SRI. SAJEESH.K.P : MEMBER
The complainant has filed this complaint under Sec.35 of the Consumer Protection Act 2019, seeking direction against the OPs to pay the insured amount of Rs.2,50,000/- and also pay Rs.2,00,000/- as compensation to the complainant .
Complaint in brief :-
Due to the Covid pandemic -19 , the 1st OP introduced a new health insurance policy and on the basis of conditions on insurance policy, complainant took a policy on 18/7/2020-27/4/2021 for a premium of Rs.1082/-. On 15/10/2020 complainant had undergone RTPCR due to the physical discomfort and diagnosed covid positive and isolated in home quarantine . After his physical condition worst , he was admitted at General Hospital,Thalassery as in patient on the advise of doctor and treated as IP from 22/10/2020 to 26/10/2020. After recovery, complainant approached OPs with necessary documents to claim insurance benefit OPs sent to claim repudiation letter stating that produced medical certificate from the treated doctor for need of hospitalization and declined complainant’s claim even though he produced all other valid documents of treatment issued from the hospital . Due to the deficiency in service and unfair trade practice, complainant filed this complaint.
After filing the complaint, commission sent notice to both OPs and both OPs entered appearance before the commission and filed their version accordingly .
Version of OPs in brief:
At the very outset, the OPs denied all allegations contained in the complaint except those admitted here under. The policy is admitted by OPs. The OPs faced difficulty to decide the admissibility of the claim due to the lack of proper documents like medical certificate, classification from treating doctor etc. The complainant failed to provide the documents within 30 days from 1st intimation date 8/12/2020 as mentioned in Document Recovery Intimation letter. Thereafter on 7/1/2021 and 6/2/2021, the OPs gave chance to complainant to produce. As the insurance policy is a contract between parties, both parties are liable to follow the terms and conditions. The complainant failed to comply the conditions and terms of policy and hence not entitled to get any relief sought. Hence the complaint is liable to be dismissed.
Due to the rival contentions raised by the OPs to the litigation, the commission decided to cast the issues accordingly.
- Whether there is any deficiency in service from the side of OPs?
- 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 to A9 . Ext.A1 is the original insurance policy certificate issued by OPs, Ext.A2 is the medical certificate dtd.2/11/2020 issued by Medical Officer Primary Health Center, Kottayam Malabar, Ext.A3 is the admission/discharge certificate dtd.22/10/2020 issued by General Hospital Thalassery, Ext.A4 is the claim repudiation letter dtd.10/2/2021, Ext.A5 is the copy of lawyer notice with postal receipt, Exts.A6 &A7 are the Acknowledgment card to Ops 1&2, Ext.A8 is the reply notice dtd.27/5/2021, Ext.a9 is the certified copy of case record issued by General Hospital Thalassery. The complainant adduced evidence through proof affidavit and examined as PW1. After that complainant filed witness list and according to witness list one Doctor Sasidharan, Senior Medical Officer, General Hospital , Thalassery was examined as PW2. The OPs have no oral evidence, produced documents which is marked as Exts.B1 to B7. Ext.B1 is the copy of policy schedule, Ext.B2 is the copy of claim intimation form, Ext.B3 is the copy of medical documents, Ext.B4 is the copy of document recovery intimation letter dtd.8/12/2020, Ext.B5 is the second document Recovery Intimation letter dtd.7/1/2021, Ext.B6 is the copy of claim Repudiation letter and Ext.B7 is the copy of policy guidelines.
Let us have a clear glance into the documents produced by both parties in order to answer the issues raised. On the perusal of Ext.A1, the policy form, waiting period, sum assured, effective policy period, the conditional requirement of 72 hours or minimum period of three continuous day of admission to claim assured, premium amount etc are in accordance with the complaint as well as version, hence no detailed discussion is necessary. The dispute arises regarding the credibility of admission and non-production of necessary documents, on the request of OPs, is to be looked into answer deficiency in service as well as unfair trade practice. It is specific from Ext.A2 that the complainant underwent home isolation on 11/10/2020 and thereafter admitted at General Hospital Thalassery from 22/10/2020 to 26/10/2020. As per the clause 4 in Ext.A1, the mandate period of 72 hours is fulfilled. Moreover, Ext.A3, issued by Junior Medical Consultant, General Hospital Thalassery who was examined as PW2, specifically stated that the complainant was admitted due to the complaint of severe fatigue. Hence, it is apparent that complainant is entitled to claim insurance as per the policy terms and norms. The another point to be discussed is with regard to the delay in production of documents by complainant as per Ext.B4 dtd.8/12/2020, Ext.B5 reminder of Ext.B4 dtd. 7/12/2021, Ext.B6 is second reminder dtd.6/2/2021. As per Ext.B7 which is the customer information sheet 7.2 of claim procedure, the mandate period submitting necessary documents is 30 days of date of discharge from hospital following positive diagnosis for covid. On the perusal nowhere it is seen that when the complainant had given documents to OPs in order to claim the insurance amount, but Document recovery intimation (Ext.B4) dtd.8/12/2020, stated that OPs received the claim of assessment, hence it can be presumed that complainant approached OP in correct time to claim the policy benefit along with the Ext.B3, the discharge summary to show the admission and discharge date and his treatment history. As per the Document Recovery Intimation, case record of complainant regarding the admission and treatment history is necessary and the complainant produced a certified copy of case records marked as Ext.A9, which has all the case history of complainant during the admission as inpatient till his discharge. The doctor who issued the certificate (Ext.A3) was cross examined by OP and the doctor (PW2) specifically stated that Ext.A3 is sufficient to know the detail of admission and discharge and the reason of admission. The OP has not adduced oral evidence. Hence the commission came into conclusion that there is deficiency in service and unfair trade practice to the extent of not allowing the claim and thereby complainant is entitled to get sum assured as per Ext.A1 and also entitled to get compensation and cost as well.
In the result complaint is allowed in part, the opposite parties are jointly and severally directed to pay Rs.2,50,000/- towards sum assured as per the policy (Ext.A1) and also pay Rs. 10,000/- as compensation and Rs.3000/- as cost of litigation to the complainant within 30 days of receipt of this order. In default the amount of Rs. 2,50,000/- carries 8% interest per annum from the date of order till realization .Failing which complainant is at liberty to file execution application against opposite parties as per the provisions of Consumer Protection Act 2019.
Exts:
A1-original insurance policy certificate
A2- Medical certificate
A3- Discharge certificate
A4- claim repudiation letter
A5- lawyer notice
A6&A7- Acknowledgment card to Ops 1&2
A8- Reply notice
A9- case records
B1- Policy schedule
B2- Claim intimation form
B3- Medical documents
B4& B5- Document recovery intimation
B6- Claim repudiation letter
B7-Copy of policy guidelines
PW1-M. Chandran-complainant.
PW2- Dr.Sasidharan- witnesses of PW1
Sd/ Sd/ Sd/
PRESIDENT MEMBER MEMBER
Ravi Susha Molykutty Mathew Sajeesh K.P
eva
/Forwarded by Order/
ASSISTANT REGISTRAR
