BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION AT BANGALORE (URBAN)

DATED 18^TH DAY OF NOVEMBER 2022

ORDER

SMT.M.SHOBHA, PRESIDENT

1. The complaint has been filed under Section 35 of C.P.Act (hereinafter referred as an Act) against the OP for the following reliefs against the OP:-

1. To pay the entire claim reimbursement of Rs.2,09,826/- in respect of Policy No.P/141113/01/2021/12758 and claim No.CIR/2022/121113/2486579.
2. Interest at 18% per annum from the due date till the date of payment;
3. Rs.50,000/- towards compensation for the mental torture, harassment, pain and agony caused to the complainant.
4.  To pass any such order.

2. The case set up by the complainant in brief is as under:-

The complainants are the insured persons have taken Corona Kavach Policy vide policy No.P/141113/01/2021/12758, from OP company on 06.11.2020 for a period of 07.11.2020 to 19.08.2021.  After payment of the entire premium the OP has issued the certificate of insurance covering each of the complainants for a sum insured of Rs.5,00,000/-.

3. The second complainant was having symptoms of covid and she has taken covid 19 antigen test on 17.04.2021 in Prima diagnostic, Jayanagar and the said report was negative.  As the symptoms of covid had aggravated she got HRCT Thorax test on 18.04.2021 in Prima Diagnostic, Jayanagar and the said report the CT severity scope was 9 and HRCT features are highly confirming covid pneumonitic –CO-RADS-6.
4. The second complainant was admitted to Narayana Super Specialty Hospital on 18.04.2021 at 6.31 pm for treatment of covid 19 Pneumonia and after treatment she was discharged on 24.04.2021 and the hospital has raised an invoice for a sum of Rs.2,09,826/-.  It is clear in the discharge summary that the treatment was for covid 19.
5. The complainants have submitted for the insurance claim on 10.05.2021 along with all the required documents and bills as sought by the OP.  To the surprise of the complainant the claim was repudiated by the OP on the ground of misrepresentation of facts on 29.08.2021.  This amounts to grass negligence and deficiency of service on the part of the OP.
6. It is further grievance of the complainant that the second complainant was suffering from covid 19 and she has done the best possible tests and treatment.  The OP has totally ignored HRCT Thorax test report and also the treatment followed and the discharge summary.  Even though the second complainant was suffering from covid and due to the acts of the OP the complainants have suffered mental agony and harassment.  The entire world was suffering from covid during the second waive and there was no proper facility for tests, oxygen and bed.  Therefore, the repudiation of the claim is against the principals of equity and justice.  
7. It is further case of the complainant they have got issued legal notice on 09.11.2021, calling upon the OP to pay the entire claim together with interest damages and compensation. In response to the said notice the OP have sent an untenable reply through email dated 10.11.2021 informing that the repudiation of the claim is in order. The OP have failed to comply the reasonable reply of the complainant nor shown any cause for non compliance of the demand made by the complainant. Hence this complaint.  
8. In response to the notice, OP appeared before this commission through their advocate but they have not filed the version.
9. The first complainant has filed his affidavit evidence and relies on 09 documents.  OP has not filed any affidavit evidence and documents.
10. Heard the arguments of advocate for the complainant only.  No oral or written argument is advanced on behalf of OP.  Perused the written arguments filed by the complainant.
11. The following points arise for our consideration as are:-

1. Whether the complainant proves deficiency of service on the part of OP?
2. Whether the complainant is entitled to relief mentioned in the complaint?
3. What order?

12. Our answers to the above points are as under:

       Point No.1:  Affirmative

      Point No.2:  Partly in Affirmative

      Point No.3: As per final orders

REASONS

13.    Point No.1 AND 2: Perused the complaint, evidence and arguments submitted by the complainant.  The OP has neither filed the version nor adduced any evidence. The allegations made in the complaint and the evidence remained unchallenged.  It is undisputed fact that the complainants are the insured persons have obtained Carona Kavach policy vide policy No.P/141113/01/2021/12758 from the OP company on 06.11.2020 for the policy period 07.11.2020 to 19.08.2021 and they have paid the premium amount.  The OP has issued the certificate of insurance as Ex.P1.  The complainant has paid the premium amount.

14.     The main grievance of the complaint is that the Smt. Jayashree B.C., was having symptom of covid and she has taken covid 19 antigen test on 17.04.2021 in Prima Diagnostic, Jayanagar and the report was negative.  The complainant has produced the report as Ex.P2., as the symptoms had aggravated she has underwent HRCT Thorax test on 18.04.2021 in Prima Diagnostics, Jayanagar, and in the said report CT severity score was 9 and HRCT features are highly confirming covid pneumonitic –CO-RADS-6.  She has produced the CT scan report as Ex.P3 in support of her contention.  

15.     It is further grievance of the complainant that she was admitted to Narayana Super Specialty hospital on 18.04.2021 at 6.31 pm for treatment of covid 19 pneumonia and after treatment she was discharged on 24.04.2021 and the hospital raised an invoice for a sum of Rs.2,09,826/-.  In support of her contention the complainant has produced the discharge summary as Ex.P4 and invoice as Ex.P5. After discharge the complainants have submitted the insurance claim on 10.05.2021 along with required documents and bills as sought by the OP.  The OP has repudiated the claim on 29.08.2021 stating that there is a misrepresentation of facts.  After that the complainant has got issued a legal notice on 09.11.2021 calling upon the OP to pay the entire claim amount together with interest damages and compensation.  The OP has sent an untenable reply through email dated 10.11.2021 informing that the repudiation of the claim is in order.  Inspite of the service of the notice the OP have failed to comply the reasonable request of the complainant nor shown any cause for non compliance of the demand made by the complainant.  

16.     It is further grievance of the complainant that even though the second complainant has suffered from covid 19 and the said diagnosis was confirmed by the doctors by conducting various tests.  Inspite of that the OP has repudiated the claim only on the ground that there is a misrepresentation of the facts and denied the claim and it amounts to deficiency of service and unfair trade practice.  

17.     On perusal of medical reports it is clear that Ex.P2 the covid 19 antigen report was negative for the second complainant as on 17.04.2021. 

18.     After that she was advised to undergo HRCT Thorax test and the report is as per Ex.P3.  It is clear from this report that as on 18.04.2021 as per the HRCT features her condition was highly suspicious for covid pneumonities – CO-RADS-6 and the CT severity score-9(out f maximum 25).

19.     As per the discharge summary Ex.P4 issued by the Narayana Super Specialty hospital, she was diagnosed covid 19 pneumonia DM2, Hypertension and she was treated by the doctor namely Dr.Meghana, Physician.  The complainant was treated for the said Covid 19 pneumonia from 18.04.2021 till 24.04.2021 and she was discharged on the same day with advise to continue the medicine and also review after 7 days and she has to get urgent care if there is any emergency as mentioned in the discharge summary.  The complainant has produced the bills and it clearly discloses that the invoice placed by the complainant amounts to Rs.2,09,826/-.

20.     We have gone through the medical reports and bills in detail.  It is clear from the discharge summary issued by the hospital as Ex.P4 that the complainant was admitted to the hospital for treatment of covid 19 Pneumonia and the same was confirmed by the doctors on the basis of the HRTC Thorax report.  The complainant was in the low oxygen saturation condition and hence she was given oxygen supplement during the treatment.  The doctor has confirmed that the complainant was suffering from covid 19 on the ground that the HRCT thorax done showed ground glass opacities CRADS-6; covid 19 RT PCR was positive.  Even though the Covid 10 Antigen test report issued by the Prima Diagnostics as per Ex.P2 shows that the complainant was negative for covid test but they have clearly mention in the said report positive result is confirmed for covid 19.

21.     If really the complainant was not suffering from covid 19 Pneumonia the hospital authorities would not have treated the complainant for the said disease.  They would have treated the complainant for any other problems.  The treatment taken by the complainant is only for four days with oxygen support in the hospital.  If the condition of the complainant was not serious the hospital authorities would not have treated the complainant as an inpatient.  When the oxygen saturation level was low for the complainant and she was treated with the oxygen support the condition of the complainant cannot be considered as not serious.  

22.     The only ground mentioned in the repudiation letter Ex.P7 for rejecting the claim of the complainant was misrepresentation.  Even though the covid antigen test was negative in the initial stages later the covid 19 pneumonia was confirmed by HRTC thorax and other clinical reports. The OP would have taken into consideration the entire medical reports along with bills for considering the claim of the complainant.   Even though the complainant has produced all the medical bills with reports and even though the complainant is entitle for the claim the OP have rejected the claim of the complainant on flimsy grounds. The conduct of the OP clearly discloses that they have not at all considered the condition of the complainant and the medical reports and they have rejected the claim only for the sake of avoiding to pay the legitimate claim of the complainant.  

23.     In view of the rejection of the claim made by the OP the complainant has suffered mentally and financially.  The OP had not paid the amount even though the complainant has taken the policy for the specific reason for covering the covid 19 and the sum assured was Rs.5,00,000/- and the policy was in force as on the date of taking treatment by the complainant.  Inspite of that the OP have rejected the claim of the complainant.  The OP would have taken the opinion from the expert doctors by placing all the medical reports before the expert doctors.  The OP would have submitted any other report based on the claim made by the complainant from any other doctors.  Instead of considering the medical report in detail and making payment of the claim amount the OP have repudiated the claim and it amounts to deficiency of service and also unfair trade practice.  Even though the OP company has given so many assurances to the insurer at the time of taking corona Kavach Policy and collecting heavy premium amount, they have not entertained the claim made by the complainant and it is nothing but unfair trade practice.  Hence the complainant is entitled for the claim made in the complaint. The complainant has also established the deficiency of service and unfair trade practice on the part of the OP.  Hence we answer point No.1 in the affirmative and Point No.2 partly in the affirmative.

24.    Point No.3:- In view the discussion referred above, OP has to be directed to pay the amount of Rs.2,09,826/- with interest at 12% p.a., from the date of repudiation of the claim dated 29.08.2021.  OP is further directed to pay compensation of Rs.50,000/- for the mental torture, harassment, pain and agony caused to the complainant.  The complainant is entitled for litigation expenses of Rs.10,000/-.  The OP is directed to pay the amount within 60 days from the date of this order.

O R D E R

1. The complaint is allowed in part.
2. OP is directed to pay the amount of Rs.2,09,826/- with interest at 12% p.a., from the date of repudiation of the claim dated 29.08.2021 till the date of realization.
3. OP is further directed to pay compensation of Rs.50,000/- along with litigation expenses of Rs.10,000/- to the complainant.
4. The OP shall comply this order within 60 days from this date, failing which the OP shall pay interest at 18% p.a. after expiry of 60 days on Rs.2,09,826/- till final payment.
5. Furnish the copy of this order and return the extra pleadings and documents to the parties.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open Commission on this 18^th day of NOVEMBER, 2022)

Documents produced by the Complainant-P.W.1 are as follows:

Documents produced by the representative of opposite party – R.W.1;

• NIL -