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 Rs.1,50,000/- as the claim amount with 12% interest and cost of the complaint.

Complaint in brief :-

   According to the complainant,  he was a holder of corona Rakshak policy issued by OP covering the period from 13/10/2020 to 24/7/2021 .  The policy was  cover all medical expenses necessarily and reasonably incurred for  inpatient hospitalization  and treatment of  covid -19 decease. The complainant was not feeling well on 29/10/2020, so he went to Govt. Hospital Kannur , from there he was detected covid positive and thereafter he was treated as inpatient from 2/11/2020 to 7/11/2020 . He had also complied  the home quarantine for a period upto 17/11/2020.  The complainant was diagnosed with covid during the insured period and was hospitalized for more than 72  hours as per the norms  specified by Ministry of Health  and Family welfare, Govt. of India.  Due to attack corona , the health of the complainant was badly affected.  He had spend an amount of Rs.8000/- for  intake of various vitamins.  The complainant approached the OP  seeking the claim benefit of policy with all the documents.  The OP denied the policy on the ground that claim  his  within the waiting period. According to  complainant he was  detected with covid on the 17^th day of taking the policy and so his case will not come within the waiting period.  Since the claim was  derived and  complainant asserted that there is a deficiency in service on the part of the OP.  Hence this complaint.

    After filing the complaint, commission  sent notice  to OP and  OP entered  appearance before the commission and filed their version accordingly.

Version of   OP in brief:

    The OP denied the entire averments except those specifically admitted.  The  OP denied the claim of the complainant  that the complainant  had taken insurance  for himself and his wife on 13/10/2020.  The complainant’s wife tested Covid positive on 18/10/2020 and the complainant was under home quarantine from 19/10/2020 onwards.  Due to fever, breathlessness, headache, tiredness etc for more than two days, the complainant went to Govt. Hospital on 29/10/2020 and tested covid  positive.  The complainant was under primary contact list of a covid patient from 18/10/2020 onwards and he was infected with  covid within 15 days of commencement of the policy.  The complainant willfully delayed the covid  test in order to avoid the waiting period exclusion of 15 days.  The facts being so, as per the terms and conditions of the policy, the complainant is not eligible for the insurance claim and this was informed by  OP and there is no deficiency of service on their part. Hence OP prayed the complaint 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.

1. Whether there is any deficiency in service from the part of  OP?
2. 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 A4.    Ext.A1 is the Doctor’s prescription dtd.29/10/2020.  Ext.A2 is the RTPCR test  was prescribed  and complainant tested covid positive(Report of Medical Board).  Ext.A3 is the report of OP(Repudiation letter) and Ext.A4 is he Discharge summary issued by District Govt. Hospital Kannur. The complainant adduced evidence through proof affidavit and examined as PW1.  The OP produced one document that is  policy schedule with  condition marked as Ext.  OP adduced evidence through proof affidavit and  examined as DW1.  Both parties filed argument note.

   The parties to the complaint produced their document.  Let us have a clear glance into the documentary  as well as oral evidence of parties to answer the issues raised.

   Here the commission is in the view that there is no detailed discussion is necessary with regard to the Ext.B1(insurance policy) as there is no dispute between the parties  about  policy validity.  The dispute arise when the  policy sum assured was denied by OP stating that complainant is not eligible to get the benefit on the basis of clause 3.20 and 5 of Ext.B1.  On the perusal of Ext.B1, it is seen that policy time and date is shown as 10.a.m on 13/10/2020 which specifies that complainant took the policy on the said time and date.  As per the clause 3.20 and 5 of the Ext.B1, the waiting period commence from 10. A,M of 13/10/2020 and will end on 10. A.M of 28^th October 2020.  The question arise whether the  complainant diagnosed corona before the waiting period.  On the perusal of Ext.A1 dtd.29/10/2020 doctor advised RTPCR and as per Ext.A2, complainant is Covid positive.  According to Ext.A4 the complainant underwent 6 days treatment of District Hospital ,Kannur.  From these Exhibits the commission hold the view  that the complainant fulfilled the mandate period of 72 hours of treatment as specified in  clause 3.8 of Ext.B1.  But the OP raised the contention that complainant is on home quarantine from 18/10/2020 as complainant’s wife was affected corona positive.  Being , the primary contact, OP  assured that complainant  may also get infected  from  18/10/2020.  During the re-examination  complainant specifically deposed that he underwent quarantine at his quarters. No evidence produced by OP to disprove the claim.  Moreover , during the cross examination of OP he deposed that no clauses in the policy stated that a person who underwent home quarantine is considered to be infected.  There is another dispute with regard to Ext.A1  dtd.29/10/2020 it denotes complainant is fever for 2 days but as per the  policy waiting period ends at  10.a.m of 28^th October  and complainant will not be disqualified to avail the benefit of Ext.B1 on the basis of waiting period.

     Hence  the commission came into a conclusion that complainant is entitled to get Rs. 1,50,000/- the sum assured specified  in Ext.B1 due to the deficiency in service from the side of  OP by  denying the  sum assured in Ext.B1 and also entitled to get compensation of Rs.10,000/- for the deficiency in service by OP even after complainant produced all relevant documents before the OP and the OP denied their service by stating  the reason of non-compliance of waiting period.

     In the result the complaint is allowed in part.  The opposite party is directed to pay Rs.1,50,000/- as sum assured specified in Ext.B1 and also pay Rs.10,000/- as compensation and cost of litigation  to  the complainant  within 30 days of receipt of this order.  In default, the amount of Rs.1,50,000/- carries interest@ 9% per annum  from the date of order till realization , failing which the   complainant is  at liberty to  execute  the  order as  per the  provisions  of Consumer Protection Act 2019.

Exts:

A1-Doctor’s  Prescription

A2- Covid test report

A3-Repudiation letter

A4-Discharge summary

B1- Policy schedule with condition

PW1-Biju.K- complainant

DW1Anoop.P.Tilak- witness of OP

Sd/                                                           Sd/                                                    Sd/

PRESIDENT                                             MEMBER                                               MEMBER

Ravi Susha                                       Molykutty Mathew                                    Sajeesh K.P

eva           

                                                                       /Forwarded by Order/

                                                                   ASSISTANT REGISTRAR