020 to 10.09.2021.  The second Opposite Party is a small savings bank working at Kalpetta as the agent of First Opposite Party in Wayanad District, Kalpetta, who is the intermediary of First Opposite Party. The Second Opposite Party’s agent approached the Petitioner and insisted him to take this policy informing him that the Petitioner would get the insured amount, if he tested COVID Positive and is admitted for 48 hours for treatment.  The petitioner was tested COVID Positive on 06.08.2021 and was admitted for treatment in CFLTC, at Sulthan Bathery with severe chest pain and further complications of the disease and he was discharged on 13.08-2021 after 7 days of treatment. In the meantime, the petitioner informed the second Opposite Party on the same day i.e., on 06.08.2021, that he was tested COVID positive and as per his advice the petitioner informed the first Opposite Party i.e. IFFCO TOKIO office and he told the petitioner that after the discharge from the CFLTC, submit the discharge certificate to the company and then the insured amount would be sanctioned by the Company.  Therefore, the petitioner submitted the discharge certificate and further documents to the first Opposite Party through e-mail and the original documents were sent to the company by post. On 27.09.2021, the first Opposite Party denied medi-claim to the petitioner stating that “On scrutiny of the claims documents we find that the insured had mild symptoms of Corona virus and admitted for the purpose of isolation. As per the ICMR and ministry of health and family welfare guide-lines; Asymptomatic/mild symptoms of COVID cases can be managed with Isolation/Home quarantine Hospitalization not justified".  When this matter is again informed to the First and Second Opposite Parties, they requested the petitioner to give an application to reopen the policy with all the available documents and as per their request the petitioner applied but the Opposite Party has not complied with the request.  That is, the Opposite Party has not complied with the assurance given in the original policy documents as promised to the petitioner.  The petitioner has undergone tremendous mental agony and pain and suffered irreparable loss and injury. The disability of  the Opposite Parties to fulfill the conditions provided in the original policy document tantamount to clear-cut deficiency in service as promised to the petitioner at the time of commencement of the aforesaid policy from IFFCO TOKIO General Insurance Company.  Being the first Opposite Party is the policy provider and the second Opposite Party is the intermediary, They are jointly and severally responsible for all the loss, mental agony and injury suffered by the Complainant.  Hence this complaint with prayers  

1. To grant the entitled policy amount of Rs.2,50,000/- to the petitioner from the First Opposite Party at the earliest.

2. To order the Opposite Parties to pay the cost of filing this petition and other expenses incurred to the tune of Rs.15,000/- to the petitioner.
3. To order the Opposite Parties to pay an amount of Rs.50,000/- for the loss, injury and the mental agony suffered by the petitioner.

4. To grant further and other reliefs as the petitioner is entitled to.

3.  The complaint was admitted in file of the Commission and summons were served to the Opposite Parties.  They appeared and the Second Opposite Party filed version. The contents of version are as follows:-   The complaint is not maintainable as the Complainant has filed the complaint with malafide aim to defame and damage the unblemished repute, reputation and goodwill of the second Opposite Party. The Complainant has suppressed the material and correct facts in order to get wrongful gain. The Second Opposite Party specifically denied the allegation in the complaint that the Second Opposite Party acted as an intermediary between the Complainant and the first Opposite Party. In fact the Second Opposite Party was only a corporate agent acted in good faith for the issuance of policy. It is further denied the allegation made in the complaint that Second Opposite Party’s agent approached the Complainant and induced him to obtain the policy and informed him that the Complainant would get the insured amount if tested COVID positive and admitted for 48 hours for treatment. With respect to the averments in the complaint it is submitted that the Second Opposite Party had given only the advices and assisted the Complainant to complete the formalities to avail the insurance policy.  The Complainant had never approached the Second Opposite Party for seeking any relief as alleged in the complaint.   Moreover, the Complainant had admitted in his complaint that he had only approached the first opposite for settlement of the claim. This Opposite Party is not jointly or severally responsible for the loss, mental agony, injury suffered by the Complainant as alleged in the complaint.  The Complainant had made the Second Opposite Party unnecessarily without any root cause or reason and the complaint is liable to be dismissed against this Opposite Party and if at all any cause of action arose, it is only against the insurance company, the First Opposite Party herein and not against this Opposite Party.  The Second Opposite Party rendered all the services probable and possible at all point of time and there is no deficiency in service or shortcoming from the part of the Second Opposite Party under any circumstances as alleged in the Complainant.  Hence, it is prayed to dismiss the complaint with compensatory cost.

4.  The Complainant filed chief affidavit, Ext.A1 to A8 and Ext.X1 marked from his side and he was examined as PW1.  First Opposite Party marked Ext.B1 but no adduced any oral evidence.  No documents were marked by the Second Opposite Party.  Second Opposite Party also had no oral evidence and the complaint was finally heard on 25.08.2023.

5.  Commission perused the complaint, version, documents marked, affidavit filed and the oral evidence adduced by the Complainant. Consequently 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. If so, relief, cost, quantum…?

6.  Point No.1:-  The Complainant had a mediclaim policy named Corona Rakshak from 30.11.2020 to 10.09.2021 for a sum assured of Rs.2,50,000/- with the First Opposite Party which is evident from Ext.B1.  The Second Opposite Party was the intermediary of the First Opposite Party.  As per the terms of the policy, the First Opposite Party had to pay the Complainant an amount of Rs.2,50,000/- in case the Complainant is tested COVID positive.  The allegation of the Complainant is that though he was admitted in CFLTC, Bathery on becoming COVID positive, for 06.08.2021 to 13.08.2021 (seven days) the Opposite Party denied benefit under the policy which is deficiency in service/unfair trade practice.  On the other hand, the contention of Opposite Party is that the insured had mild symptoms with COVID positive and admitted for the purpose of isolation.  As per the ICMR and Ministry of Health and Family welfare guideline “Asymptomatic/mild symptoms of COVID case can be managed with isolation/home quarantine” Hospitalization not justified.  The Opposite Party has stated this in Para ‘2’of Ext.A8.  On scrutiny of the policy, we see that COVID cover is seen stated in condition No.4.1 of  Ext.B1 which shows 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 government authorized diagnostic centre”.  So on a postitive reading of condition No.4.1 of the policy, the Complainant is eligible for getting 100% of the sum assured as the Complainant was tested COVID positive and as he was hospitalised for seven days for treatment.  It is seen that the Complainant was admitted for treatment for COVID in CFLTC (COVID First Line Treatment Centre). Condition No.3.6 vi of Ext.B1 states that “for the purpose of this policy any other set up designated by the government as hospital for the treatment of COVID 19 shall also be considered as hospital”.  Moreover condition No.3.7 of Ext.B1 states that “Hospitalisation means admission in a hospital designated for COVID-19 treatment by government for more than 72 hours for treatment of COVID.  If the above conditions stated in the policy document are satisfied, the Opposite Party is liable to pay the benefit under the policy to the Complainant.  On a plain reading of the conditions of the policy itself and scrutiny of Ext.A3, A4, A5, A6 and A7 it is very clear that the Complainant is eligible for 100% of the sum assured as policy benefit under the policy.  So, the repudiation of the eligible claim under the policy of the Complainant by the Opposite Party is on untenable ground as the hospitalisation of the patient is decided by the treating doctor and not by the Opposite Party.  Therefore the repudiation of the claim of the Complainant as per Ext.A8 is illegal unjustifiable and not in goodfaith and hence there has been deficiency in service/unfair trade practice from the part of the first Opposite Party alone.  Therefore, Point No.1 is proved against the First Opposite Party.

7.  Point No.2:-  As Point No.1 is proved against the First Opposite Party, they are liable to pay insurance claim, compensation for deficiency in service and cost of this complaint to the Complainant.

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

1. Pay Rs.2,50,000/- (Rupees Two lakh and Fifty Thousand Only) being the eligible insurance claim payable under the policy
2. Pay compensation of Rs.50,000/- (Rupees Fifty Thousand Only) and
3. Pay cost of Rs.15,000/- (Rupees Fifteen Thousand Only).

The above amounts shall be paid by the First Opposite Party to the Complainant within one month from the date of this Order, failing which the amount will carry interest @ 9% 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 15^th day of September 2023.

Date of Filing:-14.02.2022.

PRESIDENT   :Sd/-

MEMBER       :Sd/-                   

MEMBER       :Sd/-

APPENDIX.

Witness for the Complainant:-

PW1.              Ajeesh. P. T.                                                 Farmer.

Witness for the Opposite Parties:-

Nil.

Exhibits for the Complainant:-

A1.                  Corono Rakshak Policy.

A2.                  Tax Invoice.                                                  Dt:30.11.2020.

A3.                  COVID-19 Test Report.                             Dt:06.08.2021.

A4.                  Certificate.                                                   Dt:12.10.2021.

A5.                  Treatment Certificate.                              Dt:21.10.2021.

A6.                  Copy of Discharge Certificate.                Dt:13.08.2021.

A7.                  Copy of Claim Form.                                

A8.                  Claim denial Letter.                                    Dt:27.09.2021.

X1.                  Insurance Policy with terms and conditions.

Exhibits for the Opposite Parties:-

B1.                  Tax Invoice/ Insurance Policy with terms and conditions.

PRESIDENT   :Sd/-

MEMBER       :Sd/-

MEMBER       :Sd/-

/True Copy/

Sd/-

                                                                                             ASSISTANT REGISTRAR

                                                                                                  CDRC, WAYANAD.

Kv/-