M.V.Rajendran - Complainant(s)


The New India Assurance Co.Ltd., - Opp.Party(s)

17 May 2024


Complaint Case No. CC/143/2022
( Date of Filing : 09 Jun 2022 )
1. M.V.Rajendran
S/o Late Kunhiraman,Daiwik,P.O.Kottayampoyil,Thalassery Taluk,Kannur-670691.
1. The New India Assurance Co.Ltd.,
3rd Floor,Aditya Tower,Opp.RTO,Kannur.
 HON'BLE MRS. Moly Kutty Mathew MEMBER
Dated : 17 May 2024
Final Order / Judgement


        This is a complaint filed by the complainant U/S 35 of the Consumer Protection Act 2019  for an order directing  the OP to pay the balance claim amount of Rs.9065/-to the complainant along with Rs.20,000/- as damages caused to the complainant  for the deficiency of service and unfair trade practice  on  the  part of OP.

The brief  of the complaint :

   The complainant  is working as an Advocate in Thalassery court  and he is an account holder of  South Indian Bank Ltd,Kannur . The South Indian Bank Ltd,Kannur acted as an agent for the business of OP regarding Corona Kavach policy introduced by the OP.  As such the manager of the bank contacted the complainant explained and promoted  the benefit of corona kavach policy during the pandemic period of covid-19.  As such  the complainant availed a policy of corona kavach in the year  2020 and subsequently the  policy was renewed  for the period from 10/8/2021 to 21/5/2022 the policy  bearing No.76080034218700000017.  The effective policy period shown in the policy  is 25/8/2021 to 21/5/2022.  The premium paid  by the complainant is Rs.13,794/-.  The sum assured as per the policy is Rs.50,000/- to 5,00,000/-.  The medical expenses of  hospitalization for covid-19 for a minimum period of 24 hours shall be admissible for the coverage.  The agent of the company explained that the coverage includes the total expenses which will incur for the covid treatment .  The complainant due to the complaint of fever and wheeze rush to the laboratory for testing covid-19 on 16/9/2021 and the report was positive.  On 17/9/2021 at about  8.10 P.M the complainant was admitted in Aster Mims Hospital ,Kannur evaluated in emergency department.  ECG,X-ray and blood investigations are done from the hospital and doctor who attend the complainant advised for cocktail  antibody injection as a method of preventing  the complications of covid disease.  The approximate  amount for the medicine as explained by the doctor is more than Rs.1,50,000/-.  Then the complainant requested  the  doctor to discharge him on the same day at 10’o clock.  The complainant paid an amount of Rs.3484.83/- as expenses for his treatment and  testing  at Aster Mims hospital Kannur.  Then on the next day 18/9/2021 the complainant was taken to AKG Memorial Hospital,Kannur and he was admitted in covid ward.  From there also he was advised  to take antibody cocktail injection.  But the medicine is not in stock at  AKG hospital at that time.  Then the complainant was shifted to Thalassery Govt. Hospital for taking  antibody cocktail injection.  Then after 2 hour observation again the complainant was taken to AKG hospital for further observation and treatment.  Then the  complainant was discharged from the hospital on 20/9/2021 and he paid Rs.8620/- as the hospital bill and Rs.500/- as canteen food expenses.  The complainant submitted a claim for treatment expenses at MIMS hospital as KOC1021CL000246 and the claim KOC 1021-CL-0002465 the treatment expenses of AKG Hospital before the OP. But on 26/11/2021 the complainant received Rs.928/- has been disbursed against the claim KOC1021 CL0002467 and Rs.2670/- disbursed against the claim KOC 1021-CL-0002465, the total claim of the complainant is Rs.12,663/-.  But the complainant obtained only  Rs.3598/- from the OP.  The complainant is entitled to get the balance amount  is Rs.9065/- . As per the Corona Kavach policy the complainant is entitled to get the amount in the entire bill re-imbursed which includes the medicine as well as consumable items used for the treatment of the corona patient.  So the act of  OP, the complainant caused much mental agony and financial loss.  So there is deficiency of service and unfair trade practice on the part of OP.  Hence the complaint.

       After receiving notice the OP appeared before the commission  and filed his written version.  The OP contended  that M/s Vidal Health is the  3rd party licensed  by IRDA to process health insurance claims arising out of medi claim policies issued by the OP.  The claims are process strictly abiding  by the terms and conditions stipulated in the policy.  This OP had  disbursed an amount of Rs.3598/- to the complainant and had settled the claim.  The said amount is the maximum amount payable to the complainant under the policy applying the sub limits  as per policy  and also deducting non-admissible heads. There is no deficiency in service and unfair trade practice on the part of  OP   So the   complaint may be dismissed. 

      On the basis of the rival contentions by the pleadings the following  issues  were framed for consideration.

  1. Whether there is  any deficiency of service   on the part of the opposite party?
  2. Whether the complainant is entitled for any relief?
  3. Relief and cost.

     The evidence consists of the oral testimony of PW1 and Exts. A1 to  A10 were marked. On OP’s side DW1 was examined and  Exts.B1&B2(series) marked.

Issue No.1: 

         The  Complainant had adduced evidence before the commission by submitting  his chief affidavit in lieu of  his chief examination to the tune of the pleadings in the complaint and denying the  contentions in the version.  He was cross examined as PW1 .  According to the complainant Exts.A1 to A10 were  marked on his part to substantiate his case.  Ext.A1 is the policy issued by OP.  Ext.A2 is the discharge summary of Aster Mims and the  discharge  at request, RTPCR came to be positive on 17/9/2021.  Ext.A3 is the cash bill of Aster Mims for an amount of Rs.3464/-.  Ext.A4 is the OP record of  Government General Hospital Thalassery.  Ext.A5  is discharge summary from AKG Hospital dtd.20/9/2021.  Ext.A6 is the  discharge bill of AKG hospital, Et.A7 is the medical bills dtd.19/9/2021.  Ext.A8 is the canteen bills  dtd.21/9/2021.  Ext.A9 is the  policy  clause.  According to the complainant he is the policy holder of OP.  In the evidence of DW1 who states  that  Table of benefits  ആണ് clause-12 ൽ പറഞ്ഞിരിക്കുന്നത്? അതെ.(1) hospitalization expenses(2) pre-hospitalization expenses and (3) post hospitalization expense    എല്ലാത്തിനും coverage ഉണ്ട്? ഉണ്ട്. Complainant  claim   പ്രകാരം hospitalization  expense  ഉം pre-hospitalization നുമാണ് ആവശ്യപ്പെട്ടത്? അതെ. Home care treatment expense complainant claim ചെയ്തിട്ടില്ല? ഇല്ല.  As per the corona kavach policy the complainant  is entitled to get the claim amount of Rs.12,663/-.  But the complainant is only received Rs.3598/- from the OP. The complainant is entitled to get the balance amount of Rs.9065/-.  But the OP fails to do so.   So we  hold that there is deficiency of service and unfair trade practice on the part of  OP.  Hence the  issue No.1 is found in favour of the complainant and answered accordingly.

Issue No.2&3:

    As discussed above the complainant is the policy holder of  OP.  The OP has provided hospitalization expenses , pre-hospitalization  and post hospitalization  expenses.  The total claim  of the complainant is Rs.12663/-.  The complainant  obtained only Rs.3598/-. The complainant is entitled to get the balance amount of Rs.9065/-.  So, we hold that  the OP is directly bound  to  redressal the grievance caused to the complainant.  So the complainant is entitled to get Rs.9065/- from the  OP as the balance amount the amount  along with Rs.10000/ as compensation for mental agony caused to the complainant  and Rs.5000/- as litigation cost.  Thus issue No.2&3 are also accordingly answered. 

          In the result the complaint is allowed in part  directing the   opposite party to pay the  balance amount of  Rs.9065/- to the complainant  along with  Rs.10000/- as compensation for mental agony caused to the complainant  and Rs.5000/- as litigation cost within  30 days of  receipt  of this order. In default the amount of Rs.9065/- carries 9% interest per annum from the date of order till realization.  Failing which, the complainant is at liberty to execute the order as  per the  provisions  of Consumer Protection Act 2019.  


A1- Insurance policy

A2-Discharge summary

A3-Cash bill dtd.18/9/2021

A4- Prescription from Thalassery Govt. hospital dtd.18/9/21

A5- Discharge summary from
AKG hospital dtd.20/9/2021

A6- Discharge bill

A7- Medical bills dtd.19/9/21

A8- Canteen bill dtd.21/9/21

A9- policy clauses

A10- letter issued by TPA dtd.14/11/21

B1- Attested copy of policy

B2(series)- calculation statement(2 in Nos)

PW1- M.V.Rajendran- complainant


Sd/                                                         Sd/                                                     Sd/

PRESIDENT                                             MEMBER                                               MEMBER

Ravi Susha                                       Molykutty Mathew                                    Sajeesh K.P


                                                                        /Forwarded by Order/

                                                                   ASSISTANT REGISTRAR



[HON'BLE MRS. Moly Kutty Mathew]
[HON'BLE MR. Sajeesh. K.P]

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