IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated this the 31st day of October, 2022
Present: Sri. Manulal V.S. President
Smt. Bindhu R. Member
Sri. K.N. Anto, Member
C C No. 151/2021 (filed on 16-08-2021)
Petitioner : Sunitha Bijumon,
W/o. Bijumon,
Chakiriyattinchira,
Cheepunkal, Kumarakom,
Kottayam – 686563.
(Adv. Amala Prasad and
Adv. K. Karjet)
Vs.
Opposite Party : (1) The Oriental Insurance Company
Ltd. Divisional Office No.1,
Mattheethar Building,
III Floor, Baker Junction,
M C Road, Kottayam – 686001
(2) Branch Manager,
The Oriental Insurance Company Ltd. Divisional Office No.1
Matteethara Building,
III Floor, Baker Junction,
M C Road, Kottayam – 686001
(Op1 and 2, Adv. P.C. Chacko)
O R D E R
Sri. Manulal V.S. President
The complaint is filed under Section 35 of the Consumer Protection Act, 2019.
Crux of the complaint is as follows:
The complainant availed Corona Rakshak health insurance policy from the first opposite party through second opposite party. The said policy is a health insurance policy covering corona virus disease and it covers a sum of Rs. 2,50,000/. The period of insurance is from 4-8-2020 to 15-5-2021. On 29-4-21 the complainant was diagnosed as covid positive. She was advised by the doctor at Samohiya Arogya Kendram, Kumarakom, for hospitalization for 14 days and to undergo quarantine for seven days after the covid is negative, but for the reason that the hospitals are flooded with covid patients and there was no bed or housing facility available, the government by its Covid 18 treatment protocol directions as per the treatment guidelines issued on 10th May 2020 , by the ministry of health and family welfare the covid patients with mild symptoms were compelled to remain at home with medical supervision. In the said circumstances the complainant was compelled to undergo home quarantine considering it as hospitlization due to Govt rule.
The complainant lodged claim to the opposite party on 23-6-21 along with the documents. But the opposite party repudiated the claim stating that “as per policy coverage 4.1 Lump sum benefit equal to 100% of the sum insured shall be payable on positive diagnosis of covid 19 and hospitalisation for 72 hours and that the condition, hospitalization for minimum continuous period of 72 hours is not complied.”
The opposite party illegally repudiated the genuine claim of the complainant. It is averred in the complaint that the ground stated for the repudiation was not made known to the complainant. According to the complainant the act of the opposite party amounts to unfair trade practice and deficiency in service and she had suffered huge mental agony and hardship and financial loss due to the actions of the opposite party. Hence this complainant is filed by the complainant praying for an order to direct the opposite party to pay Rs.2.5 lakhs along with interest.
Upon notice opposite parties appeared before the Commission and filed version as follows:
The complainant has availed the policy for the period from 4-8-2021 to 15-5-2021. The complainant obtained the policy knowing the terms and conditions . The allegation that the complainant was tested positive for corona virus on 21-4-21 is not correct. The further allegation that the complainant was advised by the doctor for hospitalization for 14 days and undergo quarantine for 7 days after the covid is tested negative and since hospitals are flooded with covid patients and no bed was available for housing facilities, the government by its order dated 10-5-20 by the ministry of health and family welfare the covid patients with mild symptoms were compelled to remain at home with medical supervision etc are not correct. To avail benefit under the policy, is only on positive diagnosis of covid -19 and should have a hospitalization in a hospital designated for covid-19 treatment by government for a minimum period to 72 consecutive inpatient care hours. On receipt of claim form it was thoroughly scrutinized and found that the claim of the complainant was not maintainable in view of clause 4.1 of terms and conditions of the policy. Home quarantine for covid 19 is not coverable under the policy. Since none of the conditions of the policy was compiled by the complainant , the opposite party was forced to repudiate the claim and it was timely intimated to the complainant by letter dated 2-7-21 and thus there is no deficiency in service in processing the claim or repudiating the claim of the complainant..
Complainant filed proof affidavit in lieu of chief examination and marked exhibit A1 to A6. Nina George. who is Assistant manager of the opposite party’s Kottayam branch filed proof affidavit and filed exhibit B1 and B1(a) marked from the side of the opposite party.
On evaluation of complaint, version and evidence on record we would like to consider the following points.
- Whether there is any deficiency in service or unfair trade practice on the part of the opposite party?
- If so what are the reliefs and costs?
For the sake of convenience we would like to consider the point number 1 and 2 together.
There is no dispute on the facts that the complainant had availed a Corona Rakshak health insurance policy from the first opposite party vide Exhibit A1 policy schedule . The policy was valid from 4-8-2021 to 15-5-2021. On perusal of exhibit A1 we can see that the basic sum assured was Rs.2,50,000/-. Clause 4.1 of B1(a) policy document of the insurer describes the lump sum benefit equal to 100 % of the sum assured shall be payable if the insured person is diagnosed covid positive and hospitalized for minimum 72 hours following medical advice of a duly qualified medical practitioner. It is proved by Exhibit A2 that the complainant was tested covid positive on 29-4-2021. Exhibit A3 proves that the complainant had consulted the doctor at Samohiya Arogya Kendram, Kumarakom, on 29-4-21 she was advised to undergo for home quarantine with medication.
Complaint was resisted by the opposite parties, stating that the home quarantine for covid 19 is not covered under the policy. The counsel for the opposite party relied on clause 4.1of the terms and conditions of the policy, which is reproduced here under,
4.1 Covid Cover Lump sum benefit equal to 100% of the sum insured shall be payable on positive diagnosis of Covid , requiring hospitalization for minimum continous period of 72 hours . the positive diagnosis of covid shall be from a government authorized diagnostic centre.
Note. i. Payment shall be only on hospitalization for a minimum continuous period of 72 hours following positive diagnosis for Covid.
ii. This is onetime benefit applicable for the entire tenure of the policy and shall terminate upon payment of this benefit.
Thus it is clear that for availing the coverage of the policy there shall be hospitalization for a minimum continuous period of 72 hours .Clause 3.7 of B1(a) define hospitalization as admission in a hospital designated for covid -19 treatment by the government, for a minimum period of 72 consecutive in patient care hours and clause 3.8 define in patient care as treatment for which the insured person has to stay in a hospital continuously for more than 72 hours for treatment of covid.
Admittedly the complainant was under home quarantine and she was not hospitalized for the treatment for covid-19. Moreover according to the complainant , the government by its Covid 19 treatment protocol directions as per the treatment guidelines issued on 10th May 2020 , by the ministry of health and family welfare the covid patients with mild symptoms were compelled to remain at home with medical supervision.
Therefore it is clear that if the treating doctor advised the complainant to undergo for home quarantine , then the complainant have only mild symptom and no the hospitalization was required for her treatment. On the evaluation of the evidence we are of the opinion that the opposite party is not bound to pay the insured sum for the covid persons who are under home quarantine only.
The Hon’ble Supreme Court in a recent Judgment dtd. 6th October 2021 i.e. in “SGS India Limited v/s Dolphin International Limited”, categorically held that the onus of proof that there was deficiency in service is on the complainant.
Here in this case as discussed above we are of the opinion that the complainant has failed to prove any deficiency in service on the part of the opposite party. Thus the complaint is dismissed
Pronounced in the Open Commission on this the 31st day of October, 2022
Sri. Manulal V.S. President Sd/-
Smt. Bindhu R. Member Sd/-
Sri. K.M. Anto, Member Sd/-
Appendix
Exhibits marked from the side of complainant
A1 – Copy of insurance policy No.441300/48/2021/1262 issued by opposite party
A2 – Copy of antigen test of petitioner report dtd.29-04-21
A3 – Copy of O P ticket dtd.29-04-21 from Samoohika Arogya Kendram, Kumarakom
A4 - Copy of antigen test report of petitioner dtd.17-06-21
A5 – Copy of claim form
A6 – Copy of letter dtd.02-07-21 by opposite party to petitioner
Exhibits marked from the side of opposite party
B1 - Copy of insurance policy No.441300/48/2021/1262 issued by opposite party
B2 – Copy of terms and conditions of policy .
By Order
Assistant Registrar
