IN THE CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM
Dated this the 29thday of December, 2022
Present: Sri.Manulal.V.S, President
Smt.Bindhu.R, Member
Sri. K.M. Anto, Member
CC No. 17/2022 (Filed on 27/01/2022)
Complainant : Ramesh M.K, S/o V.P.Madhavan
Suresh Bhavan House, Veloor P.O
Kottayam – 686 003.
(Adv.Kuruvila Varghese)
Vs
Opposite party : The Divisional Manager,
The Oriental Insurance Company Limited
Divisional Office No.I, Matteethara Buildings
IIIrd floor, Baker Junction, M.C. Road
Kottayam- 686 001.
(Adv.P.C.Chacko)
O R D E R
Smt.Bindhu.R, Member
The Complaint is filed under section 12 of the Consumer Protection Act 1986.
The complaint in brief is: The complainant took the Corona rakshak policy from the opposite party company vide policy no 441300/48/2021/1115 on 29.07.2020.The assurance given by the opposite party was in the event of detection of covid -19 and treatment thereon for 72 hours will entitle the policy holder to get Rs.1,00,000/- under this scheme. The complainant was tested covid 19 positive on 30.04.2021 at Sandor Medicals Private Ltd. and as there was a shortage of IP there he was admitted in a first line treatment centre at DCC CDI Retreat Centre, Kottayam since he required medical supervision. He underwent treatment there from 01.05.2021 to 10.05.2021 when his health condition got worsened, he was shifted to District hospital, Kottayam on 10.05.2021.He was treated as in patient there till 19.05.2021.He was discharged on 19.05.2021 with an advice of further one week rest.
Thereafter the complainant approached the opposite party, the insurer for the sum assured but the claim was rejected on the ground that medical practitioners prescription advising admission is not produced and no discharge summary including complete medical history submitted. The complainant had produced all these documents before the opposite party company. The discharge certificate from FLTC, which was under the department of health service, was assigned charge to Dr.Linto Lazer, Asst.Surgeon, General hospital, Kottayam. The certificate for release in their general format was issued to the complainant on his referral to district hospital, which was signed by Dr.Aswathy, Medical Officer, General Hospital in the absence of Dr.Linto Lazar.
The complainant is entitled to get the reimbursement of the amount. The act of the opposite party is deficiency in service and the complaint is filed for compensation for the same and for the insurance amount.
On receipt of notice the opposite party appeared and filed version. The policy is admitted. The insurance under the policy is subject to terms and conditions, clauses, warranties, endorsements as per conditions attached to the policy.
The complainant preferred a claim before the company alleging that he was tested covid positive and admitted in First Line Treatment centre at DCC CSI Retreat Centre from 1/5/21 to 10/05/21.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 complaint by letter dated 20/07/2021. 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 petitioner being a contracting party, to the policy is bound by its terms and conditions. As per clause 2and other clauses of the policy conditions, 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 for the period from 01/05/2021 to 10/05/2021 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 he 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. The said certificate directs only to avoid unnecessary travel and social contract and to contract nearest hospital if symptoms exacerbate and to continue his medicine. Thus it is clear that no active treatment or hospitalization was required at the time of discharge from CFLTC. The alleged 2nd admission in the District hospital was not during the policy period and thus no liability.
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 findings no merit in it. The petition is bad for non joinder of necessary parties and hence it is only to be dismissed. The oriental insurance company is a necessary party to this case.
Towards the evidence part the complainant has filed affidavit in lieu of chief examination along with 6 documents which were marked as Exhibit A1 to A5.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 party and if so what are the reliefs allowable to the complainant. The complainant took a corona rakshak policy from the opposite party and subsequently he was diagnosed with corona positive. First he was admitted to the CFLTC and thereafter to General Hospital, Kottayam. The policy was denied by the opposite party as there was no proper hospitalization because CFLTC is not a hospital. The subsequent treatment is out of the policy period and that too not as per the discharge certificate from the CFLTC thus policy is repudiated.
The main contention of the opposite party is that the complainant had no sufficient hospitalization. On perusal of ExhibitB1 Policy conditions “3.7.defines hospitalization as admission in a hospital designated for covid19 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 a 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 complainant was first admitted to DCC CST Retreat Centre, Kottayam as is evident from Exhibit A3 issued by the Medical officer. It is evident from A3 certificate that the complainant was treated there from 1.05.21 to10.05.21. In A3, he is advised to contact nearest hospital /treating hospital if develops exacerbation of symptoms.”
Thereafter as per Exhibit A4,on 10.05.21, the same day of discharge from the CFLTC, the complainant was admitted to the general Hospital, Kottayam and discharged on 19/05/21. The complainant was diagnosed with CAT B COVID PNEUMONIA.
The opposite party has repudiated the claim as NO CLAIM vide B2 letter for the reason that the discharge summary for the period of 01.05.2021 to 10.05.2021 is not speaking about clinical findings and investigations and treatment given. As per clause7.3 of claim procedure documents to be submitted requires for Medical practitioner’s prescription advising admission and discharge summary including complete medical history of the patient along with other details. Aggrieved by this the complainant approached the Insurance ombudsman where the repudiation was confirmed and the complaint is dismissed.
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 world wide 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. 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 complainant has tested covid 19 positive and was admitted first to the CFLTC for 10 days which is more than 72 hours and thereafter on the same day admitted to the General hospital and was treated there for 9 days till 19.05.2021.So there is ample satisfaction of the policy condition.
Hence we conclude the discussion by allowing the complaint and direct the opposite party to pay Rs.1,00,000/-to the complainant with 9% interest from 20.07.2021, the date of repudiation till realisation.
The opposite party is further directed to pay Rs.15,000/- towards compensation and Rs.2,000/- towards litigation cost to the complainant. The award shall be complied within 30 days from the date of receipt 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 29th day of December, 2022.
Smt.Bindhu.R, Member sd/-
Sri.Manulal.V.S, President sd/-
Sri. K.M. Anto, Member sd/
Appendix
Exhibits marked from the side of complainant.
A1- Copy of the policy certificate No.441300/48/2021/1115.
A2- Copy of the report dated 30/04/2021 issued by the Sandor Medical Pvt.Ltd.
A3- Copy of the discharge certificate dated 10/05/2021 issued by the DCC.CSI Retreat Centre, Kottayam.
A4- Copy of the discharge slip issued by the General Hospital , Kottayam
A5- Copy of the certificate issued by Medical Officer, General Hospital, Kottayam.
Exhibits marked from the side of opposite party
B1& B1(a)- Copy of policy and its conditions of the Oriental Insurance Company Ltd.
B2- Copy of the repudiation letter
B3- Copy of order of the Ombudsman and the accompanying documents.
By Order
sd/-
Assistant Registrar
