DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KOZHIKODE

PRESENT: Sri. P.C. PAULACHEN, M.Com, LLB          : PRESIDENT

Smt. PRIYA.S, BAL, LLB, MBA (HRM) :  MEMBER

Sri.V. BALAKRISHNAN, M Tech, MBA, LL.B, FIE: MEMBER

Wednesday the 31^st day of January 2024

C.C.69/2023

Complainant

Irshad.O.K,

O.K House, Punnassery (PO),

Narikkuni,

Kozhikode – 673585.

(By Adv. Sri. Anas. V)

Opposite Parties

        Future Generali India Insurance Co. Ltd,

2^nd floor, City Mall,

No.6-1002-1,

Kannur road, Opp YMCA,

Calicut, Kerala.

(By Adv. Smt. Supriya.A.K and Smt. Mirza Aslam Beg)

ORDER

By.Sri. P.C. PAULACHEN, PRESIDENT

            This is a complaint filed under Section 35 of the Consumer Protection Act, 2019.

2. The case of the complainant, in brief, is as follows:

The complainant has been working as a nurse for the last 15 years. He is the holder of Corona Rakshak Policy of the opposite party. The period of insurance was from 24/07/2020 to 05/05/2021 (285 days). The sum insured was Rs. 2,50,000/-. As per the guidelines of the policy, a lump sum benefit equal to 100% of sum insured shall be payable on positive diagnosis of covid–19 requiring hospitalization for a minimum period of 3 continuous days ie 72 hours.

3. The complainant was tested covid-19 positive and he was under treatment in the Meitra hospital, Kozhikode from 29/10/2020 to 07/11/2020 and thereafter he was in private quarantine for 7 days and 14 days observation in his house. Approximately, a sum of Rs. 1,50,000/- was the treatment expenses in the Meitra Hospital and for quarantine Rs. 7,000/- was spent. He had loss of income for about 31 days.
4. He preferred a claim with the opposite party with necessary documents. But the claim was repudiated by the opposite party stating the ground of non-disclosure of material facts as the history of childhood asthma was not disclosed in the proposal form. The complainant has no history of childhood asthma. The act of the opposite party in repudiating the claim without valid reason amounts to deficiency of service. Hence the complaint to direct the opposite party to pay a sum of Rs. 2,50,000/- towards the claim and Rs. 2,25,000/- as compensation for the mental agony and monetary loss and Rs. 10,000/- as cost of the litigation.
5. The notice issued from this Commission on 03/03/2023 was received by the opposite party on 07/03/2023. In pursuance of the notice, the opposite party entered appearance and filed vakkalath on 03/04/2023. But the version was not filed within the prescribed time and hence the opposite party was set ex-parte. On 08/06/2023 the version was filed by the opposite party with a petition filed as IA No. 244/2023 to set aside the ex-parte order and to receive the written version. IA No. 244/2023 was dismissed by this Commission as per order dated 18/01/2024.
6. The points that arise for determination in this complaint are;

1. Whether there was any deficiency of service on the part of the opposite party, as alleged?

2) Reliefs and costs.

7. The complainant was examined as PW1 and Exts A1 to A10 were marked.
8. Heard.
9. Point No.1: The complainant has approached this Commission with a grievance that the claim put in by him under the Corona Rakshak Policy was repudiated by the opposite party without valid reason.
10.  PW1 has filed proof affidavit in terms of the averments in the complaint and in support of the claim. Ext A1 is the copy of the policy schedule, Ext A2 is the copy of the tax invoice dated 24/07/2020, Ext A3 is the copy of the insurance policy letter dated 24/07/2020, Ext A4 is the copy of the premium certificate dated 24/07/2020, Ext A5 series are the laboratory reports, Ext A6 is the admission note issued by Meitra Hospital, Ext A7 is the discharge summary issued by Meitra hospital, Ext A8 is the letter dated 08/02/2021 issued by Dr.Madhu Kallath, Ext A9 is the print out of e-mail from the opposite party and Ext A10  is the copy of the repudiation letter dated 25/03/2021.
11. The evidence of PW1 stands unchallenged. The opposite party has not produced any evidence to disprove the averments in the complaint or to rebut the veracity of the documents produced and marked on the side of the complainant. There is no contra evidence to disprove the claim.
12. Ext A10 shows that the claim was repudiated for the reason that the complainant has history of childhood asthma which was not disclosed in the proposal form. PW1 has deposed that he has no such history and such a history happened to be mentioned in Ext A7 by mistake committed by the doctor. Ext A8 letter issued by the treating doctor is produced by the complainant which shows that such a history of childhood asthma mentioned in Ext A7 was a mistake. Ext A8 shows that as the complainant’s child had a history of asthma and by mistake, his family history was mentioned in the personal history and it was corrected later. Ext A7 shows that the complainant had no history of breathing difficulty at the time of admission in the hospital. Moreover, childhood asthma has no direct nexus with covid-19. Asthma patients have no greater risk of acquiring covid-19 than general population. Moreover there is no contra evidence. That being the position, we are of the view that the claim was wrongly repudiated by the opposite party. The act of the opposite party in wrongly repudiating the claim and thereby denying the legitimate claim amounts to gross deficiency of service. The complainant is entitled to get the claim amount. It goes without saying that the act of the opposite party has caused mental agony and hardship to the complainant and he is entitled to be compensated adequately. The claim for compensation is Rs. 2,25,000/-. The claim appears to be excessive. However, he is entitled to get a reasonable compensation. Considering the entire facts and circumstances, we are of the view that a sum of Rs. 10,000/- will be reasonable compensation in this case. The complainant is also entitled to get Rs. 3,500/- as cost of the proceedings.
13. Point No. 2: In view of the finding on the above point, the complaint is disposed of as follows;

1. CC 69/2023 is allowed in part.
2. The opposite party is hereby directed to pay the claim amount of Rs. 2,50,000/-(Rupees two lakh fifty thousand only) to the complainant with interest at the rate of 6% per annum from the date of the complaint ie, 23/02/2023 till actual payment.
3. The opposite party is directed to pay a sum of Rs. 10,000/- (Rupees ten thousand only) to the complainant as compensation for the mental agony and hardship suffered.
4. The opposite party is directed to pay a sum of Rs. 3,500/- (Rupees three thousand five hundred only) as cost of the proceedings to the complainant.
5. The order shall be complied with within 30 days of the receipt of copy of this order.

Pronounced in open Commission on this, the 31^th day of January, 2024.

Date of Filing: 23/02/2023

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           PRESIDENT                                    MEMBER                                        MEMBER

APPENDIX

Exhibits for the Complainant:

Ext A1 - Copy of the policy schedule,

Ext A2 - Copy of the tax invoice dated 24/07/2020,

Ext A3 - Copy of the insurance policy letter dated 24/07/2020,

Ext A4 - Copy of the premium certificate dated 24/07/2020,

Ext A5 series - Laboratory reports,

Ext A6 - Admission note issued by Meitra Hospital,

Ext A7 - Discharge summary issued by Meitra hospital,

Ext A8 - Letter dated 08/02/2021 issued by Dr.Madhu Kallath,

Ext A9 - Print out of e-mail from the opposite party  

Ext A10  - Copy of the repudiation letter dated 25/03/2021.

Exhibits for the Opposite Parties

NIL

Witnesses for the Complainant

PW1 -     Irshad.O.K,(Complainant)

Witnesses for the opposite party

 Nil

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       PRESIDENT                                    MEMBER                                        MEMBER

True copy,

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                                                                                                Assistant Registrar.