By Smt. Beena. M, Member:-
This is a complaint filed under section 35 of the Consumer Protection Act 2019.
2. Facts of the case in brief:- The case of the Complainant is that he had taken Corona Rakshak policy from the Opposite Party which was valid for the period from 22.07.2020 to 03.05.2021 for sum insured Rs.2,50,000/-. The Complainant had paid Rs.6,127/- towards the total premium. The policy covers lump sum benefit equivalent to 100% of sum insured which shall be payable in case of positive diagnosis of Covid -19 requiring hospitalization for a minimum continuous the period of 72 hours. According to the Complainant, he was admitted in Government Taluk Head Quarters hospital at Sulthan Bathery on 10.04.2021 and he undergone treatment of Covid-19 for 8 days and on 17.04.2021 he discharged from the hospital. Now the Complainant is suffering lot of health problems due to the infection of Corona Virus. Then, the Complainant submitted claim form with all relevant documents including doctor’s certificate to the Opposite Party. But the Opposite Party repudiated the claim stating that the Complainant needs only self-isolation by home quarantine. Actually, the Complainant was admitted in the hospital for treatment for high temperature, cough, blood pressure variation, severe chest infection and body weakness. As per the terms and conditions of the policy the Opposite Parties are bound to pay the sum assured to the Complainant. According to the Complainant, the act of the Opposite Party is clear violation of the policy condition and the Opposite Party is liable to pay the claim amount to the Complainant. Hence, this Complaint.
3. Upon notice, the Opposite Party appeared and filed version. The Opposite in his version has submitted that the Complainant obtained Corona Rakshak policy and the terms and conditions of the policy were explained to the Complainant at the time of proposing policy and the same were served to the Complainant along with the policy schedule. 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 hospitalization for a minimum continuous period of 72 hours. The positive diagnosis of covid shall be from a government authorized diagnostic center. The policy is designed to mitigate the huge expenses incurred for the prolonged treatment. The Opposite Party stated that as per the condition No. 7.3 of the policy, the claim has to be supported with duly filled and signed claim form, medical practitioner’s prescription advising admission, discharge summary including complete medical history of the patient along with other details, investigation reports including insured person’s test reports from authorized diagnostic center for Covid. It is submitted that in the above case, none of the medical documents were submitted by the Complainant to the Opposite Parties. The Opposite Party further stated that in the discharge summary issued by the hospital was silent about the clinical parameters of the patient like Temperature, pulse rate, Respiratory rate and SPO2 level. The hospital record reveals that the Complainant’s clinical parameters as follows;-
Dated 10.04.2021:
Blood Pressure: 120/80
Pulse Rate: 86/m t (Normal Range: 58-100 beats per minute)
SPO2: 100% (Normal Range: 94% to 100%).
Temperature: 1000 F
Dated 11.04.2021
Blood Pressure: 117/76
Pulse Rate: 82/mt
SPO2: 98%
Temperature: 1000 F
Dated 12.04.2021
Blood Pressure: 122/82
Pulse Rate: 110/mt
SPO2: 98%
Temperature: 100oF
Dated 13.04.2021
Blood Pressure: 118/77
Pulse Rate: 68/ m t
SPO2: 99%
Temperature: Normal
Dated 14.04.202
Blood Pressure: 128/91
Pulse Rate: 74/ mt
SPO2: 99%
Temperature: Normal
Dated15.04.2021
Blood Pressure:130 /100
Pulse Rate: 62/ m t
Spo2: 99%
Temperature: Normal.
Dated 16.04.2021
Blood Pressure: 142/90
Pulse Rate: 72/m t
SPO2 :98%
Temperature: Normal.
Dated 17.04.2021:
Blood Pressure: 130/98
Pulse Rate: 80/ m t
SPO2: 98%
Temperature: 98.6.
4. It is submitted that as per the case sheet, the Complainant’s vitals were stable & minor symptoms are only noted. As per the terms and conditions of the policy it is clearly mentioned that ‘’ the claim shall be payable on positive diagnosis of Covid-19 requiring hospitalization for a minimum period for 72 hours’’. Here Covid positive has been diagnosed but the patient’s vitals were stable, Respiration rates, SPO2, Pulse Rate seems normal, hospitalization was not wanted and he was under observation. 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 and hence oxygen support is mandatory in such cases. But in this case the SPO2 is well within normal range only. In the discharge summary there was no mentioning about throat, chills, loss of smell or taste, Congestion or runny nose, Nausea or vomiting, Diarrhea and low level of SPO2. Hence it is clear that no specific treatment was given to the Complainant. It is submitted that as per the discharge summary, the Complainant got discharged on his request which means that the Complainant was not under any serious condition. As per the hospital records, Complainant’s vitals are stable and stayed at hospital only for observation under isolation and it doesn’t require admission in a hospital. Hence the Opposite Parties had repudiated the claim and the same was informed to the Complainant on 05.07.2021. 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. If at all condition of the Complainant was severe, then he would not be discharged. Hence the allegations of the Complainant that he was admitted for treatment for high temperature, cough, severe chest infection and body weakness is baseless. According to the Opposite Party the Complainant was discharged from the hospital on his request which shows that he was admitted at the hospital only for the purpose of getting the claim. The Opposite Parties had acted according with the terms and conditions of the policy and guidelines issued by IRDA and the Central Government. So there has been no deficiency in service from the part of the Opposite Parties. So, the complaint had no merit and liable to be dismissed.
5. On perusal of complaint and documents the Commission raised the following points for consideration:
1. Whether any deficiency of service on the part of Opposite
Parties?
2. Relief and cost.
6. On the side of the Complainant, he was examined as PW1 and the documents produced were marked as Ext.A1 to A9 and treated doctor has been examined as PW2. On the other hand, the Opposite Party filed affidavit of Balu.M and he was examined as OPW1 and Ext.B1 to B4 marked.
7. The Complainant had obtained Corona Rakshak Policy, Ext.A1 w.e.f. 22.07.2020 to 03.05.2021 for a sum assured of Rs.2,50,000/- from the Opposite Party. The Complainant was found Corona positive on 10.04.2021, when test was conducted by the Assistant Surgeon at Family Health Center, Naiketty and referred to Taluk Hospital Sulthan Bathery, Ext.A5. The Complainant was admitted in Taluk Head Quarters Hospital Sulthan Bathery by the doctor of the hospital. The Complainant admitted in hospital from 10.04.2021 to 17.04.2021 as per discharge summary Ext.A2. The Complainant was advised to avoid non-essential travel and social contact for 7 days, Ext. A6.
8. We have heard the counsels for the parties and gone through the record of the case carefully. The counsel for the Complainant submitted that as per the terms and conditions of the Corona Rakshak policy, the Complainant was entitled for Rs.2,50,000/- as a sum insured after he had taken medical treatment for Covid-19 in Government Head Quarters Sulthan Bathery, for more than 72 hours.
9. While going through contents of Version of the Opposite Party and also the clause no.7.2 of the terms and conditions of the Corona Rakshak Policy, produced by the Opposite Party, Ext.B1, we are of the view that the Opposite Party ,insurance Company, has illegally and arbitrarily repudiated the valid claim of the Complainant because, the clause no. 7.2 is regarding the procedure for getting the sum insured and as per that procedure, the insured person had to submit claim for sum insured for Rs.2,50,000/- with papers of medical treatment for covid-19 in hospital for 72 hours. Here the document produced by the Opposite Party, Ext.B4, Repudiation letter itself shows that the Complainant had produced documents along with the claim application. So, in our view, the Opposite Party has illegally and arbitrarily interpreted that clause no.7.2 of the Corona Rakshak policy and thereby, illegally repudiated the valid claim of the sum insured.
10. There is also no dispute that the Complainant tested Corona-positive and admitted in Sulthan Bathery Taluk Headquarters hospital and he was treated for 8 days from 10.04.2021 to 17.04.2021. After discharge from the hospital, the Complainant submitted his claim to the Opposite Party and the same was repudiated by the Opposite Party stating that, as per the guidelines of AIMS the Complainant needs only self-isolation by home quarantine based on submitted claim documents. All the documents produced by the Complainant shows that he took treatment as an inpatient for 8 days. It was submitted on behalf of the Opposite Party that Complainant was admitted in the hospital on his request and also discharged on his request and no admission was required and only home quarantine, so his claim has rightly been repudiated by the Opposite Party. As per the available documents the Complainant was suffered with high grade fever (103oF) breathlessness, tiredness etc. At the time of the examination of Doctor, (PW2) deposed that “Admit BIpt¼mÄ BP High Bbncp¶p. Blood  oxygen Afhv Ipdhmbncp¶p. IqSnb ]\nbpw izmkXSÊhpw Dmbncp¶p. Risk Chance due to Covid & suffocation low oxygen level F¶nh DffXpsImmWv admit sNbvXXv. Case Sheet {]Imcw 10.04.2021 apX 17.04.2021 hsc admit & treatment  Bbncp¶p (Ext.A2). hcpt¼mÄ aäv AkpJ§Ä CÃmbncp¶p. Ext.A2, Request sNbvXv discharge BIpIbmWpmbXv”. The treating doctor alone is to decide whether a patient is to be admitted in the hospital or not. So, in our view, the Complainant is entitled for sum assured of Rs.2,50,000/- from the Opposite Party, as he was hospitalized for more than 72 hours for Covid-19 positive medical treatment. Hence, the Complaint is deserved to be allowed with cost of litigation and compensation.
For the reasons recorded above, the complaint is partly allowed and Opposite Parties are directed
- To pay Rs.2,50,000/- (Rupees Two Lakh Fifty Thousand only) to the Complainant as per Corona Rakshak policy.
- To pay Rs.8,000/- (Rupees Eight Thousand Only) as compensation and Rs.5,000/- (Rupees Five Thousand Only) as litigation expenses.
The opposite Parties No.1 and 2 are held liable jointly and severally for making payment to the Complainant. The above order shall comply within 30 days from the date of receipt of copy of this order, failing which the Complainant is entitled to interest @ 8% p.a. till the realization of the amount.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 23rd day of February 2024.
Date of Filing:-13.09.2021
PRESIDENT : Sd/-
MEMBER : Sd/-
APPENDIX.
Witness for the Complainant:-
PW1. Sujith. K. Nair. Nurse.
PW2. Dr. Karnan. T. K. Doctor.
Witness for the Opposite Parties:-
OPW1. Balu. M. Assistant Manager, Legal.
Exhibits for the Complainant:-
A1. Copy of Corona Rakshak Policy Certificate of insurance for the
period of 22.07.2020 to 03.05.2021.
A2. Copy of Discharge Card/Discharge Summary.
A3. Copy of Nurse Record & Reports.
A4. Copy of Repudiation of Claim letter. Dt:05.07.2021.
A5. Copy of Reference letter. Dt:10.04.2021.
A6. Discharge Certificate. Dt:17.04.2021.
A7. Treatment Record from Aster Mims, Calicut.
A8. Treatment Record from Aster Mims, Calicut.
A9(a). Treatment Record from Aster Mims, Calicut.
A9(b). Treatment Record from Aster Mims, Calicut.
A9(c). Treatment Record from Aster Mims, Calicut.
Exhibits for the Opposite Parties:-
B1. Copy of Corona Rakshak Policy Certificate of insurance for the
period of 22.07.2020 to 03.05.2021.
B2. Copy of Discharge Card/Discharge Summary.
B3. Copy of Summary Sheet.
B4. Copy of Repudiation of Claim letter. Dt:05.07.2021.
PRESIDENT :Sd/-
MEMBER :Sd/-
/True Copy/
Sd/-
ASSISTANT REGISTRAR
CDRC, WAYANAD.
Kv/-