District Consumer Disputes Redressal Commission ,Faridabad.

Consumer Complaint  No.573/2021.

 Date of Institution: 09.11.2021.

Date of Order: 16.06.2022.

Pinki D/o Mr. Prem Pal, R/o House No. 51/95, Near Janta Band, NIT-5, Faridabad.

                                                                                    …….Complainant……..

                                                            Versus

Universal Sompo General Insurance Company Limited, Health Claim Management at Joy Tower, 5^th floor, C/20/1A, C Block, Sector-62, Noida (UP) and Branch office at Anupam House, Shop No. 34, Sector-19, Faridabad through its Branch Manager.

                                                                                    …Opposite party……

Complaint under section-12 of Consumer Protection Act, 1986

Now  amended  Section 34 of Consumer protection Act 2019.

BEFORE:                  Amit Arora……………..President

Mukesh Sharma…………Member.

PRESENT:                Sh. Arun Dua ,  counsel for the complainant.

                                    Sh. Nitish Kumar, counsel for opposite party.

ORDER:  

                        The facts in brief of the complaint are that the complainant purchased a “Corona Rakshak Policy” from the opposite  party bearing NO. 2856/IMD/OL/0003608/00 for sum insured of Rs.2,50,000/- valid for the period from 08.09.2020 – 23.06.2021.  The complainant suffered from fever, shivering, body pain cough/cold and consulted Dr. Lokesh Kr. Garg, Physician: Arsh Hospital, Opp. ERA Redwood Esidency, Tigaon Road, sector-78, Faridabad on 06.04.2021 and on the advice/recommendation of the said doctor underwent RT/PCR test on 08.04.2021 at SRL Diagnotices, Faridabad. The complainant tested positive for COVID 19 and was, therefore, rushed to emergency ward of QRG Medicare Limited,  plot  NO.1, Sector-16, Faridabad on 09.04.2021 with Bilateral Pneumonia – COVID related and complaints of fever, bodyache and headache for treatment.  The complainant was discharged from hospital on14.04.2021 in stable condition with advice for further follow up on OPD basis.  The complainant intimated the opposite party regarding her illness and hospitalization and the opposite party acknowledged the receipt of the same and registered the claim of the complainant vide claim registration No. 250191.  The complainant thereafter submitted necessary papers with the opposite party.  The opposite party thereafter vide deficiency letter dated 01.05.2021 sought certain documents/information/clarification from the complainant.  The complainant thereafter immediately submitted necessary papers with the opposite party.  The complainant had purchased another policy bearing No. 222100/28/20P107/572674 of  United India Insurance Company and the complainant submitted claim form with Safeway Insurance TPA Private Limited and the said insurance company admitted the claim of the complainant vide claim No. UNI-53671 towards medical expenses and paid a sum of Rs.80,222/- to the complainant on 26.04.2021.  The opposite party, however, out of the blue, repudiated the claim of the complainant vide claim repudiation letter dated 20.05.2021 as under:

“The insured was admitted as a case of covid positive.  The insured had complaints of fever, bodyache, headache.  At the time of admission insured was conscious, oriented, febrile, mild respiratory distress, mild wheeze, all vitals were within normal limits, spO2 98% CT scan, X ray – no abnormality seen, no doctor’s prescription advising hospitalization provided.  As per the vitals and investigation reports, insured could have been managed on home quarantine basis as per Mohfw guidelines.  Hospitalization for monitoring/observation purpose was not payable.  Based on these facts, the claim stands repudiated.”

In this regard, they regret to inform  him that the claim was not admissible as per following policy clause:

2.         OPERATIVE CLAUSE if  during the policy period the insured person was diagnosed with COVID and hospitalized for more than seventy two hours following medical advise of a duly  qualified medical practitioner as per the norms specified by Ministry of Health and Family Welfare, Government of India, the Company shall pay the agreed sum insured towards the coverage mentioned in the policy schedule.

6.         Exclusions The company shall not be liable to make any payment under the policy, in respect of any expenses incurred in connection with or in respect of:

Investigation and Evaluation (Code-Exc104) Express related to any admission primarily for diagnostics, observation and evaluation purposes.

Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment.”

The opposite party had malafidely and wrongly repudiated the claim of the complainant and the complainant thus referred a complaint  before the Insurance Ombudsman.  The Insurance Ombudsman, however, had rejected the complaint of the complainant vide award dated 27.09.2021 and observed that the complainant could have managed with home isolation and did not require hospitalization in terms of the MoH&FW norms. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint.  The complainant has prayed for directions to the opposite party to:

a)                     accept the claim of the complainant and release policy benefits of Rs.2,50,000/- in favour of the complainant under policy N O. 2856/IMD/OL/0003608/00.

 b)                     pay Rs.1,00,000/- as compensation for causing mental agony and harassment .

c)                      pay Rs.33,000/ - as litigation expenses .

2.                     Opposite party  put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that  the opposite party  has rightly refused the claim of the complainant as the complainant was not entitled to any claim as he was hospitalized without doctor’ prescription and thus, was not entitled for any claim.  It was further submitted that the opposite party had issued proper repudiation letter to the complainant stating the ground of rejection.  The claim of the complainant was rejected on the following ground:

            “2. OPERATIVE CLAUSE if  during the policy period the insured person was diagnosed with COVID and hospitalized for more than seventy two hours following medical advise of a duly  qualified medical practitioner as per the norms specified by Ministry of Health and Family Welfare, Government of India, the Company shall pay the agreed sum insured towards the coverage mentioned in the policy schedule.

            6.         Exclusions : The company shall not be liable to make any payment under the policy, in respect of any expenses incurred in connection with or in respect of:

6.1  Investigation and Evaluation (Code-Exc104)

i.  Express related to any admission primarily for diagnostics, observation and evaluation purposes.

ii. Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment.”

 Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.

3.                     The parties led evidence in support of their respective versions.

4.                     We have heard learned counsel for the parties and have gone through the record on the file.

5.                     In this case the complaint was filed by the complainant against opposite party – Universal Sompo General Insurance Company Limited           with the prayer to : a)  accept the claim of the complainant and release policy benefits of Rs.2,50,000/- in favour of the complainant under policy N O. 2856/IMD/OL/0003608/00.  b)   pay Rs.1,00,000/- as compensation for causing mental agony and harassment . c)  pay Rs.33,000/ - as litigation expenses .

                        To establish his case the complainant has led in his evidence Ex.CW1/A  - affidavit of Pinki, Ex.C1 – insurance policy, Ex.C2 – doctor’s prescription, Ex.C-3 – certificate, Ex.C-4 – Discharge on request, Ex.C-5 – Claim intimation letter, Ex.C-6 – deficiency letter, Ex.C-7 – claim repudiation letter, Ex.C-8 – Emergency certificate.

                        On the other hand counsel for the opposite party strongly agitated and opposed. As per the evidence of the opposite party, Ex. RW1/A – affidavit of Shri Prashant V. Shukla S/o Shri Vinod Shukla, Office at Mumbai, Ex.RW1/1 – claim repudiation letter dated 20.05.2021, Ex.RW1/2 – Insurance  Ombudsman order dated 27.09.2021. Ex.RW1/3 – Written statement of opposite party.

6.                     It is evident form   Emergency Certificate vide Ex.C8  that the patient  i.e. Pinki was came in this hospital as emergency case on 09.04.2021 at 03:55p.m. vide UHID No. 100140284 with the diagnosis as a case of Bilateral Pneumonia – COVID related.  As per  Discharge on request vide Ex.C4, the insured had complaints of fever, bodyache, headache.  At the time of admission insured was conscious, oriented, febrile, mild respiratory distress, mild wheeze, all visits were within normal limits, spO2 98%, CT Scan, X ray – no abnormality seen, no doctor’s prescription advising hospitalization provided.  As per the vitals and investigations report, insured could have been managed  on home quarantine basis as per MOHFW guidelines.  Hospitalization for monitoring/observation purpose is not payable.

7.                     It is evident from Insurance Ombudsman  award dated 27.09.2021 vide Ex.RW1/2 in which it has been stated that five cases  relate to the family and personal staff of Shri Kamal Narang.  All cases relate to the repudiated claim under Corona Rakshak, which is Benefit Policy.  Each of the 5 complainants had undergone hospitalization for Covid in April 2021,  Details are presented in a tabular form as below:

Each complainant has stated that S/he was declared Covid Positive  RTPCR test and an MBBS doctor had recommended hospitalization.  S/he was also stated that their house ha d8 residents including the two maidservants, but only 3 bedrooms and, as such, home isolation was not possible. Tthe insurers had repudiated the claim on the ground that the incidence of Covid in each case was mild and as per the  norms notified by the Ministry of Health & Family Welfare Hospitalization.  The insurers have pointed out that in each case, all the vital parameters such as BP, Body Temperature, Pulse Rate, SPO2 level and Respiration Rate were normal on the date of admission.  The complications for Covid patients start after 4 days, but they all, except for Rajni Khakha, got discharged on request after 4-5 days of admission.   As all members of the household had suffered from mild  Covid almost at the same time, they could have stayed together in the same house in home isolation with due care and caution.  But if they were really serious about their isolation, they should not have got discharged on request prematurely to stay together in the same house.  All these factors lead to the conclusion that the complainant could have managed with home isolation and did not require hospitalization in terms of the MoH&FW norms cited above, which was a necessary requirement for admissibility of the claim as per the Operative Clause of the policy.  Hence, the insurers were justified in repudiating the claim.

8.                     After going through the evidence led by the parties, the Commission is of the opinion that no deficiency in service on behalf of the opposite party is proved.  Hence, the complaint is dismissed. Copy of this order be sent to the parties concerned free of costs. File be consigned to the record room.

Announced on:  16.06.2022                                                   (Amit Arora)

                                                                                                     President

                         District Consumer Disputes

             Redressal  Commission, Faridabad.

                                                            (Mukesh Sharma)

                  Member

            District Consumer Disputes

                                                                                    Redressal Commission, Faridabad.