SRI. SAJEESH.K.P : MEMBER
The complainant has filed this complaint under Sec.35 of the Consumer Protection Act 2019, seeking direction against the OP to pay an amount of Rs.2,00,000/- as the benefit equal to the 100% of the sum assured payable on positive diagnosis Covid 19 as per the Corona Rashak policy and also pay Rs.50,000/- as to the complainant .
Complaint in brief :-
According to the complaint, complainant took an insurance policy belong to OP named as Corona Rashak which is a health benefit policy having sum assurance on positive diagnosis of covid -19 which requires minimum conditions period of 72 hours and diagnosis of covid shall be from a govt. authorized center. The complainant paid Rs.2079/- as gross premium and the sum assured was Rs.20,000/- and the period of insurance commence from 27/8/2020 to 7/6/2021. The complainant got infected by corona virus and tested at District Government Hospital Kannur on 22/11/2020 an underwent treatment at Kannur Medical College as inpatient. Thereafter complainant discharged after 4 days of hospitalization. As per the condition of policy. Complainant is entitled to get the coverage of policy which he was taken and the complainant submitted claim form duly filled by the Resident Medical Officer of district hospital Kannur. The complainant sent all the documents demanded by OP but to the surprise, on 12/4/2021, the claim made by complainant was rejected by OP by stating the reason that as per the stipulation of policy, the hospitalization of complainant will not be justified and complainant took only oral medication. Moreover, rejection letter also stated the policy requires 72 hours admission. The claim was decided on flimsy conditions and hence this complaint.
After filing the complaint, commission has sent notice to OP and the OP entered appearance before the commission and filed their version accordingly .
Version of OP in brief:
The OP denied the entire averment except those specifically admitted . According to OP, clause 2 of the policy clearly indicates that of the insured person is diagnosed with covid and hospitalized for more than 72 hours following medical admission of a duly qualified medical practitioner as per the norms specified by Ministry of Health and family welfare. The hospital records and treatment records produced by complainant doesn’t satisfy the stipulations of policy. The complainant never produced any of the records to show his continuous hospitalization for more than 72 hours. The time of discharge is not shown in any of the records produced by complainant. Therefore the complainant failed to substantiate his claim. Moreover, the doctor examined his prescribed oral medication only for 5 days and he was advised to undergo home quarantine for 10 days. The OP is liable to give insurance benefit to the insured only if the terms and conditions are fully satisfied and thereby the claim was rejected and there is no deficiency in service from the side of OP and the complaint is false and frivolous and is liable to be dismissed.
Due to the rival contentions raised by the OP to the litigation, the commission decided to cast the issues accordingly.
- Whether there is any deficiency in service from the side of OP?
- Whether there is any compensation & cost to the complainant?
In order to answer the issues, the commission called evidence from both parties. The complainant produced documents which is marked as Exts.A1 & A2and Ext.X1 series. Ext.A1 is the insurance policy issued by OP and Ext.A2 is the claim rejection letter issued by OP and Ext.X1 series is the case records from Health & Family Welfare Department Kerala,District Covid -19 Treatment Centre,Anjarakandy,Kannur. The complainant adduced evidence through proof affidavit and examined as PW1. OP produced documents which is marked as Exts.B1 to B8. Ext.B1 is the certified copy of insurance policy. Ext.B2 is the claim form, Ext.B3 is the OP ticket, Ext.B4 is the Discharge card, Ext.B5 is the certificate issued by Medical Officer,Kannur District Hospital, Ext.B6 is the OP ticket, Ext.B7 is the certificate issued by Health Center, Peralassery and Ext.B8 is the certificate issued by District Health Officer, Kannur. No oral evidence from the side of OP.
On the perusal of documents produced by parties as well as the court exhibits, the commission looked in to Ext.A1(Ext.B1) which was issued by OP to complainant, it is seen that it goes in tune with version. Ext.A2 which is issued by OP to complainant stating the reasons of rejection. Here the dispute arise with regard to the application of operative clause in Ext.B1. First upon let us have clear glance into the deposition given by complainant during the cross-examination of PW1 clearly deposes that at the time of discharge he was not mentioned anywhere in Exts.B2 to B8 documents produced in order to prove one of the operative clause of Ext.B1, ie, 72 hours of admission required to get the claim benefit except Ext.X1 series . On the perusal of Ext.X1 series(case records of complainant) issued by District Medical Officer, Kannur clearly indicates that the date of admission is 2.45 p.m on 22/11/2020 and the date of discharge shown as 6.p.m on 25/11/20220 that means the complainant underwent treatment of Corona for 75 hours when the Ext.B1 demands only 72 hours of admission. The version of OP was filed on 17/9/2021 and explained the reasons of rejection of claim. Thereafter, on 4/1/2022 complainant filed petition to call for the documents and on 1/11/2022 the Dist. Medical Officer produced documents which was marked as Ext.X1 series, in order to show the exact time and date of admission and discharge of complainant. At the time of production of documents by complainant to claim the benefit under the policy issued by OP, no documents(Exts.B2 to B8) revealed the duration of admission. It is revealed only after the production of Ext.X1 series on 1/11/2022 by the District Medical Officer,Kannur. Hence, the commission is in the view that at the time when rejection of claim made by OP, there was no deficiency in service as the complainant failed to produce documents showing the exact time of admission to avail the claim benefit. But after the production of Ext.X1 series, the complainant is entitled to get the benefit of claim as assured by Ext.B1. Therefore issue No.1 is answered accordingly.
As per the Exts.B2 to B8, the time of admission and discharge is not seen and the complainant is there by eligible to get the sum assured on the policy issued by OP. But as discussed later, the claim rejection by OP was prior to the production of Exts.B2 to B8 . Hence it is clear that there is no deficiency in service and the complainant is not entitled to get compensation and cost.
In the result complaint is allowed in part, the opposite party is directed to pay Rs.2,00,000/- towards the claim amount as per Ext.A1(Ext.B1) policy to the complainant within 30 days of receipt of this order. No compensation and cost. In default the amount of Rs. 2,00,000/- carries 12% interest per annum from the date of order till realization .Failing which complainant is at liberty to file execution application against opposite party as per the provisions of Consumer Protection Act 2019.
Exts:
A1-Copy of insurance policy
A2- Rejection letter.
X1 series – case records of complainant
B1- Ext.A1
B2- Claim form
B3- OP ticket
B4- Certificate issued by Medical officer,
B6- OP ticket
B7-Certificate issued by Health Center
B8- certificate issued by Deist. Health Officer.
PW1-Nafseer.T.C-complainant.
Sd/ Sd/ Sd/
PRESIDENT MEMBER MEMBER
Ravi Susha Molykutty Mathew Sajeesh K.P
eva /Forwarded by Order/
ASSISTANT REGISTRAR
