Haryana

Kaithal

CC/4/2022

Parveen - Complainant(s)

Versus

Oriental Insurance Co. - Opp.Party(s)

Sh.Amarjeet Singh

05 Oct 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KAITHAL.

                                                     Complaint Case No.4/2022.

                                                     Date of institution: 10.01.2022.

                                                     Date of decision:04.10.2023.

Parveen age about 34 years son of Sh. Ram Karan, resident of near Govt. School Bhuna, Tehsil Guhla, District Kaithal.

                                                                        …Complainant.

                        Versus

1. Oriental Insurance Company Ltd. Haffed Road, Cheeka, Kaithal-136034 through its Branch Manager.
2. Oriental Insurance Company Ltd., Divisional Office, 87-88, Mahila Ashram Complex, Behind Bus Stand, Karnal-132001, through Senior Divisional Manager.
3. M/s. Vipul Medcorp TPA Pvt. Ltd., 515, Udyog Vihar, Phase V, Gurgaon-122016 through authorized authority. 

….OPs.

        Complaint under Section 35 of the Consumer Protection Act, 2019.

CORAM:     SMT. NEELAM KASHYAP, PRESIDENT.

                   SMT. SUMAN RANA, MEMBER.

                   SH. SUNIL MOHAN TRIKHA, MEMBER.

       

Present:     Sh. Vinay Garg, Advocate, for the complainant.   

                Sh. Amit Kaushik, Advocate for the OPs.No.1 & 2.

                OP No.3 exparte.

               

ORDER

NEELAM KASHYAP, PRESIDENT

        Parveen-Complainant has filed this complaint under Section 35 of Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the OPs.

2.             In nutshell, the facts of present case are that on 15.10.2020 the complainant purchased a policy from OP No.1 namely “CORONA RAKSHAK POLICY” bearing No.261390/48/2021/304 for the insured sum of Rs.2,50,000/- valid w.e.f. 16.10.2020 to 28.04.2021.  On 06.04.2021 the complainant felt the symptoms of Covid-19 disease and he got his RT-PCR Test from District Civil Hospital, Kaithal.  As per the guidelines of the Govt. and instructions of Doctors of Govt. Hospital, Kaithal, the complainant admitted in the said hospital in isolation ward and remained there upto 13.04.2021.  After discharge from the hospital, the complainant duly submitted all his record i.e. Covid-19 positive report, admission and discharge slip alongwith medical treatment record to OPs No.1 & 2 but the OPs No.1 & 2 repudiated the claim of complainant vide letter dt. 28.12.2021.  The said repudiation of claim is stated to be wrong and illegal.  So, it is a clear cut case of deficiency in service on the part of OPs and prayed for acceptance of complaint.     

3.          Upon notice, the OPs No.1 & 2 appeared before this Commission, whereas OP No.3 did not appear and opted to proceed against exparte vide order dt. 01.09.2022 passed by this Commission.  OPs No.1 & 2 contested the complaint by filing their written version raising preliminary objections with regard to locus-standi; maintainability; cause of action; jurisdiction; that the policy in question is contractual in nature and the claims arising therein are subject to terms and conditions forming party of the policy.  The terms and conditions were explained to the complainant at the time of proposing the policy and the same were served to the complainant alongwith the policy schedule.  From perusal of record of the hospital for said admission submitted by the complainant and medical opinion given by TPA, it is observed by competent authority that the patient had 98 C fever throughout with SP02 level 96-97% and he was given oral treatment without any specific symptom of Covid-19 and hence, advised by Govt. Hospital for supervision in isolation ward without any active line of treatment for the reason that he had no symptoms of COVID and only his report dt. 08.04.2021 was found +ve.  As per clause 6.1.i of the policy, the claim has been repudiated as per terms and conditions of the insurance policy.  There is no deficiency in service on the part of OPs.  On merits, the objections raised in the preliminary objections are rebutted and so, prayed for dismissal of complaint.

4.             To prove his case, the complainant tendered into evidence affidavit Ex.CW1/A alongwith documents Annexure-C1 to Annexure-C5 and thereafter, closed the evidence.

5.             On the other hand, the OPs tendered into evidence affidavit Ex.RW1/A alongwith documents Annexure-R1 to Annexure-R20 and thereafter, closed the evidence.

6.             We have heard the learned Counsel for both the parties and perused the record carefully.

7.             Ld. counsel for the complainant has argued that on 15.10.2020 the complainant purchased a policy from OP No.1 namely “CORONA RAKSHAK POLICY” bearing No.261390/48/2021/304 for the insured sum of Rs.2,50,000/- valid w.e.f. 16.10.2020 to 28.04.2021.  It is further argued that on 06.04.2021 the complainant felt the symptoms of Covid-19 disease and he got his RT-PCR Test from District Civil Hospital, Kaithal.  As per the guidelines of the Govt. and instructions of Doctors of Govt. Hospital, Kaithal, the complainant admitted in the said hospital in isolation ward and remained there upto 13.04.2021.  It is further argued that after discharge from the hospital, the complainant duly submitted all his record i.e. Covid-19 positive report, admission and discharge slip alongwith medical treatment record to OPs No.1 & 2 but the OPs No.1 & 2 repudiated the claim of complainant vide letter dt. 28.12.2021.  The said repudiation of claim is stated to be wrong and illegal.  So, it is a clear cut case of deficiency in service on the part of OPs.

8.             On the other hand, ld. counsel for the OPs No.1 & 2 has argued that from perusal of record of the hospital for said admission submitted by the complainant and medical opinion given by TPA, it is observed by competent authority that the patient had 98 C fever throughout with SP02 level 96-97% and he was given oral treatment without any specific symptom of Covid-19 and hence, advised by Govt. Hospital for supervision in isolation ward without any active line of treatment for the reason that he had no symptoms of COVID and only his report dt. 08.04.2021 was found +ve.  As per clause 6.1.i of the policy, the claim has been repudiated as per terms and conditions of the insurance policy. 

9.             We have considered the rival contentions of both the parties.  It is clear from Annexure-C1 that the complainant purchased the policy from the OPs namely “CORONA RAKSHAK POLICY” bearing No.261390/48/2021/304 valid for the period w.e.f. 16.10.2020 to 28.04.2021 for the insured sum of Rs.2,50,000/-.  The OPs No.1 & 2 have repudiated the claim of complainant vide letter dt. 28.12.2021 as per Annexure-C5/Annexure-R2 on the ground that the patient had 98 C fever throughout with SP02 level 96-97% and he was given oral treatment without any specific symptom of Covid-19 and hence, advised by Govt. Hospital for supervision in isolation ward without any active line of treatment for the reason that he had no symptoms of COVID.  During the course of arguments, ld. counsel for the complainant has drawn our attention towards COVID-19 RT PCR REPORT as per Annexure-C2, wherein it is mentioned in the column of result “SARS COV-2 POSITIVE.  As per OPD Card of Civil Hospital, Kaithal (Annexure-C3), it is mentioned that Covid-19 Positive and advised admit in isolation.  So, the complainant was admitted in Govt. Hospital Kaithal in isolation ward and remained there upto 13.04.2021.  Hence, we are of the considered view that the OPs No.1 & 2 have wrongly repudiated the claim of complainant and there is deficiency in service on the part of OPs No.1 & 2.

10.            Thus, as a sequel of aforesaid discussion, we direct the Ops No.1 & 2 to the pay the insured amount of Rs.2,50,000/- to the complainant within 45 days from today, failing which, the aforesaid amount shall carry interest @ 7% p.a. from the date of this order till its realization.  Hence, the present complaint is accepted accordingly against OPs No.1 & 2 and dismissed against OP No.3.  There is no order as to costs.

11.            In default of compliance of this order, proceedings against OPs No.1 & 2 shall be initiated under Section 72 of Consumer Protection Act, 2019 as non-compliance of court order shall be punishable with imprisonment for a term which shall not be less than one month, but which may extend to three years, or with fine, which shall not be less than twenty five thousand rupees, but which may extend to one lakh rupees, or with both.  A copy of this order be sent to both the parties free of cost.  File be consigned to the record room after due compliance.     

Announced in open court:

Dt.:04.10.2023.

                                                                (Neelam Kashyap)

                                                                President.

 

(Sunil Mohan Trikha),           (Suman Rana),          

Member.                            Member.

 

Typed by: Sanjay Kumar, S.G.