IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated this the 28th day of November, 2023
Present: Sri.Manulal.V.S, President
Smt.Bindhu.R, Member
Sri.K.M.Anto, Member
CC No.124/2022 (Filed on 09/06/2022)
Complainants : (1) Prakasan.T S/o Thankappan,
Kochuparambil House,
Kumarakom P.O,
Kottayam – 686 563.
(2) Beenakumari P.G W/o Prakasan.T,
Kochuparambil House,
Kumarakom P.O,
Kottayam – 686 563.
(Both by Adv: P.C. Chacko)
Vs.
Opposite parties : (1) The Oriental Insurance Company Ltd.,
TRIO Chambers,
Kanjikuzhy P.O,
Kottayam – 686 004.
(2) The Oriental Insurance Company Ltd.,
Regional Office,
Metro Palace,
Opposite North Railway Station,
Ernakulam – 682 018.
(Both by Advs: M.S. Rajagopal &
Muhammad Musthafa)
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 complainants availed Corona Rakshak health insurance policy from the first opposite party. The insurance cover was an amount of Rs.2,00,000/- each for the period of 9/10/2020 to 20/07/2021. As per the terms of the policy a lump sum benefits equal to 100% of the sum insured shall be payable on positive diagnosis of Covid requiring hospitalization for a continuous 72 hours.
The complainants approached the Government’s Community Health Centre, Kumarakom with the symptoms of severe temperature, cough, throat and body pain. After tested Covid positive, the complainants were admitted to CFLTC, Muttambalam on 3/05/2021 and were discharged on 9/05/2021 and advised home quarantine for 10 days. The first complainant became Covid negative on 14/05/2021and second complainant became negative on 9/05/2021.
The first opposite party repudiated the claim of the complainants stating that “there is no active line of treatment during hospitalization”. Thereafter the complainants submitted grievance to the second opposite party on 2/07/2021. The second opposite party rejected the claim of the complainant on 22/07/2021 for the reason that, both complainants were asymptomatic. The opposite party illegally repudiated the genuine claim of the complainants. After that the complaint filed by the complainants was dismissed by the Insurance Ombudsman stating that the patients were admitted in a CFLTC for isolation/observation and diagnostic purpose only.
According to the complainants the act of the opposite parties amounts to unfair trade practice and deficiency in service. Hence this complaint is filed by the complainants praying for an order to direct the opposite parties to pay Rs.4 lakhs and to direct the opposite parties to pay compensation of Rs.2 lakhs and Rs.50,000/- as cost of this litigation.
On receipt of notice the opposite parties appeared and filed version. The policy is admitted. The sum insured under the policy was Rs.2,00,000/- each. The insurance under the policy is subject to terms and conditions, clauses, warranties, endorsements as per conditions attached to the policy.
The complainants preferred a claim before the company alleging that they were tested Covid positive and admitted in First Line Treatment Centre CFLTC at Muttambalam from 3/05/2021 to 9/05/2021 and later advised quarantine at home. CFLTC is not a hospital. It is a first line centre for management of Covid, meant to quarantine, observe and evaluate those who found Covid positive. Persons who develop serious symptoms are referred from there to regular hospital for actual treatment and that on specific medical advice. On receipt of the claim form, it was thoroughly scrutinized and found not admissible and the claim was repudiated as ‘no claim’ and it was intimated to the complainants by letter dated 22/07/2021. The claim was processed legally and repudiated on valid and convincing grounds and there is no deficiency in service on the part of the company in repudiating the claim. The petitioners being a contracting parties, to the policy is bound by its terms and conditions.
As per Clause 3.6 of the policy conditions, the hospital means any institution established for inpatient care and day care treatment of decease/injuries and which has been registered as hospital with the local authorities under the Clinical Establishment Act 2010. If during the policy period, the insured person is diagnosed with Covid and hospitalized for more than 72 hours following medical advice of a duly qualified medical practitioner as per the norms specified by Ministry of Health and Family Welfare, Govt of India, the company shall pay the agreed sum insured towards the coverage mentioned in the policy schedule. However, it is to be noted that the discharge summary produced along with claim form of the first complainant is H/o HTN asymptomatic and of the second complainant suspected NRH, asymptomatic and did not speak about clinical findings, investigations and treatment given during the period of admission.
As per clause 7.3, it is mandatory for the complainant to produce (1) Medical practitioner’s prescription advising admission in the hospital (2) discharge summary including complete medical history of the patient along with other details from a hospital as defined in the policy. Moreover, they had not undergone any active treatment in any hospital during the policy period. CFLTC is not a hospital as required by the terms and conditions of the policy. It is meant for quarantine and observation. The certificate of discharge from CFLTC did not suggest for any hospitalization. Thus, it is clear that no active treatment or hospitalization was required at the time of discharge from CFLTC.
The complainant has also preferred appeal against the repudiation of the claim before the Grievances Cell of the Oriental Insurance Company and Ombudsman, Cochin. But both the above fora dismissed the complaints finding no merit in it.
Towards the evidence part the complainant has filed affidavit in lieu of chief examination along with 13 documents which were marked as Exhibits A1 to A13.The opposite party has filed affidavit along with 3 documents which are Exhibits B1 to B3.
On the basis of the pleadings and evidence the issues to be raised are:
- Whether there is any deficiency of service on the part of the opposite parties ?
- If so, what are the reliefs allowable to the complainants ?.
For the sake of convenience we would like to consider Point Nos.1 and 2 together.
POINTS 1 & 2 :-
The complainants took a corona Rakshak policy from the opposite party and subsequently they were diagnosed with corona positive. They were admitted to the CFLTC, Muttambalam. The claim was denied by the opposite party as there was no proper hospitalization because CFLTC is not a hospital and there is no active line of treatment.
The main contention of the opposite party is that the complainants had no sufficient hospitalization. On perusal of Exhibit B1 Policy conditions “3.7. defines hospitalization as admission in a hospital designated for Covid 19 treatment by Government for a minimum period of 72 consecutive in-patient care hours.” 3.8. Inpatient 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. Medical practitioner means a person who has valid registration from the Medical Council of any state or Medical Council of India or Council for Indian Medicine for Homeopathy set up by the Government of India or State Government and thereby entitled to practice medicine within its jurisdiction; and is acting within the scope and jurisdiction of the licence.”
Here in the case on hand, the first complainant was admitted to CFLTC Muttambalom is evident from Exhibit A7 issued by the Medical officer. It is evident from A7 discharge card that the first complainant was treated there from 3/05/2021 to 9/05/2021. In A7, he is advised to undergo strict home quarantine for 10 days.
The second complainant was admitted to CFLTC Muttambalom is evident from Exhibit A8 issued by the Medical Officer. It is evident from A8 discharge card that the 2nd complainant was treated there from 3/05/2021 to 9/05/2021. In A8, she is advised to undergo strict home quarantine for 10 days.
The opposite party has repudiated the claim as there was no active line of treatment during hospitalization. Hence the claim is not admissible as per the policy exclusion clause No. 3.6.
Aggrieved by this the complainant approached the Insurance Ombudsman where the repudiation was confirmed and the complaint is dismissed vide Exhibit B2.
On perusal of the facts and evidence we are of the opinion that the insurance policy Corona Rakshak was to give the sum assured amount in lump sum in the event of the insured tested Covid positive and undergo 72 hours hospitalization. Nowhere in the policy or conditions, the opposite party has excluded the Primary Health Centres (Covid First Line Treatment Centres) from the definition of the term Hospital.
As we all know, in the tragic period of the pandemic, it was an accepted practice worldwide that as the hospitals were flooded with Covid 19 patients; first line treatment centres were opened where patients were given primary treatment. The CFLTCs were functioning in the same way as hospitals in managing the primary health issues of Covid 19 patients.
In Star Health and Allied Insurance Company Ltd vs. Avinash T. and others, Hon’ble High Court of Kerala has held that “CFLTCs are Primary Level Health Care Centres set up for providing care to less serious cases and referral of serious cases to COVID hospitals, so as to avoid crowding in COVID Hospitals and avoid wastage of resources. It can therefore be unhesitatingly held that CFLTCs are designated as hospitals for the treatment of COVID-19”.
So, treatment taken in the CFLTC can also be considered as hospitalization. The argument in contrary of the opposite party is not admissible.
Again, for the eligibility of the claim to be settled, hospitalization for a continuous period of 72 hours and to have affected with Covid 19 is the only criteria. So as the complainants have tested Covid 19 positive and was admitted first to the CFLTC for 7 days which is more than 72 hours. So there is ample satisfaction of the policy condition.
Hence, we conclude the discussion by allowing the complaint and direct the opposite parties to pay Rs.2,00,000/- (Rupees Two Lakhs only) each to the complainants with 9% interest from 20/07/2021, the date of repudiation till realization.
The opposite parties are further directed to pay Rs.25,000/- (Rupees Twenty Five Thousand only) towards compensation and Rs.2,500/- (Rupees Two Thousand and Five Hundred only) towards litigation cost to the complainant.
The award shall be complied within 30 days from the date of receipt of copy of the order failing which the compensation amount shall carry 9% interest from the date of receipt of the order till realization.
Pronounced in the Open Commission on this the 28th day of November, 2023
Sri.Manulal.V.S, President Sd/-
Smt.Bindhu.R, Member Sd/
Sri.K.M.Anto, Member Sd/
APPENDIX :
Exhibits from the side of the Complainant :
A1 - Copy of Corona Rakshak Policy Schedule issued by the
1st opposite party
A2 - Copy of Policy Terms issued by the 1st opposite party
A3 - Copy of Covid Test Positive result of the 1st complainant
dated 03/05/2021 issued from SR Diagnostics, Kottayam
A4 - Copy of Covid Test Positive result of the 2nd complainant
Dated 03/05/2021 issued from SR Diagnostics, Kottayam
A5 - Copy of Covid Test Negative result of the 1st complainant
dated 14/05/2021 issued from SR Diagnostics, Kottayam
A6 - Copy of Covid Test Negative result of the 2nd complainant
dated 09/05/2021 issued from SR Diagnostics, Kottayam
A7 - Copy of Discharge Card of the 1st complainant dated
09/05/20212 issued by CFLTC, Mutttambalam
A8 - Copy of Discharge Card of the 2nd complainant dated
09/05/20212 issued by CFLTC, Mutttambalam
A9 - Copy of Repudiation letter dated 28/06/2021 issued by
the 1st opposite party
A10 - Copy of complainants’ complaint dated 24/07/2021 addressed
to the Insurance Ombudsman, Ernakulam
A11 - Copy of complainants’ complaint dated 2/07/2021 addressed
to the Manager, Grievance Cell of the opposite party at Ernakulam
A12 - Copy of e-mail dated 22/07/2021 issued by Administrative
Officer of the opposite party
A13 - Letter No.KOC-H-050-2122-0463 dated 20/10/2021 issued by
the Asst. Secretary, Insurance Ombudsman, Kochi
Exhibits from the side of Opposite parties :
B1 - Copy of Corona Rakshak Policy
B1(a) - Copy of Policy Conditions
B2 - Copy of Award in Complaint No. KOC-H-050-2122-0463
dated 19/10/2021 of Insurance Ombudsman, Kochi
B3(series) - Copy of the Discharge Cards of 1st & 2nd complainants
from CFLTC, Muttambalam, dated 09/05/2021
By Order,
Sd/-
Assistant Registrar
