Punjab

Sangrur

CC/910/2021

Ranjit Kaur - Complainant(s)

Versus

Jatinder Kumar - Opp.Party(s)

Sh. Manpreet Singh Grewal

03 Jun 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .

                                                                        Complaint No. 910

 Instituted on:   19.07.2021

                                                                         Decided on:     03.06.2024

 

Ranjit Kaur wife of Jasvir Singh, resident of Village Qila Bharian, Tehsil and District Sangrur.

                                                         …. Complainant.     

                                                 Versus

1.             Jatinder Kumar (D3000302) IFFCO-TOKIO General Insurance Company Limited India, Servicing Office: A.R.Estate Pvt. Hotel Hot Chop, Kaula Park Market, Sangrur 148001 (Insurance Advisor).

2.             Managing Director, IFFCO-TOKIO General Insurance Company Limited India, Registered office: IFFCO SADAN C1, Court Chowk Road, District Centre, Sec-6, Saket-New Delhi 110017.

3.             Managing Director, IFFCO-TOKIO General Insurance Company Limited India, Corporate Office: IFFCO TOWER II, 4^th & 5^th Floor, Plot No.03, Sector 29, Gurgaon, Haryana 122001.  

                                                        ..Opposite parties.

 

For the complainant  :       Shri Manpreet Singh Grewal, Adv.

For Opp.party No.1  :       Shri Gurmukh Singh, Adv

For Opp.Party No.2&3:     Shri Bhushan Garg, Adv.

 

Quorum                                          

Jot Naranjan Singh Gill, President

Sarita Garg, Member

                        Kanwaljeet Singh, Member

 

ORDER

SARITA GARG, MEMBER

1.             Complainant has preferred the present complaint against the opposite parties  on the ground that the complainant got herself insured with the OPs under Corona Rakshak policy as the complainant is a health worker vide policy number H0318980 dated 20.7.2020 for Rs.2,50,000/- against the payment of requisite premium of Rs.2839/- for the period from 20.7.2020 to 30.4.2021.  Further case of complainant is that the complainant got her corona test (RT PCR) done on 7.9.2020 under SRF Id. 030430053948 alongwith VRDLGM CNCov No. 370993 at PHC Longowal whose report came out on 09.09.2020 which was prepared by VRDL, Govt. Medical College, Patiala in which complainant was found Corona positive and after that on 10.9.2020 complainant was shifted to Covid Care Centre, Ghabdan through 108 ambulance. The complainant remained admitted there from 10.09.2020 to 15.09.2020 under the observation of concerned doctors of medical staff, where complainant got proper treatment of corona and was discharged on 15.09.2020. Thereafter the complainant lodged the claim with the OPs and submitted relevant documents to the OP number 1, but the OP wrongly and illegally repudiated the rightful claim of the complainant vide letter dated 08.01.2021.  Thus, alleging deficiency in service on the part of the Ops, the complainant has prayed that the Ops be directed to pay to the complainant the claim amount of Rs.2,50,000/- alongwith interest @ 18% per annum from 9.9.2020 till realisation and further claimed compensation and litigation expenses.

2.             In reply filed by OP number 1, preliminary objections are taken up on the grounds that the complainant has no locus standi and cause of action to file the present complaint, that the OP number 1 is only agent of OP number 2 and 3 and nothing has to be done with the insurance policy, that the complaint is not maintainable,  that the complainant has not come to this Commission with clean hands and that the complaint is false, bad vague and vexatious. On merits, it is admitted that the complainant approached the OP number 2 for purchase of the policy in question and as such he explained all the terms and conditions of the policy to the complainant. It is stated further that if any claim arises then it was to be settled by OP number 2 and 3. Other allegations levelled in the complaint have been denied and lastly OP number 1 has prayed that the complaint be dismissed with special costs.

3.             In reply filed by OP number 2 and 3, legal objections are taken up on the grounds that there is no deficiency in service on the part of the OPs, that the claim of complainant does not fall under the purview of the insurance policy and same is not payable, therefore, the claim of the complainant was repudiated vide letter dated 08.01.2021. It is further averred that the complainant is claiming benefit under Corona Rakshak Policy on the ground that the complainant was found positive on 10.09.2020 and was sent to Covid Care Centre, Ghabdan, Sangrur on same day where he remained admitted upto 15.09.2020. It is further averred that the complainant stayed in Covid Care Centre which was set up by the Govt. for isolation/quarantine only for the cases that has been clinically assigned as mild or very mild or Covid suspect cases and are not designated Covid Hospitals where moderate to severe cases of Covid-19 are required to be admitted for impatient care. It is stated further that as per insurance policy if the insured person is diagnosed with Covid and hospitalized for more than 72 hours following medical advice of a duly qualified medical practitioner as per the norms specified by Ministry of Health, the company shall pay the sum insured to the insured.  It is further averred that the policy sum insured is payable only in case the Covid patient is hospitalised for minimum consecutive period of 72 hours for impatient care basis, whereas in the present case the complainant was tested positive on report dated 10.09.2020 and sent to Covid Care Centre, Ghabdan, Sangrur on same day for isolation/quarantine purpose only  as the patient was asymptomatic with no complications, so that patient in the present case was not hospitalized and stayed in Covid Care Centre which has been set up by the government for isolation/quarantine only for the cases that has been clinically assigned as mild or very mild or Covid suspect cases and are not designated Covid Hospitals as stipulated under the policy conditions.  On merits, it is admitted that the complainant purchased the policy in question for Rs.2,50,000/- for the period from 20.07.2020 to 30.04.2021. It is stated further that no claim of the complainant was made out under the policy, therefore, the claim of complainant has been repudiated vide letter dated 08.01.2021. Any deficiency in service on the part of the OPs has been denied.   

4.             The learned counsel for the complainant has produced Ex.CW1/A affidavit of complainant, Ex.C-1 to Ex.C-12 copies of documents and closed evidence. On the other hand, the learned counsel for OP number 1 has produced Ex.OP1/1 affidavit and closed evidence. The learned counsel for OPs number 2 and 3 has produced Ex.2&3/1 to Ex.2&3/7 copies of documents and affidavit and closed evidence.

5.             We have heard the learned counsel for the parties and heard the learned counsel for the parties.

6.             The learned counsel for the complainant has argued vehemently that the complainant got herself insured with the OPs under Corona Rakshak insurance policy  bearing number H0318980 dated 20.7.2020 for Rs.2,50,000/- against the payment of requisite premium of Rs.2839/- for the period from 20.7.2020 to 30.4.2021.  Further the learned counsel has argued that the complainant got her corona test (RT PCR) done on 7.9.2020 under SRF Id. 030430053948 alongwith VRDLGM CNCov No. 370993 at PHC Longowal whose report came out on 09.09.2020 which was prepared by VRDL, Govt. Medical College, Patiala in which complainant was found Corona positive and after that on 10.9.2020 complainant was shifted to Covid Care Centre, Ghabdan through 108 ambulance. The complainant remained admitted there from 10.09.2020 to 15.09.2020 under the observation of concerned doctors of medical staff, where complainant got proper treatment of corona and was discharged on 15.09.2020. Thereafter the complainant lodged the claim with the OPs and submitted relevant documents to the OP number 1, but the OP wrongly and illegally repudiated the rightful claim of the complainant vide letter dated 08.01.2021 as such the complainant has prayed for acceptance of the complaint. To support her case, the complainant has produced on record Ex.CW1/A affidavit of complainant, Ex.C-1 is the copy of insurance policy showing coverage of Rs.2,50,000/-. Ex.C-2 is the copy of corona test report dated 9.9.2020, Ex.C-3 is copy of shifting letter dated 10.9.2020, Ex.C-4 is copy of admission/discharge summary. Ex.C-5 is the copy of OPD Slip, Ex.C-6 is the copy of claim form and Ex.C-7 is the copy of repudiation letter.  Though the complainant got served the legal notice upon the OP, but the claim was not paid.

7.             The learned counsel for OPs number 2 and 3 has  contended that the claim has rightly been repudiated vide letter dated 08.01.2021. It is further contended that the complainant is claiming benefit under Corona Rakshak Policy on the ground that the complainant was found positive on 10.09.2020 and was sent to Covid Care Centre, Ghabdan, Sangrur on same day where he remained admitted upto 15.09.2020. It is further contended that the complainant stayed in Covid Care Centre which was set up by the Govt. for isolation/quarantine only for the cases that have been clinically assigned as mild or very mild or Covid suspect cases and are not designated Covid Hospitals where moderate to severe cases of Covid-19 are required to be admitted for impatient care. It is stated further that as per insurance policy if the insured person is diagnosed with Covid and hospitalized for more than 72 hours following medical advice of a duly qualified medical practitioner as per the norms specified by Ministry of Health, the company shall pay the sum insured to the insured.  It is further contended that the policy sum insured is payable only in case the Covid patient is hospitalised for minimum consecutive period of 72 hours for impatient care basis, whereas in the present case the complainant was tested positive on report dated 10.09.2020 and sent to Covid Care Centre, Ghabdan, Sangrur on same day for isolation/quarantine purpose only  as the patient was asymptomatic with no complications, so that patient in the present case was not hospitalized and stayed in Covid Care Centre which has been set up by the government for isolation/quarantine only for the cases that has been clinically assigned as mild or very mild or Covid suspect cases and are not designated Covid Hospitals as stipulated under the policy conditions. Further it is contended that the claim of the complainant has rightly been repudiated. In the present case, it is no doubt true that the complainant was found Corona positive on 10.09.2020 and as such was admitted in Covid Care Centre Ghabdan, as is evident from the copy of certificate issued by MPHW (M) Longowal. Ex. C-5 is the copy of OPD slip dated 9.9.2020, wherein it has been clearly mentioned that the sample was taken on 9.9.2020 and as per report of RTP-CR, the complainant was found Covid positive and was discharged on 15.09.2020 whereas she was admitted for corona positive on 10.09.2020, which clearly shows that the complainant remained admitted in the hospital for Corona Positive for more than 72 hours. We failed to understand how the OPs number 1 and 2 are pleading that the claim is not payable as the complainant never remained admitted in the hospital for more than 72 hours.  On the other hand, the learned counsel for the OPs number 2 and 3 has drawn our attention towards the document Ex.OP2&3/3, wherein it was clearly mentioned that the complainant Ranjit Kaur wife of Jasvir Singh resident of Village Killan Bharian was shifted to  Covid Care Centre, Ghabdan as per the guidelines of the Govt.   Ex.OP2&3/5 is the copy of certificate for home hospitalisation of Covid-19 patients, wherein it was mentioned that the complainant Ranjit Kaur was advised for home isolation on 15.09.2020 after keeping her in the hospital. Accordingly, we find that the complainant remained admitted in the hospital for more than 72 hours due to Corona positive case.  As such, we find it to be a clear cut case of deficiency in service on the part of OPs number 2 and 3 for not settling the rightful claim of the complainant.

8.             The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 Civil) 111.

9.             Accordingly, in view of our above discussion, we allow the complaint and direct OPs number 2 and 3 to pay to the complainant the claim amount of Rs.2,50,000/- alongwith interest @ 7% per annum from the date of filing of the present complaint i.e. 19.07.2021 till realisation. Further they are directed to pay to the complainant an amount of Rs.5000/- as compensation for mental tension, agony and harassment and further an amount of Rs.5000/- on account of litigation expenses. This order be complied with within a period of sixty days of receipt of copy of this order.

10.           The complaint could not be decided within the statutory time period due to heavy pendency of cases.

11.           Copy of this order be supplied to the parties free of cost. File be consigned to the records after its due compliance.  

                        Pronounced.

                        June 3, 2024.