By Sri. MOHANDASAN.K, PRESIDENT
Complaint in short is as follows: -
1. The complainant availed insurance policy of the opposite party band the policy No. is P/181314/01/2021/002320. The said policy valid is from 10/08/2020 to 22/05/2021 and covering covid 19 treatment also. The policy is Known as “Corona Rakshak policy”.
2. While the policy was in force the complainant was diagnosed Covid 19 positive on 27/08/2020 in RTPCR test, and consequently he was admitted in government Taluk Hospital, Tirurangadi with In patient No.3664 on 29/08/2020. He was discharged on 05/09/2020 after inpatient treatment of 8 days. Thereafter, the complainant was in home quarantine for a further period of 14 days. Immediately after admission in the hospital, the complainant called to the toll-free No.1800-425-2255 of opposite party as directed in his insurance certificate. In addition to that the complainant sent an email to the opposite party in official ID claiming lump sum compensation for which he is entitled to as per the policy conditions. Moreover, after the quarantine period, the complainant sends all the necessary records to the office of the second opposite party through courier to get his insurance benefit. But on 04/12/2020, complainant received a letter from first opposite party stating that they are unable to admit his claim for the reason that as per the terms and conditions of the policy issued to him, lump sum benefit shall be payable on positive diagnosis of covid, requiring hospitalization and not for institutional quarantine.
3. The complainant submitted that he was treated for his positive covid virus from the government Taluk hospital Tirurangadi, admitting there for 8 days from 29/08/2020 to 05/09/2020 and not as institutional quarantine as stated in above letter dated 04/12/2020. Moreover, the complainant has complied all the conditions mentioned in his insurance policy during the period of his inpatient treatment itself. Therefore, the rejections of complainant’s insurance claim are illegal. Moreover, the complainant has suffered much agony due to this illegal rejection of his claim. Though the mental agony suffered by the complainant is uncountable in terms of money, he is entitled to get compensation of Rs.50,000/- as token from the opposite parties. This being the position, the complainant has issued a lawyer notice to the first and second opposite parties stating all the above details and demanding lump sum benefit of Rs.1,50,000/- as per policy condition and compensation on 22/12/2020. The third opposite party sent a reply notice dated 06/01/2021 without any signature or seal in it and that too with unsustainable grounds. All the grounds alleged in the reply notice for rejecting the insurance claim by the opposite parties are neither correct nor sustainable.
4. The statement in the reply notice that, in the discharge card issued by Taluk Hospital Tirurangadi, nothing was mentioned about the condition of the patient and medicines which were prescribed and the complainant did not submit sufficient medical document as per the condition No.7.3 of policy and the complainant was asymptomatic and no active line of treatment was given are absolutely false and hence denied by complainant. The allegation in the reply notice that, the claim shall be payable, on positive diagnosis of covid 19 requiring hospitalization for a minimum period for 72 hours and no document have been submitted by complainant which confirms Covid positive and corona symptoms were absent and thus it does not require admission in a hospital are also false, baseless, unsustainable, and so denied by the complainant. The contention in the replay notice is illegal and against the rules and guidelines framed by Insurance Regulatory and Development Authority of India for covid standard health policies.
5. The government of Kerala has introduced a treatment protocol for covid 19 patients which has been appreciated by several international agencies. As per the protocol followed by state government in August 2020, every covid patient shall be hospitalized and treated there. The complainant here in complied all conditions of his insurance policies during the period of his inpatient treatment itself. As per rejection letter dated 04/12/2020, the third opposite party stated that they repudiated the claim because the lump sum benefit shall be payable only on positive diagnosis of covid requiring hospitalization not institutional quarantine. It is submitted that the complainant herein was treated from 29/08/2020 to 05/09/2020 in government taluk hospital, Tirurangadi, which was declared by the state government as a first line treatment center for positive covid patient, that too in order to ensure efficient, better as well as timely treatment for all covid positive patient in the state to save their life. Hence the submission of the complainant is that the opposite parties have no right to deny the claim and the rejection of his claim is nothing but baseless and illegal. The act of the opposite party amounts deficiency in service and the opposite parties are liable to pay the insured lump sum benefit of Rs.1,50,000/- to the complainant. The complainant further prayed for compensation of RFs.50,000/- along with cost of proceedings.
6. On admission of the complaint notice was issued to the opposite parties and on receipt of notice the opposite parties filed version denying the all averments and allegations in the complaint. The complaint, according to the opposite party is filed without any bonafides and the same has been done with the ulterior motive of making illegal gains.
7. The opposite party admitted that the complainant took a Corona Rakshak policy form the second opposite party for the period commencing from 10/08/2020 to 22/05/2021 for sum insured of Rs.1,50,000/- vide policy No. P/181314/01/2021/002320. At the time of issuing the policy the complainant was supplied with the terms and condition of the policy. The complainant after accepting the terms and conditions of the policy had availed the policy.
8. The opposite party submitted that during the aforesaid policy period, the complainant had submitted a claim as CIR /2021/18/13/14/0389884 along with the claim form and discharge card from Taluk hospital, Tirurangadi which states that the complainant had undergone treatment at the hospital form 29/08/2020 to 05/09/2020 and was diagnosed with “Covid 19 recovered “. It is submitted that in the discharge card issued by Taluk hospital Tirurangadi , nothing was mentioned about the condition of the patient, level of SPO2 and line of treatment given to the patient. Moreover, the complainant has not submitted any prescription / report from the treating doctor requiring hospitalization as in patient.
9. The condition 7.3 of the policy, the claim has to be supported with duly filed and signed claim form, medical practitioner’s prescription advising admission, discharge summary including complete medical history of the patient along with other details, investigation reports including insured persons test reports from authorized diagnostic center for Covid. None of the medical documents were submitted by the complainant till the date of filing version.
10. The opposite parties further submitted that the condition of patient i.e., category of condition (A, B &C) was silent in the discharge summary as per the condition of the policy it is clearly mentioned that “the claim shall be payable on positive diagnosis of COVID 19 requiring hospitalization for a minimum period for 72 hours “. There were no symptoms required inpatient care / admission in a hospital. Corona symptom like fever, sore throat, headache, Chills, loss of smell or taste, congestion or runny nose, Nausea or Vomiting diarrhea or breathing difficulty are absence. Hence, according to opposite party he does not require admission in hospital. No special treatment given to the complainant and no document submitted other than discharge card.
11. In a covid case the primary symptoms are fever, sore throat, headache, chills, loss of smell and taste, congestion or runny nose, Nausea or Vomiting, diarrhea and low level of SPO2. SPO2 is oxygen saturation, it is measures of the amount of oxygen – carrying hemoglobin in the blood relative to the amount of hemoglobin not carrying oxygen. The body needs certain level of oxygen in the blood or it will not function as efficiently. In fact, very, low less of SPO2 can result in very serious respiratory symptom, the normal oxygen level which is measured by a pulse oxy meter usually range from 95% to 100 %. The blood oxygen levels below 90 % are considered low (hypoxemia) and hence oxygen support is mandatory in such cases. In this case, no parameters of SPO2, heart rate, temperature were noted in the discharge summary.
12. As per the terms and conditions of policy lump sum benefit equal 100% of the sum insured shall be payable for positive diagnosis of covid, requiring hospitalization for a minimum continues period of 72 hours. The positive diagnosis of covid shall be from a government authorized diagnosis center. The policy designed to mitigate the huge expenses inured for the prolonged treatment. It is further noticed that-
- payment will be made only on hospitalization for a minimum continues period of 72 hours following positive diagnosis for covid,
- This is one time benefit applicable for the entire tenure of the policy and shall terminated upon payment of this benefit.
13. It is submitted as per the definition clause 3.7 of the policy, hospitalization means admission in a hospital designated for covid 19 treatment by government for the minimum period of 72 consecutive in patient care hours.
14. Definition clause (3.8) of the policy stated in impatient care means treatment for which the insured person must stay in a hospital continuously for more than 72 hours for treatment of Covid. The submission of the opposite party is that no treatment was given to the complainant herein and so stay in the hospital was not an essential one. The discharge card reveals nothing required hospitalization and so the complainant is not eligible for the lump sum benefit as stated in the policy.
15. According to the opposite party the guidelines for covid 19, clearly states that “quarantine means the separation restriction of movement for activities of persons who are not ill but who are believed to have been exposed to infection, for the purpose of preventing transmission of deceases “. In short, the purpose of quarantine is to reduce transmission by separating contacts of covid 19 patients from community, monitoring contacts for development of sign and symptoms of covid 19, and segregation of covid 19 suspects, as early as possible from among other quarantine persons.
16. The opposite parties repudiated the claim based on terms and conditions of the policy and the same was informed to the complainant vide letter dated 04/12/2020. The submission of the opposite party is that the cardinal rule of law is that all provisions of law should literally interpreted unless the provision or clause has an alternative construction to its ordinary meaning. The contract of insurance, the rights and obligations are governed by the terms of the contract. The terms of the contract of insurance had to be strictly construed and no exemption can be made on ground of equity. The terms of the policy had to be construed as it is and the court cannot add or subtract something.
17. The complainant had issued notice to the opposite party after the repudiation of the claim and the opposite parties had duly replied vide letter dated 06/01/2021.
18. The opposite party contended that the complainant had not complied all the conditions mentioned in the policy. The available document there has been no mentioning that the complainant had received any treatment from the hospital. Hence the submission of the opposite party is that the complainant in order to get the claim amount unlawfully had submitted the documents to the opposite party. The complainant has not suffered mental agony due to the rejection of the claim. The opposite party issued reply notice stating the correct facts based on the terms and conditions of the policy which was approved by IRDA. The complainant has not submitted any proof which stating that he had undergone treatment at the hospital.
18. The opposite party submitted that there is no deficiency of service from the part of the opposite parties and the claim was repudiated as per the terms and conditions of the policy. The complainant is not entitled for the lump sum benefit of the policy. He has not full filed the conditions stated in the policy and the complainant is trying to make unlawful gain by making false allegations. Therefore, the prayer of the opposite party is to dismiss the complaint with compensatory cost to the opposite parties.
19. The complainant and opposite parties filed affidavit and documents. The documents on the side of complainant marked as Ext. A1 to A11. The documents on the side opposite parties marked as Ext.B1 to B5. Ext. A1 is copy of policy of Corona Rakshak as vide No. P/181314/01/2021/002323 issued by opposite parties to complainant which is valid for the period 10/08/2020 to 28/05/2021 dated 10/08/2020. Ext. A2 is advance premium receipt for insurance policy issued by opposite party dated 10/08/2020. Ext. A3 is copy of RTPCR test result of complainant dated 28/08/2020. Ext. A4 is copy of discharge card issued from government Taluk hospital Tirurangadi dated 05/09/2020. Ext. A5 is copy of consignment receipt issued by professional courier for sending relevant records to second opposite party dated 30/10/2020. Ext. A6 is copy of delivery report of professional courier showing that consignment received by second opposite party nil dated. Ext. A7 is copy of letter issued by opposite party to the complainant denying policy claim 2 pages dated 04/12/2020. Ext. A8 is copy of notice issued by the complainant to the first and second opposite parties with postal receipt. Ext. A9 is copy of acknowledgment card for receipt of lawyer notice by first opposite party dated 26/12/2020. Ext A10 is copy of acknowledgement card for receipt of lawyer notice by second opposite party dated 24/12/2020. Ext.A11 is copy of reply notice sent by third opposite party along with cover (without seal and sign) dated 06/01/2021. Ext. B1 copy of insurance policy /certificate No. P/181314/01/2021/002323. Ext. B2 is copy of discharge card. Ext. B3 is copy of repudiation letter issued by opposite party to the complainant dated 04/12/2020. Ext. B4 is copy of guidelines dated 24/07/2020 issued by health and family department government of Kerala. Ext. B5 is copy of advisory on home care of asymptomatic covid 19 positive patients issued by health and family welfare department of Kerala.
20. Heard complainant and opposite parties. Perused affidavit and documents.
The following points arise for consideration.
- Whether the complainant is entitled insurance benefit?
- Relief and cost?
21. Points 1 and 2
The case of the complainant is that he was the holder of policy of Corona Rakshak as vide No. P/181314/01202/002323 issued by the opposite parties. He was undergone treatment at government Taluk hospital Tirurangadi due to covid 19 positive while the policy was in force. Complainant produced Ext. A4 to prove that he was in the hospital for the period 29/082020 up to 05/09/2020 and he was recovered from covid 19. The complainant also produced Ext. A3 RTPCR test result issued from government medical college Manjeri dated 28/08/2020 which shows positive result. Hence, as per the terms and conditions of the insurance policy Ext. A1, the complainant is entitled to the insurance benefit which the opposite party stands denied.
22. The opposite parties here in filed detailed version and affidavit stoutly opposing the claim of the complainant. The contention of the opposite party is that the repudiation of the insurance claim is strictly according to the terms and conditions of the policy . The contention of the opposite party is that Ext. B2 and Ext. A4, the discharge card does not reveal the exact treatment details which the complainant undergone. The contention of the opposite party is that the complainant does not require hospitalization for the covid 19 which the complainant sustained. But the opposite party admitted the terms as per the policy that the claim shall be payable on positive Diagnosis of covid 19 requiring hospitalization for a minimum period for 72 hours.
23. The perusal of documents, it is evident that there was a policy admitted by the opposite party in favor of the complainant to cover insurance while the insurer undergoes 72 hours hospitalization due to covid 19 positive result. It is evident that as per Ext. A3 the complainant was with RTPCR result of positive obtained from government medial college, manjeri dated 28/08/2020. Ext. A4 the discharge card issued from government Taluk hospital Tirurangadi shows that he was hospitalized from 29/08/2020 to 05/09/2020 and he was recovered from Covid 19. Hence, Ext. A3 reveals the complainant was in the government Taluk hospital TiruarngadI for 8 days due to Covid 19 positive result. In addition to that, though there is no document, the complainant submitted that he was in quarantine at his residence for the next 14 days. In short, the case of the complainant stands proved through the documents and affidavit. It is evident that complainant was met with covid 19 positive and was in hospital for 8 days that too in government hospital. The admitted case of the opposite party is that they are liable to pay insured amount in case of hospitalization for a minimum period for 72 hours on diagnosis of Covid 19. So, there is absolutely no justification for repudiation of insurance claim of the complainant through Ext. B3. The right to determine the medicine and hospitalization is vest with the doctor and not with the insurance company. The insurance company cannot dictate the mode of covid treatment and hospitalization. Hence the insurance company is liable to pay the insured sum as per Exits. A1 and B1.
24. It appears the opposite party repudiated the claim without sufficient reason. The contention of opposite party is absolutely without any merit. The denial of insurance to the rightful claimants amounts unfair trade practice and deficiency in service. The insurance policy called corona rakshak policy was introduced as part of social welfare measure to provide protection to the interest of public at large. But the opposite party cut the very root of the intention contending unsustainable reasons for denying the genuine claim. The complainant herein met with Covid 19 during 2020 August but after this long period the claim of the complainant stands not settled. The complainant is naturally entitled for the interest on insured sum from the date of claim to till dale of payment. In addition to that the complainant entitled reasonable amount of compensation which the complainant claims Rs.50,000/-. The commission finds the claim of the complainant as reasonable one. The complainant also entitled cost of the proceedings and so we fix the same as Rs.5,000/-.
25. Considering the entire facts and circumstances of the complaint, we allow this complaint as follows: -
- The opposite parties are directed to pay the lump sum amount of policy Rs.1,50,000/ - (Rupees one lakh fifty thousand only) to the complainant with interest at the rate of 9% interest per annum from the date of complaint to till date of payment.
- The opposite parties are directed to pay Rs.50,000/- (Rupees Fifty thousand only) to the complainant as compensation on account of deficiency in service and thereby caused inconvenience and hardships to the complainant.
- The opposite parties directed to pay Rs.5,000/ (Rupees five thousand only) to the complainant as cost of the proceedings.
The opposite parties shall comply this order within one month from the dale of receipt of copy of this order, failing which the opposite parties are liable to pay interest at the rate of 12% per annum for the entire above amount from the date of order to till date of payment.
Dated this 11th day of April , 2023.
APPENDIX
Witness examined on the side of the complainant: Nil
Documents marked on the side of the complainant: Ext.A1 to A11
Ext.A1: Copy of policy of Corona Rakshak as vide No.P/181314/01/2021/002323
issued by opposite parties to complainant which is valid for the period
10/08/2020 to 28/05/2021 dated 10/08/2020.
Ext.A2: Advance premium receipt for insurance policy issued by opposite party dated
10/08/2020.
Ext A3: Copy of RTPCR test result of complainant dated 28/08/2020.
Ext A4: Copy of discharge card issued from government Taluk hospital Tirurangadi
dated 05/09/2020.
Ext A5: Copy of consignment receipt issued by professional courier for sending
relevant records to second opposite party dated 30/10/2020.
ExtA6: Copy of delivery report of professional courier showing that consignment
received by second opposite party nil dated.
Ext.A7: Copy of letter issued by opposite party to the complainant denying policy
claim 2 pages dated 04/12/2020.
Ext.A8: Copy of notice issued by the complainant to the first and second opposite
parties with postal receipt.
Ext.A9: Copy of acknowledgment card for receipt of lawyer notice by first opposite
party dated 26/12/2020.
Ext.A10: Copy of acknowledgement card for receipt of lawyer notice by second
opposite party dated 24/12/2020
Ext.A11: Copy of reply notice sent by third opposite party along with cover (without
seal and sign) dated 06/01/2021.
Witness examined on the side of the opposite party: Nil
Documents marked on the side of the opposite party: Ext. B1 to B5
Ext.B1: Copy of insurance policy /certificate No. P/181314/01/2021/002323.
Ext.B2: Copy of discharge card
Ext.B3: Copy of repudiation letter issued by opposite party to the complainant dated
04/12/2020.
Ext.B4: Copy of guidelines dated 24/07/2020 issued by health and family department
government of Kerala.
Ext.B5: Copy of advisory on home care of asymptomatic covid 19 positive patients
issued by health and family welfare department of Kerala.
