D.O.F:17/04/2021

                                                                                                                         D.O.O:28/02/2023

IN THE CONSUMER DISPUTES  REDRESSAL COMMISSION, KASARAGOD

CC.84/2021

Dated this, the 28^th day of February 2023

PRESENT:

SRI.KRISHNAN.K                          : PRESIDENT

SRI.RADHAKRISHNAN NAIR.M   : MEMBER

SMT.BEENA.K.G                              : MEMBER

Aneesh. R, aged 34 years

R/at Sunil Mandiram,

Cheppara (P.O)                                                                    : Complainant

Vappala, Kollam- 691520

(Adv. P. Rakesh Thamban)

                                                                                    And

1. Universal Sompo General Insurance

Company Limited, Joy Tower,

5^th floor, C-20/IA

C-Block, Sector- 62,

Noida, Uttar Pradesh – 201309.

2. Universal Sompo General Insurance

Company Limited, Regd Office: 103,

First Floor Ackrutistar,

MIDC Central Road, Andheri (east),: Opposite Parties

Mumbai- 400093

3. Universal Sompo General Insurance

Company Limited, Express IT Park,

Plot No. EL- 94, T.T.C. Industrial Area,

M.I.D.C, Mahape, Navi Mumbai- 400710

(Adv. AnnammaJohn.V)

ORDER

SRI.KRISHNAN.K     :PRESIDENT

                 The complaint filed under section 35 of Consumer Protection Act, 2019

1.      The case of the complainant is that he obtained Corona Rakshak Insurance Policy bearing 2856/61812580/00/000 from opposite party No.1 by paying a premium of Rs.1,945/- on 30/07/2020.  Policy is covering a liability of Rs.2,50,000/-.  The insurance is valid from 30/07/2020 to 11/05/2021.  The opposite party made a promise to indemnify the expenses incurred by insured in case the insured gets effected by Covid Pandamic and diagnosed Covid positive and hospitalized for more than 72 hours a lump sum amount equal to 100% of the sum insured shall be paid to the insured.
2.      That on 27/01/2021 morning he suffered head ache and fever.  He was removed to District Hospital Kanhangad.  He consulted Dr.Vishnu.M, who adviced and referred to undergo Covid test on the same day.  Samples were taken from his body for RTPCR test.  By 28/01/2021 evening results showed Covid positive.
3.      On 30/01/2021 he had severe fever, body pain and cough and he is referred to KIMS Hospital and he was hospitalized for 4 days and by 02/02/2021 night he was discharged from the hospital providing medicines and was directed to stay at home under quarantine.
4.      The complainant approached opposite party for insurance claim as per the policy terms, but opposite party illegally repudiated the claim, there is unfair trade practice and Deficiency in service from opposite party in denying liability without justifiable reasons.  The complainant claimed insurance benefit of Rs.2,50,000/- and compensation and cost of the litigation.
5.      The opposite party filed their written version.  The opposite party denied the claim of complainant.  The opposite party claim that complainant has taken the policy for Corona Rakshak with coverage details.  Claim is submitted for insurance.  As per opposite party NO.1 admission is made for observation purpose and evaluation, as per conditions insurance is not payable, as per revised guidelines April 2021, patients who are clinically assigned to be mild asymptomatic are recommended for home isolation and therefore repudiation is for valid reasons.  The contention of the opposite party is that during the days admitted in the hospital, the complainant had no fever and that vitals and SPO2 level are normal.  The opposite party further contends that the complainant could have undergone home quarantine instead.  The opposite party denies fraud and caused mental agony and emotional distress during the illness by directing to produce unnecessary documents in order to escape from the claim made.  The insured was diagnosed as covid positive and was managed for the same.  As per documents provided, the claim was referred for verification.  As per verification reports and indoor papers, it has been observed that insured was a febrile at the time of hospitalization and throughout the hospitalization period, all vitals were with normal limits, SPO2 levels were also within normal limits, the insured was managed with oral medications.  Hence, the admission was primarily for observation/ quarantine purpose and the same is not payable as per policy terms and conditions, insured could have managed on have quarantine /opd basis.  Based on the facts, claim stands repudiated.
6.      The complainant filed chief affidavit and documents.  Ext.A1 ispolicy and details.  Ext.A2 is letter sent by Opposite Party to produce medical documents.  Ext.A3 is Repudiation letter sent by opposite party.  Hospital records A to J marked as Ext.A4 series, Adhar Card marked as Ext.A5, Quarantine certificate is Ext.A6, Quarantine release certificate marked as Ext.A7.

Opposite party did not file chief affidavit but produced documents marked as Ext.B1 and B2.  Ext.B1 is policy certificate.  Ext.B2 is clinical guidelines for covid patient.  Heard both side, perused documents.

                 Following points arise for consideration:-

1. Whether repudiation of claim is justifiable?
2. Whether the opposite party can oppose the claim on the ground that hospitalization is ill advised?
3. Whether there is Deficiency in service? Whether complainant is entitled for compensation? If so for what reliefs?

Points No. 1 and 2 are considered together.

7.      The insurance policy is admitted by opposite party.  As per hospital records.  Ext A4 series, complainant admitted as inpatient from 30/01/2021 till 02/02/2021 due to covid positive on 27/01/2021 and discharged only on 02/02/2021.  Ext.A1 is the insurance policy details with certificate, policy period is 9 months and 15 days,  sum insured is 2,50,000/-.  Exclusion shown there in area admission primarily for observation and evaluation.  Ext. A2 letter dated 20/02/2021 shows insurance company has sought additional particulars including bank account details for NEFT transfer.  Ext A3 is repudiation letter is dated 09/03/2021.  It shows liability is repudiated on the ground of exclusion, admission primarily for observation and evaluation.  Ext.A4 series shows the complainant was found positive on 28/01/2021 and admitted as impatient number 11302 due to complaint of fever and headache.
8.      The opposite party company did not adduce any oral evidence to prove their case of denial of insurance for valid reason.  Hospital records shows that admission is made for treatment for fever, headache and weakness for three days.  No evidence available to show that admission is made for observation or evaluation purpose except suggestions made to PW1.  While in box.  Mere suggestions will not disprove the case set up by complainant, in the absence and legal and acceptable evidence on the contrary. 

The repudiation of policy benefits without reason is against the terms of policy.  He was admitted in the hospital on 30/01/2021.  All the hospital records are produced. 

9.     The Commission finds that complainant was admitted in the hospital for treatment and not for evaluation and observation and hence repudiation of liability is not justified and not sustainable in law.  As regards to deficiency in service, not paying of insurance benefits to those who are entitled as per policy conditions amounts to clear deficiency in service and negligence on the part of opposite party.  Thus complainant is entitled to compensation from opposite party besides the insurance benefits and cost of litigation.  Commission finds Rs.20,000/- will be reasonable amount to compensation and Cost as Rs.5,000/-

     In the result complainant is allowed in part as follows:-

1. Opposite parties are directed to pay the complainant a sum of Rs.2,50,000/- (Rupees Two Lakh Fifty Thousand only) as insurance benefits with 8% interest per annum from date of filing Complaint till payment thereof to Complainant.
2. The Opposite parties are directed to pay Rs.20,000/- (Rupees Twenty Thousand only) towards compensation with interest at 6% per annum from the date of Complaint till date of payment and also pay Rs.5,000/-(Rupees Five Thousand only).  The cost of litigation within 30 days of the receipt of the order.
3.  

MEMBER                                          MEMBER                              PRESIDENT

Exhibit

A1: Policy and details

A2: Letter sent by Opposite Party to produce medical documents.

A3: Repudiation letter sent by opposite party

A4: Series are hospital records

A5: Aadhar card

A6: Quarantine Certificate

A7: Quarantine release certificate

B1: Policy Certificate

B2: Clinical guidance for Covid Patient

Witness Cross examined

              Pw1: Aneesh. R

                  Sd/-                                                Sd/-                                      Sd/-

MEMBER                                          MEMBER                              PRESIDENT

Forwarded by Order

Ps/                                                                              Assistant Registrar