D.O.F:21/06/2021 D.O.O:29/07/2022
IN THE CONSUMER DISPUTES REDRESSAL COMMISSION KASARAGOD
CC.No.98/2021
Dated this, the 29th day of July 2022
PRESENT:
SRI.KRISHNAN.K :PRESIDENT
SRI.RADHAKRISHNAN NAIR.M : MEMBER
SMT.BEENA.K.G : MEMBER
T.V. Vamanan
S/o. Kannan, Maruthalam
Munnad – Post,
Chengala – Via, Kasaragod – 671541 : Complainant
(Adv: T.C. Narayanan)
And
1. Chief Manager,
Regd and Corporate Office,
Star Health and Allied Insurance
Insurance Company Ltd,
1,New Tank Street, Nungampakkam,
Chennai, - 600034
2. The Branch Manager, : Opposite Parties
Star Health and Allied Insurance
Insurance Company Ltd,
2nd Floor, Aramzna Arcade,
Bank Road, Kasaragod. 671121
(Adv: K. Vinodkumar)
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SRI.RADHAKRISHNAN NAIR.M : MEMBER
The complaint is filed for compensation on the ground of service deficiency on the part of the opposite party. The facts of the case in brief is that the complainant, influenced by an agent of the opposite parties, took a Corona Rakshak Health policy of the opposite parties by paying an amount of Rs.6,178/- towards its total premium on 05.11.2020. The period of policy was from 05.11.2020 and the sum insured under the said policy is Rs.2,50,000/- . It was offered that at the event of the complainant being diagnosed Covid-19 and hospitalized for 72 hours, the opposite parties shall pay Rs.2,50,000/-.
There after the complainant was tested positive with Covid 19 and admitted in Tata Trust Govt. Hospital (under Govt. Hospital Kasaragod ) on 22-01-2021 and treated there for ten days till he was discharged on 30.01.2021.
As per the terms and conditions policy the complainant informed the opposite parties about his hospitalization and after discharge , he requested the opposite parties for the insurance amount through a letter. But the opposite parties repudiated the claim as per letter dated 20 03.202l, stating that insured patient's vitals are stable throughout admission, investigation are within normal limit and could have been managed under home isolation. There is no such condition and the repudiation is illegal.
Since opposite parties repudiated the claim the complainant was put to great mental agony. There is service deficiency on the part of opposite parties and hence this complaint is filed for a direction to the opposite parties to pay the insurance amount of Rs. 2,50,000/- along with compensation and cost.
The opposite parties entered appearance through their counsel and filed written Version.
As per the written version of the opposite parties, the complaint is not maintainable either in law or on facts.
It is admitted that the complainant had taken a Corona Rakshak Health policy for a period from 05.01.2020 to 17. 08.2021, which has been renewed up to 18.10.2020., with a sum insured of Rs. 2,50,000/- vide. Policy No. P/181325/01/2021/ 001198. It is also submitted that the insurance under this policy is subject to conditions, clauses, warranties, exclusions etc. attached. After discharge from hospital, the complainant had submitted claim with discharge summary from General Hospital - TATA Covid Hospital Kasaragod, which states that the complainant had undergone treatment from 22.01.2021 to 30 .01.2021. The discharge summary clearly noted that insured patient's vitals are stable throughout admission, investigation are within normal limit and could have been managed under home isolation. As per terms and conditions of the policy Lump Sum benefit equal to 100 % of the sum insured shall be payable on positive diagnosis of Covid requiring hospitalization, for a minimum continuous period of 72 hours . Here in this case no treatment is provided to the patient. Hence the stay in hospital is not at all essential. Hence the opposite party has repudiated the claim and the same was informed to the insured on 20.03.2021.
There is no service deficiency on the part of the Opposite Party. The complainant has not suffered any mental shock or agony. The complaint is liable to be dismissed.
The complainant filed proof affidavit in lieu of chief examination and documents Ext. A 1 to Ext. A 5 are marked . The Ext - A1 is a copy of guide lines on Covid Standard Health Policy, Ext. A 2is the Policy Certificate, Ext A3 is the Policy Document, Ext. A4 is the Medical Certificate dated 22.03.2021 , Ext - A 5 is the Repudiation Letter.
The opposite parties did not adduce any oral evidence but produced a document which is marked as Ext. B1. The document Ext B1 is a copy of Discharge Summary of the Complainant.
Based on the pleadings and evidence of the rival parties in this case, the following issues are framed for consideration.
1. Whether the complainant is entitled for any amount towards the insurance benefit?
2. Whether there is any service deficiency on the part of any of the opposite parties?
3. If so, what is the relief?
For convenience, all these issues are considered together.
Here the specific case of the complainant is that he took a Corona Rakshak Health policy of the opposite parties as influenced by their agent by paying an amount of Rs.6,178/- towards its total premium on 05.11.2020. The period of policy was from 05.11.2020 and the sum insured under the said policy is Rs.2,50,000/- . It was offered that at the event of the complainant being diagnosed Covid-19 and hospitalized for 72 hours, the opposite parties shall pay Rs.2,50,000/-.
There after the complainant was tested positive with Covid 19 and admitted in Tata Trust Govt. Hospital (under Govt. Hospital Kasaragod ) on 22-01-2021 and treated there for ten days till he was discharged on 30.01.2021.
As per the terms and conditions policy the complainant informed the opposite parties about his hospitalization and after discharge , he requested the opposite parties for the insurance amount through a letter. But the opposite parties repudiated the claim as per letter dated 20 03.202l, stating that insured patient's vitals are stable throughout admission, investigation are within normal limit and could have been managed under home isolation. There is no such condition and the repudiation is illegal.
The opposite party admits that the complainant had taken a Corona Rakshak Health policy for a period from 05.01.2020 to 17. 08.2021, which has been renewed up to 18.10.2020., with a sum insured of Rs. 2,50,000/- vide. Policy No. P/181325/01/2021/ 001198. It is submitted that the insurance under this policy is subject to conditions, clauses, warranties, exclusions etc. attached. After discharge from hospital, the complainant had submitted claim with discharge summary from General Hospital - TATA Covid Hospital Kasaragod, which states that the complainant had undergone treatment from 22.01.2021 to 30 .01.2021. The discharge summary clearly noted that insured patient's vitals are stable throughout admission, investigation are within normal limit and could have been managed under home isolation. As per terms and conditions of the policy Lump Sum benefit equal to 100 % of the sum insured shall be payable on positive diagnosis of Covid – 19 requiring hospitalization, for a minimum continuous period of 72 hours . Here in this case no treatment is provided to the patient. Hence the stay in hospital is not at all essential. Hence the opposite party has repudiated the claim and the same was informed to the insured on 20.03.2021.
Here the opposite party has no case that the complainant was not tested Covid positive or not hospitalized. It is also admitted that as per terms and conditions of the policy Lump Sum benefit equal to 100 % of the sum insured shall be payable on positive diagnosis of Covid requiring hospitalization, for a minimum continuous period of 72 hours . But their main argument is that as per the Discharge Summary clearly noted that insured patient's vitals are stable throughout admission, investigation are within normal limit and could have been managed under home isolation and no treatment is provided to the patient. Hence the stay in hospital is not at all essential.
Here the Opposite Party has no case that the complainant’s case is within exclusion clause of the policy. It is not contented that the claim is made after limitation period of thirty days of discharge from hospital. The complainant was tested Covid 19 Positive from an authorized lab and admitted in a government hospital by a Government doctor. It shall be presumed that the complainant was admitted and treated from 22.01.2021 to 30.01.2021, since it was absolutely necessary. So the arguments of the Opposite parties to the effect that insured patient's vitals are stable throughout admission, investigation are within normal limit or that he could have been managed under home isolation or no treatment is provided to the patient and hence the stay in hospital is not at all essential etc. cannot be accepted.
Therefore, considering the facts and circumstance of the case, the complaint is entitled for the sum insured as per the policy. So this commission is of view that the complainant is entitled for the sum insured under the said policy which is Rs. 2,50,000/-. Denial of the amount for no valid reason is service deficiency on the part of opposite parties, due to which the complainant suffered mental agony. Therefore the Opposite Party is liable to pay compensation for that. This commission hold that Rs.10,000/- will be a reasonable amount of compensation.
ln the result , the complaint is allowed in part and the Opposite Party is directed to pay a total amount of Rs.2,50,000/- with 8% interest per annum from 21.06.2021, the date of complaint till payment, to the complainant . The Opposite Party is also directed to pay Rs. 10,000/-(Rupees Ten thousand only) towards Compensation for mental agony and hardships and Rs. 5,000/- (Rupees five thousand only) towards the costs.
Time for compliance is 30 days from receipt of the copy of the Judgement.
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Exhibits
A1- Copy of guide lines on Covid Standard Health Policy
A2- Policy Certificate
A3- Policy document
A4- Medical Certificate Dt:22/03/2021
A5- Repudiation letter
B1-Copy of the discharge summary of the petitoner
Witness Examined
T.V. Vamanan
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Forwarded by Order
Assistant Registrar
Ps/
