DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION ERNAKULAM
Dated this the 23th day of April 2024
Filed on: 21.11.2022
PRESENT
Shri.D.B.Binu President
Shri.V.Ramachandran Member Smt.Sreevidhia.T.N Member
C.C. No. 530/2022
COMPLAINANT
Prasoon M., S/o.K.V.Maniyan, Kaniyamparambil, Kurippamkulangara P.O., Cherthala, Alappuzha Pin-688 524
(By Adv.Denny Varghese, Lijo Raju, Basil Simon, Joel Thomas, Vijay V.Menon, 1st Floor, Room No.I, H.B.51, Near KSHB Building, Panampilly Nagar, Kochi-36)
VS
OPPOSITE PARTY
The Oriental Insurance Company Ltd., Divisional Office, Rukiyabagh, 2nd Floor, Ravipuram, MG Road, Ernakulam, Pin-682 016 Rep.by its Manager.
(O.p by Adv.Dr.Sasikumar P.V., Saphalyam, 37/2014 A, Jawahar Nagar, Kadavanthra, Kochi-682 020)
F I N A L O R D E R
V.Ramachandran, Member
This consumer complaint is filed by Sri.Prasoon M, Kaniyamparambil, Kuruppamkulangara P.O., Cherthala Alappuzha against the Oriental Insurance Company Limited represented by its Divisional office, Ravipuram, Ernakulam as the opposite party.
The gist of the complaint is that the complainant had availed a Corona Rakshak Policy bearing No.P/440200/48/2021/4967 for the period from 28.08.2020 to 06.06.2021. The total sum assured under policy was Rs.2,50,000/-. The complainant had paid policy premium of Rs.2602/- at the branch office of the opposite party at Ernakulam.
On 14.05.2021 the complainant tested covid positive. He was suffering from severe fever and cough. Complainant was advised hospitalization at the treatment centre. Complainant was therefore admitted at Covid First Line Treatment Centre (CFLTC), Valavanad for 9 days. During the said period due to serious breathing difficulty and chest pain complainant was administered with Deriphyllin tablets and other supportive medicines. He was also provided with oxygen supplementation. Deriphyllin tablets are given when flow of air to the lugs is blocked. After the treatment on 23.05.2021 the complainant was discharged, but considering the health condition of the complainant doctor advised him to stay at home quarantine till 31.05.2021.
After the discharge the complainant produced the documents for the insurance claim during the 1st week of June 2021. Subsequently additional documents were also directed to be produced before the opposite party, and the same were produced on 03.06.2021 as directed. As per the insurance policy issued by the opposite party the complainant is eligible for the lumpsum benefit equal to 100% of the sum insured ie. Rs.2,50,000/-. But the above claim was repudiated by the opposite party. Aggrieved by the action of the opposite party, the complainant approached the Commission praying for issuing direction to the opposite party to pay Rs.2,50,000/- along with other reliefs.
2) Notice
Upon notice from this Commission, the opposite party appeared but filed their version after the statutory period. Hence version filed by the opposite party was rejected and the opposite party is set ex-parte.
3) Evidence
The complainant filed proof affidavit and 6 documents which are marked as Exbt.A1 to A6.
Exbt.A1 is a copy of test report of covid 19 test. Exbt.A2 is the admission card of CFLTC. Exbt.A3 is a discharge summary issued by CFLTC DC Mills Valavanad. Exbt.A4 is the rejection letter of the opposite party dated 26.10.2021. Exbt.A5 is a copy of letter from the insurance ombudsman.
5) The following are the main points to be analysed in this case:
- Whether there is any deficiency in service or unfair trade practice from the side of the opposite party to the complainant?
-
(iii) Costs of the proceedings if any?
6) Point No. (i)
On perusal of the records produced from the side of the complainant it is seen that the complainant had subscribed to Corona Rakshak Policy bearing No.P/440200/48/2021/4967 the date of coverage for which is from 28.08.2020 to 08.06.2021 midnight, from which it can be seen that the complainant had paid policy premium of Rs.2,602/- to the opposite party. The policy is issued in favour of the complainant and nominee is Smt.Jyothi Lakshmi and the total amount insured is Rs.2,50,000/-. Further on perusing document No. Exbt.A1 which is issued by CFLTC DC Mills Valavanad from which it can be seen that the complainant was admitted there on 14.05.2021 and discharged on 23.05.2021. It is very clearly shown in that the patient was affected by Covid during the period covered under the insurance policy. Therefore the only question to be answered in this case is as to whether the complainant had been admitted in a hospital as per the direction of a medical officer which is one of the main conditions for the grant of the amount by the opposite party as per this insurance policy conditions. One more aspect to be examined and finalized by the Commission is as to whether the admission in CFLTC is equalent to the admission in a hospital for treatment of covid. On perusing the records it is seen that the complainant had not produced any records to prove that he was admitted in a hospital as per the direction of a qualified doctor on diagnosis of covid. What is produced by the complainant is a test report of a laboratory and subsequent admission in a covid front line treatment centre. The covid front line centre is not a hospital which was only an arrangement made by the administration during the pandemic period intended to keep away the patients from others. He was under ‘A’ category as is noted in the CFLTC records. Eventhough the opposite party is ex-parte, the complainant had not proved his case with necessary records that he was admitted in a hospital and was under treatment as per the direction of a doctor which was the condition stipulated in the rules regulated in the policy conditions. Hence the Commission came to the conclusion that the complainant is not eligible to get the coverage offered under the above policy as per the policy conditions of the opposite party and hence there is no merit in the complaint. Under circumstances sated above the complaint is dismissed with no cost.
Pronounced in the Open Commission this 23rd day of April 2024.
Sd/-
V.Ramachandran, Member
Sd/-
D.B.Binu, President
Sd/-
Sreevidhia.T.N, Member
Forwarded by Order
Assistant Registrar
APPENDIX
Complainants’ Evidence
Exbt.A1 is a copy of test report of covid 19 test.
Exbt.A2 is the admission card of CFLTC.
Exbt.A3 is a discharge summary issued by CFLTC DC Mills Valavanad. Exbt.A4 is the rejection letter of the opposite party dated 26.10.2021.
Exbt.A5 is a copy of letter from the insurance ombudsman.
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