D.O.F:20/01/2021     

                                                                                                              D.O.O:21/06/2024

IN THE CONSUMER DISPUTES  REDRESSAL COMMISSION KASARAGOD

                                  CC.19/2021

Dated this, the 21^th day of June 2024

PRESENT:

SRI.KRISHNAN.K                                         : PRESIDENT

SMT. BEENA. K.G                                      : MEMBER

Mohammed Faisal.C.H,

Fareeda Manzil, Kombanadukkam,                            :Complainant

Chemnad. P.O. Kasaragod.

                                        And

1. Future Generali India Insurance Co.Ltd

Building – A, G-O Square, Sr. No.249+250,

Near Mankar Chowk, Aundh Hinjewadi Link Road,

Wakad, Pune, - 411057.

2. UCO Bank,                                                                     : Opposite Party

Branch Office, 1^st floor, Kalpaka Arcade,

Nulllipady, Kasaragod- 671121.

(Adv: Sathyashankara.M)

ORDER

SRI. KRISHNAN.K : PRESIDENT

          The case of the complainant is that he obtained a Corona Rakshak Insurance Policy covering for the period from 22/07/2020 to 02/05/2021 issued by Opposite Party No:1 through Opposite Party No:2 with a coverage of 100% sum insured on positive diagnosis of covid requiring hospitalization for more than 72 hours.  He suffered throat pain fever cough from 28/09/2020 and on diagnosed as covid positive admitted on 28/09/2020 in Carewell hospital and discharged on 11/10/2020.

          The complainant claims the full coverage insurance amount of 2.5 lakh but Opposite Party repudiated without valid reason.  The complainant alleges deficiency in service in repudiating the claim for which he claims Rs. 1,00,000/- and cost of the litigation.

          The opposite party No:1 filed written version denying the allegations in the complaint.  The case of Opposite Party No:1 is that it is a risk commencement policy valid from 08/08/2020 till 04/05/2021 client intimation form such other forms were required.  As per medical records complainant was only admitted for investigation purpose that he did not receive active treatment in hospital and thus repudiated the claim as per letter dated 03/12/2020.  The complainant not complied terms and conditions of policy and hence claim may be rejected.  Insurance policy is admitted.  There is no promise of 100% payment in each and every case unless eligibilities are full filled and for the reason prayed to dismiss the complaint.

          The Opposite Party No:2 filed written version denying any liability to the complainant.  The Opposite Party No:2 is a bank no privity of contract between complainant and Opposite Party No:2.  The Opposite Party No:1 is the insurance company collected the premium and if Complainant is eligible for the claim it is Opposite Party No:1 to pay the insurance benefits Opposite Party No:2 is an unnecessary party to the case and prayed to dismiss the claim against Opposite Party No:2.

          The complainant filed chief affidavit and was cross examined by Opposite Parties.  Ext A1 to A6 document marked from his side.  The Opposite Party produced Ext B1 to B7 documents.  Ext B1 is the policy, Ext B2 is customer sheet, Ext B3 is the health insurance claim form, Ext B4 is case sheet, Ext B5 and B6 is document recovery intimations the repudiation letter, Ext B7 is claim repudiation letter.

          Following points arise for consideration in the above case:

1. Whether complainant is entitled to insurance benefits claimed in the case and whether repudiation of liability is justifiable as per terms and conditions of the policy?
2. Whether complainant is entitled to any compensation and if so what reliefs?

The complaint is against rejection of the claim of insurance amount by Opposite Parties. The Opposite Party No:1 not disputing to undergo treatment.  But contents during hospitalization, the complainant has only taken oral medication, which he could have taken at home, and he did not require to be hospitalized.  For those with mild illness, hospitalization may not be required unless.  There is concern for rapid deterioration.  All patients discharged for home and instructed to return to hospital if they develop any worsening of illness.  The complainant has produced the case note where it is as stated that the history of fever and cough for 7-8 days of RTPCR covid positive date of admission and discharge mentioned.

          From the record it is clear that the complainant was admitted in the hospital as per the guidelines issued by the Health ministry.

          In the present case, the onus is on the insurer to show that the insured had fraudulently given false information and the said information was related to a material fact.

          The question before us in the case whether the repudiation could be sustained on the ground mentioned in repudiation letter.

          The insured cannot claim anything more than what is covered by the insurance policy, the terms of the contract have to construed strictly, without alterning the nature of the clauses of an insurance policy, have to be read as they are consequently, the terms of the insurance policy, that from the responsibility of the insurance company, must also be read strictly.  The contract must be read as a while and every attempt should be made to harmonise the elementary principals .  having heard the learned counsel for the respective counsel, the point that arises for consideration is, whether the Opposite Party herein was correct is repudiating the claim of the petitioner on the ground patient had not received any active line of treatment during admission.  This observation is falsified by medical records of complainant produced in the case.

          In a claim against the insurance company for compensation it was for the insurance company to disprove such claim with evidence if any vide Shobika Attire Vs New Indian Assurance Co. Ltd, (2006 SCC 35)

          In the light of above discussion the Insurance Company is liable to make the payment of insure claim under the policies to the complaint amounting to Rs. 2,50,000/- with interest at the rate of 6% per annum from the date of filing the complaint till the actual realization.

          The Commission found deficiency in service on the part of the opposite Party in repudiating the claim filed by the complainant and therefore the repudiation of the policy was without any or justification.

          The Opposite Party No:2 is exonerated from liability since insurance company alone to pay the insurance benefits.  Repudiating the claim without valid grand amounts deficiency in service for which opposite party No:1 has to pay compensation.  The Commission finds Rs. 10,000/- in the reasonable compensation and also complainant is entitled for cost of litigation.

          In the result complaint is allowed in part directing the Opposite Party No:1 to pay Rs. 2.50,000/-(Rupees Two lakh Fifity thousand) with 6% from date of complaint till realsiation as insurance policy amount and Rs. 10,000/-(Rupees Ten thousand only) as compensation of deficiency in service and Rs. 5000/-(Rupees Five thousand only) as cost of litigation within30 days of the receipt of the order. 

       Sd/-                                                                                                 Sd/-

MEMBER                                                                                          PRESIDENT

Exhibits

A1- Health insurance claim form.

A2- Covid Test Report

A3- Case sheet

A4- Nurses record

A5- Medication Sheet

B1- Policy

B2- Customer information sheet

B3- Health insurance claim form

B4- Case sheet

B5 & B6- Document Recovery intimation

B7- Claim repudiation letter

Witness examined

 Pw1-   Mohammed Faizal C.H

Dw1- Sudheesh.C

     Sd/-                                                                                               Sd/-

Forwarded by Order

                                                                      Assistant Registrar

Ps/