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 Complainant had taken Corona Rakshak insurance policy from the Opposite Parties on 31.07.2020 on payment of total premium amount of Rs.9,887/- and the policy period starts from 31.07.2020 to 12.05.2021. As per policy, the coverage is for Complainant, his wife and two children and the sum insured is Rs.1,00,000/- each to all the insured persons. The policy provides lump sum benefit of 100% of sum insured on positive diagnosis of covid-19 requiring hospitalization for a minimum continuous period of 72 hours. That on 24.02.2021 the Complainant was admitted in Covid-19 Second line treatment center at Pulpally and the Complainant undergone treatment for Covid-19 for 8 days and discharged on 03.03.2021 as per the decision of Medical Board. Now the Complainant is suffering lot of health problems due to the infection of Corona virus. Subsequently, the Complainant forwarded the claim form with relevant documents including Doctors certificate to the Opposite Party. But the Opposite Party has repudiated the claim of the Complainant on the ground that the Complaint has not treated in hospital. Actually, the Complainant was admitted in second line treatment center constituted by the government as per Covid-19 protocol. As per the guidelines of the government, the second line treatment center is equal to a hospital. As per the terms and conditions of the policy the Opposite Parties are bond to pay sum insured that is Rs.1,00,000/- to the Complainant. The above said acts of the Opposite Parties are clear violation of the policy condition and it caused heavy damages to the Complainant and the Opposite Parties liable to pay the amount to the Complainant. The repudiation of claim on illegal ground amounts to deficiency in service on the part of Opposite Parties. The acts of the Opposite Party had caused great inconvenience and hardships to the Complainant. Apart from the sum insured the Opposite Parties are legally liable to pay compensation and cost to the complainant. Hence, this complaint.
3. Summons served to the Opposite Parties, the Opposite Parties appeared and filed version as follows:
It is submitted that the Complainant took a Corona Rakshak Policy from the first Opposite Party for the period commencing from 31.07.2020 to 12.05.2021 covering the Complainant and two children for a sum insured of Rs.1,00,000/- each vide policy No.P/181315/01/2021/002020. At time of issuing 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 policy schedule. The Complainant after accepting the terms and conditions of the policy had availed the policy. It is submitted that during the aforesaid policy period, the Complainant had submitted a claim with discharge summary issued by Covid-19 Second Line treatment center, Pulpally which states that the Complainant was diagnosed with Covid-19 positive and was under treatment from 24.02.2021 to 03.03.2021. It is submitted that the discharge summary issued by covid-19 Second Line treatment center, Pulpally was silent about line of treatment and medications given to the Complainant. Moreover, the Complainant’s clinical parameters like temperature, pulse rate, SPO2 level etc., were not mentioned in the discharge summary and the Complainant has not submitted any lab report confirming that Complainant had contacted with Covid-19. Moreover, the Complainant has not produced any prescription or report from the treating doctor requiring hospitalization as in-patient. Thus, it is clear that all the clinical parameters were within the normal limits and it does not need any hospitalization and hence he was referred to quarantine in order to avoid overcrowding in the hospital. Thereby the Complainant was admitted at Covid-19 second Line treatment center, Pulpally. On 24.02.21 and after the treatment he was discharged on 03.03.21. Based on the available documents it is clear that the Complainant was kept under observation in the quarantine center and not availed any treatment. It is submitted 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 persons test report from authorized diagnostic center for Covid. None of the medical documents were submitted by the Complainant till this date. It is submitted that the condition of the patient i.e., category of the condition (A, B and C) was silent in the discharge/reference card. As per the terms and conditions of the policy it is clearly mentioned that “the claim shall be payable on positive diagnosis of covid requiring hospitalization for a minimum period for 72 hours”. Here Covid positive has been diagnosed but hospitalization was not warranted and hence referred to CSLTC for observation. There were no symptoms requiring inpatient care/admission in a hospital. Corona symptoms like fever, sore throat, headache, chills, loss of smell or taste, congestion or runny nose, Nausea or vomiting, Diarrhoea or breathing difficulty were absent and all the clinical parameters were normal. Hence it doesn’t require admission in a hospital. No specific treatment given to the patient and no documents submitted other than discharge summary. In a Covid case, the primary symptoms are fever sore throat, headache, chills, loss of smell or taste, congestion or runny nose, nausea or vomiting, diarrhoea, and low level of SPO2. SPO2 is oxygen saturation, it is a measure of the amount of oxygen carrying hemoglobin in the blood relate to the amount of hemoglobin not carrying oxygen. The body needs certain level of oxygen in the blood or it will 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. In this case as per the discharge card the SPO2 value was not mentioned which means that it is well within the normal limits. 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. 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. Payment will be made only on hospitalization for a minimum continuous period of 72 hours following diagnosis for Covid. This is onetime benefit applicable for the entire tenure of the policy and shall terminate upon payment of this benefit. As per the definition clause (3.7) of the policy hospitalization means admission in a hospital designated for Covid-19 treatment by government for the minimum period of 72 consecutive in-patient care hours. As per the clause (3.8) of the policy in- patient care means treatment for which the insured person has to stay in hospital continuously for more than 72 hours for treatment of Covid. Here in the instant case no treatment provided to in-patient. Hence stay in the hospital is not all essential. Based on the above-mentioned definitions it is clear that, the claim is payable only the insured person has to stay/ admitted in a hospital for the treatment of Covid and requires hospitalization. In this case, the Complainant was admitted at Covid-19 Second Line Treatment Center (CFLTC) and it is only an institutional quarantine facility and not a hospital. Hence CSLTC doesn’t come under the definition of hospital as per the policy norms. CSLTCs provide institutionalized care and treatment to mild or asymptomatic Covid positive patients. This level provides essential Covid care as well as specialized care via telemedicine facility linked to the Covid hospital. Schools, Colleges, Training centers, Community-hall, Marriage halls, religious buildings etc are considered as CSLT center. The patient stayed at CSLT center i.e., under institutional quarantine for observation. Since CSLTC is not a hospital and lack the infrastructure of a hospital as per policy clause, the insurer had rightly repudiated the claim. The guidelines for Covid-19, clearly states that “Quarantine means the separation and restriction of the movement or activities of the persons who are not ill but who are believed to have been exposed to infection, for the purpose of preventing transmission of diseases.” The purpose of quarantine during the current outbreak is to reduce transmission by separating contracts of Covid-19 patients from community. Monitoring contacts for development of sign and symptoms of Covid-19, and segregation of Covid-19 suspects, as early as possible from among other quarantined persons. This level provides essential Covid cares as well as specialized care via telemedicine facility linked to Covid hospital. Corona Rakshak policy is designed to meet the huge expenses of hospitalized care/treatment to a symptomatic patient only. Asymptomatic patients does not need hospitalization. If there are severe symptoms of Covid, then such patients are to be referred to Covid hospital for inpatient care. That means such symptoms patients will never Treated under CSLTC. Hence based on the terms and conditions of the policy, the Opposite Party had repudiated the claim and the same was informed to the Complainant vide letter dated 26/04/21. It is submitted that at the time of taking policy, it was clearly explained to the complainant that the “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 “which means the policy holder will only be eligible for the lump sum benefit if he/she had an admission in a hospital for the m minimum periods of 72 consecutive in-patient case hours. Here in this case the Complainant was only under quarantine at a CSLTC which is not a hospital and where he does not needed any treatment. It is the submitted that CSLTC provide institutional care and treatment to mild or asymptomatic Covid positive patients only. This level provides essential Covid care as well as specialized care via telemedicine facility linked to the Covid hospital. If there is a severe symptom of covid, then such patients are to be referred to Covid hospital for in patient care. That means such symptomatic patients will never treat under CSLTC. It is the complainant, wo is trying to make unlawful gain by making false allegations. The Opposite Party had acted according with the terms, conditions and guidelines issued by IRDA and the central government. No guidelines have been violated by the Opposite Party. There has been no deficiency of service from the part of the respondent. The Complainant has not suffered any inconvenience, hardships as alleged by him. The Complainant is not entitled for any of the reliefs mentioned in the Complaint. The Complainant has filled this complaint frivolously for the sole purpose of harassing these Opposite Parties with intention for getting unlawful enrichment from these Guideline of IRDA controlled by the government of India. As public money is held in trust, the company must exercise abundant caution in dealing with claims by applying all conditions correctly. The Opposite Parties prays to dismiss the complaint.
4. On the side of the Complainant, he was examined as PW1 and the document produced were marked as Ext. A1, A2 and A3 and treated doctor has been examined as PW2. On the side of the Opposite Party, Balu, Assistant Manager Legal, of Opposite Party, was examined as OPW1 and Ext. B1 and B2 marked.
5. Points for consideration:
- Whether there is any deficiency in service from the part of Opposite Parties?
- Whether the Complainant is entitled for the reliefs as prayed for?
6. We have gone through the record of the case carefully and have heard for the parties.
7. The evidence of the Complainant is that he took Ext. A1/B1 Corona Rakshak policy from the Opposite Party insurance company by paying an amount of Rs.9,887/- towards premium for sum assured of Rs.1,00,000/- for the period from 31.07.2020 to 12.05.2021. The Complainant was found Corona positive on 24.02.2021 and admitted in Second Line Treatment Centre, Pulpally from 24.02.2021 to 03.03.2021 as per Ext A2. The Complainant was advised to stay home under observation. So, the Complainant was entitled for Rs.1,00,000/- as a sum insured after he had taken medical treatment for Covid-19 in Second Line Treatment Centre at Pulpally for more than 72 hours therefore, he was entitled for the sum insured. But the Opposite Party had repudiated the claim on the ground that the Complainant admitted in CLTSC.
8. It is an undisputed fact that the Complainant remained hospitalized in Second Line treatment Centre Pulpally from 24.02.2021to 03.03.2021, as he was diagnosed as Covid-19 positive patient. Here the short question arising for consideration is whether a Covid Second Line Treatment Centre can be termed as hospital for the purpose of considering the Complainant’s insurance claim. For deciding this question, it is essential to refer Clause 3.6, 3.7 and 3.8 of Ext.B1 policy. As per Clause 3.6, hospital means any institution established for in-patient care and day care treatment of disease/injuries and which has been registered as hospital with the local authorities under the clinical establishments (Registration and Regulation) Act, 2010 or under the enactments specified under schedule of section 56(1) of the said Act, or complies with all minimum criteria as under:
- has qualified nursing staff under its employment round the clock.
- has at least ten inpatient beds, in those towns having a population of less ten lakhs and fifteen in-patient beds in all other places.
- has qualified medical practitioner in charge round the clock
- has a fully equipped operation theatre of its own where surgical procedures are carried out.
- maintains daily records of patients and shall make these accessible to the Company’s authorized personnel.
- 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.’’
9. It is clarified in Clause 3.6 vi that, for the purpose of the policy any other set up designated by the government as hospital for the treatment for Covid-19 shall also be considered as hospital. As per Clause 3.7, admission in a hospital designated for Covid treatment for a period of 72 consecutive in-patient care hours will qualify a policy holder for the insurance coverage. Clause 3.8 makes it clear that in-patient means treatment for which the insured person has to stay in hospital continuously for more than 72 hours for treatment of Covid.
10. In order to understand whether CFLTCs are designated by the government for Covid-19 treatment, one need only read the Covid-19 advisory for patient admission to CFLTCs issued by the Government as per order No. 31/F2/2020/Health dated 24.07.2020. Therein, it is specifically stated that the Centre identified as Covid Health Care Centre should treat all mild and moderate symptomatic persons under surveillance and should be utilized for treating positive cases, we need arises. It is to be noted that CFLTCs are Primary Level Health Care Centers set up for providing care to less serious cases and referral of serious cases to Covid hospitals, so as to avoid crowding in Covid hospitals and avoid wastage of resources. It can therefore be unhesitatingly held that CFLTCs are designated as hospitals for the treatment of Covid-19. As regards the contention that the Complainant have any symptoms of Covid-19 and was not treated for such illness at the CFLTCs, Ext A2 reveals that he was having throat pain, breathlessness and headache at the time of admission.
11. In Ext A2 discharge summary issued by Medical Officer, Covid Second Line Treatment Centre Pulpally clearly shows that the Complainant took treatment as an inpatient for 8 days. Hence as per Ext. B1 policy terms and conditions in column no. 4 mentioned that Lump sum benefit equal to 100% of the sum insured shall be payable on positive diagnosis of Covid, requiring minimum continuous period of 72 hours. After going through the terms and conditions of the policy it is clear that if the policy holder affected and admitted in government hospital for 72 hours is entitled for the insured amount. In this case the Complainant fulfilled all the condition of the policy, but the Opposite Party illegally repudiated the claim.
12. At the time of the examination of doctor (PW2) deposed that ‘’ “Pulpally PHC Covid Second Line Treatment Centre BWv. Ct¸mÄ Fs¶ ImWn¨ A2 AhnsS \n¶pw issue sNbvX Certificate BWv. AXv {]Imcw ]cmXn¡mcs\ 24.02.2021 apX 03.03.2021 hsc AhnsS admit sNbvXv NnInÕn¨ncp¶p. Oxygen Support Bhniyapff patients s\ Covid Second Line Treatment Centre  BWv admit sN¿mdpffXv. kÀ¡mÀ D¯chv {]Imcw Covid Second Line Treatment Centre hospital \v XpeyamWv. First Line Treatment Centre Ifpw hospital \v XpeyamWv. Cross:- A2  Oxygen level saturated Aà F¶v ]dªn«nÃ. Covid Positive Bb patient \v oxygen monitor sNt¿Xv A\nhmcyamWv. First and Second Line Treatment Centre Ifnepw C§s\ sN¿mdpv. Re:- A2 document discharge summary BWv. Oxygen saturation level record sN¿p¶Xv case sheet  BWv”. The deposition of PW2 shows that the Complainant is very much entitled for the insured amount. Hence, we are of the opinion that, the act of Opposite Party to repudiate claim of the Complainant is deficiency in service on the part of the Opposite Parties.
In the result, the complaint is allowed in part, directing the Opposite Parties, jointly or severally, to pay an assured amount of Rs.1,00,000/- (Rupees One Lakh only) to the Complainant and to pay compensation of Rs.20,000/- (Rupees Twenty Thousand only) towards deficiency in service and to pay Rs.10,000/- (Rupees Ten Thousand only)towards the cost of the proceedings. The order shall be complied within 30 days from the date of receipt of this order, failing which the whole amount will carry 8% interest per annum from the date of default till realization.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 3rd day of April 2024.
Date of Filing:-19.07.2021.
PRESIDENT : Sd/-
MEMBER : Sd/-
APPENDIX.
Witness for the Complainant:-
PW1. Prahladan. K. LD Clerk, KSBC.
PW2. Dr. Dineesh. P. Doctor.
Witness for the Opposite Parties:-
OPW1. Balu. M. Deputy Manager, Legal.
Exhibits for the Complainant:-
A1. Corona Rakshak Policy, Certificate of Insurance for the period of
31.07.2020 to 12.05.2021.
A2. Copy of Discharge Summary.
A3. Claim Repudiation Letter. Dt:26.04.2021.
Exhibits for the Opposite Parties:-
B1. Copy of Corona Rakshak Policy, Certificate of Insurance for the
period of 31.07.2020 to 12.05.2021.
B2. Copy of Covid-19 Guidelines.
PRESIDENT :Sd/-
MEMBER :Sd/-
/True Copy/
Sd/-
ASSISTANT REGISTRAR
CDRC, WAYANAD.
Kv/-
