IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated, the 28th day of November 2022.
Present: Sri. Manulal V.S. President
Smt. Bindhu R. Member
Sri. K.M. Anto, Member
C C No. 12/2022 (Filed on 19-01-2022)
Petitioner : Gokul Unnikrishnan,
S/o. Unnikrishnan,
Retna vilas,
Moolavattom P.O.
Nattakom, Kottayam
Pin – 686012
(Adv. Akash K.R.)
Vs.
Opposite party : The Oriental Insurance Co. Ltd.
Divisional Office No.1,
Mattethara Building,
3rd floor, Baker Junction,
Kottayam – 686001.
Rep. by its Divisional Manager.
(Adv. P.C. Chacko)
O R D E R
Sri. K.M. Anto, Member
The complaint is filed under section 35 of the Consumer protection Act 2019
The complainant had taken Corona Raksha Policy from the opposite party with
Policy No.441300/48/2021/2244.The policy is valid from 22/09/2020 to 03/07/2021.The policy condition is that if the complainant undergoes treatment in any of the network hospitals of the opposite party they shall indemnify the complainant and are liable to pay the sum assured of Rs.1,50,000/- to the complainant. During the period of insurance on 19.04.2021 the complainant showed symptoms of Covid-19 and tested Positive in RTPCR test.
The complainant was treated in family Health center, Nattakom and then at St. Thomas Hospital Chethipuzha as inpatient. The claim of the petitioner was
repudiated by the opposite party on 03.11.2021 as No claim. The act of the opposite party in repudiating the genuine claim of the complainant amounts to unfair trade practice and deficiency in service. The complainant had suffered much hardship, loss, sufferings and mental agony due to the act of the opposite
party. Hence this complaint is filed.
On admission of the complaint copy of the complaint was duly served to the opposite party. The opposite party appeared and filed their version.
In the version filed by the opposite it is admitted that the Corona Rakshak Policy was issued to the complainant for the period from 22.09.2020 to 03.07.2021 with sum assured of Rs1,50,000/-.The complainant preferred a claim before the company alleging that he was tested Covid Positive and admitted in Family Health Center, Nattakom and Health centre authorities advised him to go for better treatment and accordingly he was admitted at St. Thomas Hospital, Chettipuzha for a period from 21.04.2021 to 28.04.2021 and expended an amount of Rs.50.000/-.
The family Health center is not a hospital as defined in the terms and conditions of the policy. It is a first line centre for management of Covid, meant to Quarantine, observe and evaluate those who are found to be Covid positive. The expenses relating to admission primarily for diagnostic and evaluation purposes are excluded as per exclusion clause 6.1 of the policy condition.
On receipt of the claim it was thoroughly scrutinized and found not admissible and the claim was repudiated as no claim and was intimated to the complainant by letter dated 03.11.2021.The claim was processed legally and repudiated on valid and convincing grounds and thus there is no deficiency in service on the part of the opposite party in processing or repudiating the claim.
As per the medical reports produced along with the claim form shows that the complainant got admitted with complaints of headache, lethargy and no active line of treatment was done. The discharge certificate from family health centre did not suggest for any hospitalization. The second admission at St Thomas Hospital was also not for any active line of treatment on medical advice of a qualified medical practitioner. The complainant is not entitled for any relief in the petition.
The complainant filed proof affidavit and marked documents Exhibits A1 to A5. The opposite party filed proof affidavit and marked documents Exhibit B1 to B3.
On the basis of the complaint, version of the opposite party and evidence adduced we would like to consider the following points.
- Whether there is unfair trade practice or deficiency in service on the part of the opposite party
- If so, what are the reliefs and costs?
Point Nos. 1 and 2
On a careful evaluation of the complaint, version of the opposite party and
evidence on record it is clear that the complainant had availed a Corona Rakshak
policy from the opposite party. The policy was having a period of coverage from
22.09.2020 to 03.07.2021 vide policy No.441300/48/2021/2244 with a sum assured of Rs.1, 50,000/-.
Ext A4 is the Covid-19 Test report dated 5.6.21issued by the medical officer in charge, Family Health Centre, Nattakom, Kottayam which shows that complainant was tested RTPCR Positive on 19.04.2021.
Ext A5 which is the same as Ext B2 is the claim repudiation letter issued by the opposite party dated 3.11.2021. The reason cited for the repudiation of the claim of the complainant is that “As the patient vitals are in normal limits and patient was suffering only from headache and lethargy at the time of admission and has no other difficulty, patient does not need hospitalization as per the norms specified by the Ministry of health and family welfare, Government of India and needs only home isolation. Also, patient admission was not following medical advice of a qualified medical practitioner as per the norms specified by ministry of health and family welfare, Government of India. As per TPA Investigation team report no active line of treatment was done during the hospitalization period.
Ext A2 is the Discharge Summary issued by the Department of Internal Medicine Covid Care, St. Thomas Hospital, Chethipuzha, Kottayam. Ext A2 clearly shows that the complainant was tested positive on 21/04/2021 and admitted in Covid Care isolation Ward and was managed with supportive medications. The complainant was tested Negative on 28/04/2021 and was discharged on 28/04/2021 Dr. Julie Sebastian, MBBS, MD, DNB, Consultant Physician, Reg No.27713 St. Thomas Hospital, and Chettipuzha had issued the Discharge Summary.
Ext B1 is the corona Rakshak policy schedule issued to the complainant with policy document. Clause 3.7,3.8,3.10,3.11 of the policy conditions are as follows.
3.7: Hospitalization means admission in a hospital designated for Covid-19 treatment by government for a minimum period of seventy-two 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.
3.10: Medical advice means any consultation or advice from a medical practitioner including the issue of any prescription or follow up prescription.
3.11: Medical Practitioner means a person who holds a valid registration from the
medical council of any state or Medical Council of India or Council for Indian medicine or for Homeopathy set up by the Government of India or a state government and is there by entitled to practice medicine within its jurisdiction and is acting within the scope and jurisdiction of the license.
Ext B3 is the Doctors progress Notes with regard to the treatment given to the complainant and from ExtB3 it is clear that the complainant was tested positive for Covid-19 on 21/04/2021 at St. Thomas Hospital, Chethipuzha and he was admitted by Dr Julie on 21/04/2021.The complainant was under inpatient care up to 28/04/2021 until he was tested negative on that day. Further from Ext A2 and Ext B3 it is clear that the medical practitioner who admitted the patient and issued the A2 Discharge summary is Dr. Julie Sebastian, MD, DNB, consultant physician with Reg No.27713.
On the basis of the above findings, it is clear that the reasons cited in ExtB2 letter for the repudiation of the claim is totally against the policy conditions issued by the opposite party. The claim of the complainant is genuine as per the issued Ext B1 policy and conditions. The act of the opposite party in repudiating the genuine claim of the complainant is deficiency in service on the part of the opposite party. The act of the opposite party on repudiating the policy on flimsy ground is a clear case of exploitation. The opposite party received the premium from its consumer, the complainant giving offer of financial support at the time of pandemic, was utilising the fear of a common man about the life threatening decease covid 19. Being a public limited company, the opposite party has a bounden duty to show some more responsibility towards its customers. The complainant herein has availed proper hospitalisation and medication warranted by the policy conditions for the policy to be awarded. Even then the opposite party arbitrarily repudiated the claim throwing the bonafide purchaser of the policy to unending mental agony. The opposite party is bound to compensate the complainant for the same.
The complaint is allowed and we pass the following orders.
(1) The opposite party is directed to pay Rs.1,50,000/- to the complainant within 30 days from the date of receipt of the copy of this order.
(2) Considering the nature and circumstances of the complaint we direct the opposite party to give compensation of Rs.30,000/- and cost of Rs.2,000/- to the complainant.
Order shall be complied within 30 days from the date of receipt of copy of this Order. If not complied as directed, the amounts will carry 7% interest from the date of Order till realization.
Pronounced in the Open Commission on this the 28th day of November. 2022
Sri. K.M. Anto, Member Sd/-
Sri. Manulal V.S. President Sd/-
Smt. Bindhu R. Member Sd/-
Appendix
Exhibits marked from the side of complainant
A1 – Copy of Corona Rakshak Policy vide No.441300/48/2021/2244
A2 – Copy of discharge summary dtd.28-04-21by St. Thomas Hospital,
Chethipuzha
A3 – Copy of corona quarantine release certificate
A4- Copy of covid – 19 test report from PHC Nattakom
A5 – Copy of letter dtd.03-11-21 by opposite party to complainant
Exhibits marked from the side of opposite party
B1 – Corona Rakshak Policy vide No.441300/48/2021/2244 with conditions
B2 – Copy of letter dtd.03-11-21 by opposite party to complainant
B3 – Copy of Doctor’s progress notes of complainant by St.Thomas Hospital
By Order
Assistant Registrar
