By: Sri. Mohamed Ismayil C.V., Member
The grievance of the complainant is as follows:
1. It is averred in the complaint that on 20/07/2020 an agent of the opposite party (Intermediary code BA0000044955) approached the complainant and introduced a scheme of health insurance policy named Corona Rakshak. As per the information given by the agent, the complainant and his wife would be covered for an amount of Rs 2,50,000/- each for a period of 285 days, if either the complainant or his wife is hospitalised for treatment of Covid-19 for more than 72 hours in any Government or Government approved Hospitals. Believing the words of opposite party’s agent, on 28/07/2020 the complainant availed above said insurance policy and paid premium amount of Rs.12,358/- to the opposite party and the opposite party issued policy document No P/181312/01/2021/002600. Thereafter the complainant suffered symptoms of Covid-19 on 27/09/2020 and on 29/09/2020 he undergone for RTPCR Test. On 02/10/2020 the test result revealed as Covid-19 positive, so the complainant was admitted to Government Medical College Hospital, Manjeri and treated for Covid-19 and on 08/10/2020 he discharged from the hospital. According to the complainant, he undergone treatment of Covid-19 for seven days i.e. 168 hours in Government Medical College Hospital, Manjeri during the pendency of policy. The complainant submitted insurance claim form with all original documents to the opposite party for securing insurance benefit but the opposite party repudiated the claim No CIR/2021/1813120374858 of complainant on the ground that requiring hospitalisation and not for institutional quarantine. It is stated by the complainant that he was hospitalised for seven days in Government Medical College Hospital, Manjeri. So he is entitled to get Rs 2,50,000/- under the coverage of policy. According to the complainant the claim of the complainant was repudiated arbitrarily and reason stated for repudiation was illegal, unfair, against the principle of natural justice, and opposed to the terms and conditions of the policy. The act of the opposite party has caused deficiency in service and unfair trade practice. It is also contented by the complainant that he suffered a lot of hardship, mental agony and pain due to the deficient act of the opposite party and so the complainant approached the Commission to get redressed his grievances. The complainant prayed to get an order directing the opposite party to pay Rs 2,50,000/- with interest at the rate of 12% per annum from 07/12/2020, date of claim till its realisation. The complainant claimed Rs 1,00000/- from the opposite party as compensation for mental agony, hardship and pain suffered due to the act of opposite party. The complainant also claimed Rs 25,000/- as cost of the proceedings from the opposite party. Hence the complainant was entitled to get Rs 2,50,000/- as full amount of insurance coverage from the opposite party as per the terms and conditions of the policy.
2. The complaint is admitted on file and issued notice to the opposite party. The opposite party entered appearance through counsel and filed version.
3. The opposite party denied averments and allegations made in the complaint except those portions which are specifically admitted. According to the opposite party the complainant has no bonafides and filed the complaint with ulterior motive. It is admitted by the opposite party that the complainant had availed insurance policy from a period commencing from 28/07/2020 to 09/05/2021 covering the complainant and his wife for a sum of Rs 2,50,000/- each wide policy No P/181312/01/2021/002600. At the time of issuance of policy, the complainant was supplied with terms and conditions of the policy and explained the content and policy schedule also handed over to him. According to the opposite party after accepting the terms and conditions the complainant availed the policy. The opposite party conceded that claim application No CIR/2021/181312/0374882 along with the claim form and discharge card from Government Medical College Hospital, where submitted by the complainant stating that the complainant had undergone treatment for Covid-19 from 02/10/2020 to 08/10/2020. It is contented by the opposite party that no details of treatment were disclosed in discharge card submitted by the complainant. The condition of the patient, level of spO2 and line of treatment given to the patient were not mentioned. More over patient was asymptomatic and stable as per the observation made by the doctor. It is also stated in the version that complainant was asymptomatic and no active line of treatment was taken. According to the opposite party as per the terms and conditions of the policy the claim shall be payable on positive diagnosis of covid-19 requiring hospitalisation for a minimum period of 72 hours. It is also added in the version that corona symptoms like fever, sour throat, headache, loss of smell or taste, running nose, nausea or omitting, diarrhoea or breath difficulty were absent and hence it doesn’t require admission in a hospital. No specific treatment was given to the complainant and no documents are submitted other than discharge card.
4. According to the opposite party in patient care means treatment for which the insured person has to stay in a hospital continuously for more than 72 hours for treatment of Covid-19. In this case no treatment was provided to the complainant. It is also contented by the opposite party that patient was asymptomatic and stable and stayed at hospital only for observation i.e. under institutional quarantine. So according to the opposite party the claim is repudiated based on the terms and conditions of the policy. It is also stated in the version that all provisions of law should be literally interpreted unless the provision or clause has an alternative construction to its ordinary meaning. In contract of insurance the rights and obligations are governed by terms of the contract. The terms of the contract of insurance had to be strictly construed and no exemptions can be made on ground of equity. It is admitted in the version that the opposite party returned original discharge summary and original OP card to the complainant vide letter dated 23/04/2021. It is also stated in version that there has been no violation of the policy condition by the opposite party. According to the opposite party, the complainant has not suffered any hardship, mental agony and pain. There was no wilful negligence or deficiency of service from the part of the opposite party .So the complainant is not entitled for compensation of Rs 1,00000/-. The opposite party is working under the guideline of IRDA controlled by Government of India and dealt with public money held in trust and must exercise abundant caution in dealing with the claims of its clients. So the opposite party prayed for dismissal of this complaint with compensatory cost.
5. The complainant and the opposite party filed affidavits. Both parties were also produced documents to support their contentions raised before the Commission. The documents filed by the complainant marked as Ext A1 to A4. Ext A1 document is the copy of insurance policy certificate issued by the opposite party to the complainant. Ext A2 series documents include copy of claim form submitted by the complainant to the opposite party is marked as Ext A2(a) document, copy of discharge card is marked as Ext A2(b) document and casualty ticket dated 29/09/2020 issued from Government Medical College Hospital, Manjeri is marked as Ext A2(c) document. Ext A3 document is the copy of repudiation letter dated 07/12/2020 issued by the opposite party to the complainant. Ext A4 document is the copy of letter sent by complainant to the grievance redressal officer of opposite party demanding to pay the insured amount. The opposite party also filed documents and marked as Ext B1 to B5. Ext B1 document is the copy of policy schedule and condition issued to the complainant by the opposite party. Ext B2 document is the copy of discharge card issued by Government Medical College Hospital, Manjeri. Ext B3 document is the copy of repudiation letter dated 07/12/2020 issued by the opposite party to the complainant. Ext B4 document is the copy of request dated 19/04/2021 submitted by the complainant to the opposite party. Ext B5 document is the copy of letter dated 23/04/2021 issued by the opposite party to the complainant for returning of documents submitted along with claim application.
6. Heard both sides in detail. Perused affidavits and documents. The complainant filed notes of argument also and gone through it. The following points arisen for the consideration of the Commission:
(1) Whether the opposite party committed deficiency in service towards the
Complainant?
(2) If yes, relief and cost.
7. Point No (1) and (2).
The complainant stated that on 28/07/2020 he availed an insurance policy coverage from the opposite party worth Rs 2,50,000/- for a period of 285 days and made payment of Rs 12,358/- as premium. According to the complainant the policy scheme was introduced by the agent of the opposite party and policy was titled as Corona Rakshak policy. As per terms and conditions of the policy the complainant and his wife were covered if either of them hospitalised for treatment of Covid-19 for more than 72 hours in any Government or Government approved hospital. The complainant produced Ext A1 document to prove that he was under the coverage of the insurance policy. Unfortunately, on 27/09/2020 the complainant suffered symptoms of Covid-19 and RTPCR test was conducted on 29/09/2020 from Government Medical College Hospital, Manjeri. On 02/10/2020 the test result was came out and he became Covid-19 positive and immediately he admitted in the hospital for treatment. He was discharged from the hospital on 08/10/2020. The complainant produced Ext A2 (b) and Ext A2 (c) documents to prove the treatment undergone in the hospital. Ext A2 (b) document is the copy of discharge card and Ext A2 (c) is the copy of casualty ticket issued from Government Medical College Hospital, Manjeri. Under the strength of insurance policy coverage the complainant submitted claim application for getting Rs 2,50,000/- from the insurer, opposite party. The claim form submitted before the opposite party was marked as Ext A2 (a). But the opposite party repudiated the claim on the ground that lump sum benefit shall be payable on positive diagnosis of Covid, requiring hospitalisation and not for institutional quarantine. The repudiation letter was produced before the Commission and marked as Ext A3 document. Subsequently the complainant issued a letter to the opposite party demanding to pay the insured amount and same letter is marked as Ext.A4 document. But, on the contrary, the opposite party contented that the claim No. CIR/2021/151312/0374858 of the complainant was repudiated on the ground of requiring hospitalisation for minimum period of 72 hours. The opposite party produced copy of insurance certificate before the Commission and marked as Ext B1 document. Ext B1 document and Ext A1 document are one and same. The opposite party also produced discharge card and marked as Ext B2 document. Ext B2 document and Ext A2 (b) document are one and same. The opposite party produced repudiation letter and marked as Ext B3 document. Ext B3 document and Ext A3 document are one and same. According to the opposite party the complainant was asymptomatic and no hospitalisation was warranted. More over the opposite party contented that Corona symptoms like fever, sore throat, headache, loss of smell or taste, congestion or runny nose, nausea or vomiting, diarrhoea or breathing difficulty were absent in the complainant. According to the opposite party the complainant made an application to get back the documents submitted for insured amount. The copy of application also produced by the opposite party and same is marked as Ext B4 document. Ext B5 document was issued by the opposite party and which shows that discharge summary and OP record were produced at the time of making claim application before the opposite party. When going through Ext A2(c) document it can be seen that the complainant was approached for medical aid with symptoms of Covid-19 disease. Ext A2(c) document clearly says that at the time of conducting RTPCR test he was affected with sore throat, nasal block and headache. The Commission also finds that the opposite party utterly failed to scrutinize the above said document produced for securing insured amount. When going through Ext A2 (b) document (the opposite party produced same document and marked as Ext B2). It can be seen that he was hospitalised in Government Medical College Hospital, Manjeri on 02/10/2020 and discharged on 08/10/2020. From the content of Ext A2 (b) document it is evident that the complainant had hospitalised for seven days. As per the terms of policy it was sufficient period to release the insured amount to the complainant. During the time of pandemic due to the influx of patients, Government was bound to find out many mechanism for their treatment. The government has got power to decide the treatment protocol to deter Corona virus with the aid of medical experts. It is not fair on the part of the opposite party to dictate the terms of protocol for treatment of Covid-19 pandemic especially in a situation where in the entire world was stunned over the pandemic. During those time of pandemic, the only way available to the patients to follow the stringent instructions of the authority including doctors. So, if any kind of shifting of patient as part of arrangement for treatment from Government Medical College hospital to another premise took place, that would not change the nature and condition of the disease affected to the patient. In this juncture the content in Ext A2 (a) document cannot be treated as the complainant had undergone for institutionalised quarantine. From the available evidence it can be find that the complainant had undergone treatment for Covid-19 disease as per the terms of the insurance policy. So the act of repudiation on the part of the opposite party can be treated as deficiency in service. The Commission also finds that the opposite party acted arbitrarily which resulted mental agony and hardship to the complainant. So the Commission allows the complaint as follows:
- The opposite party is directed to pay Rs 2,50,000/- to the complainant as the insured amount of the policy No. P/181312/01/2021/002600.
- The opposite party is directed to pay Rs. 50,000/- to the complainant as compensation for the mental agony and hardship suffered by the complainant due to deficiency in service of the opposite party.
- The opposite party also directed to pay Rs 10,000/- as the cost of the proceedings to the complainant.
The opposite party shall comply this order within one month from the date of receipt of this order, otherwise the entire amount shall bear 9% of interest per annum from date of order till realisation.
Dated this 2nd day of December , 2022.
Mohandasan K., President
PreethiSivaraman C., Member
Mohamed Ismayil C.V., Member
APPENDIX
Witness examined on the side of the complainant: Nil
Documents marked on the side of the complainant: Ext.A1to A4
Ext.A1: Copy of insurance policy certificate issued by the opposite party to the
complainant.
Ext.A2 (a) : Copy of discharge card..
Ext A2(b) :Casualty ticket dated 29/09/2020 issued from Government
Medical College Hospital, Manjeri..
Ext A2(c) : Copy of casualty ticket issued from Government Medical College
Hospital, Manjeri.
Ext A3: Copy of repudiation letter dated 07/12/2020 issued by the opposite party to the
complainant.
Ext A4: Copy of letter sent by complainant to the grievance redressal officer of
opposite party demanding to pay the insured amount.
Witness examined on the side of the opposite party: Nil
Documents marked on the side of the opposite party: Ext. B1 to B5
Ext.B1: Copy of policy scheduled and condition issued to the complainant by the opposite party.
Ext.B2: Copy of discharge card issued by Government Medical College Hospital, Manjeri.
Ext.B3: Copy of repudiation letter dated 07/12/2020 issued by the opposite party to the complainant.
Ext.B4: Copy of request dated 19/04/2021 to the opposite party submitted by the complainant to the opposite party.
Ext.B5: Copy of letter dated 23/04/2021 issued by the opposite party to the complainant for returning of documents submitted along with claim application.
Mohandasan K., President
PreethiSivaraman C., Member
Mohamed Ismayil C.V., Member
VPH
