IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated, the 29th day of July, 2022.
Present: Sri. Manulal V.S. President
Smt. Bindhu R. Member
Sri. K.M. Anto, Member
C C No. 196/2020 (Filed on 02-12-2020)
Petitioner : Geetha P.T.
Areesseryil,
Karapuzha,
Pin – 686 003.
(Adv. D.Zaibo)
Vs.
Opposite parties : (1) The Manager,
Universal Sompo GIC Ltd.
2nd Floor, Grace Corner,
Opp. Petrol Pump, Kadavanthara,
Cochin – 682020.
(Adv. Saji Isaac K.J. and
Adv. Nithin Sunny Alex)
(2) The Branch Manager,
Indian Overseas Bank,
Muthoot Towers,
T.B. Road, Kottayam.
(Adv. Agi Joseph)
O R D E R
Sri. Manulal V.S. President
The complaint is filed under Section 35 of Consumer Protection Act, 2019.
Crux of the complaint is as follows:
The complainant is holding a savings bank account with the second opposite party. She availed Corona Rakshak health insurance policy from the first opposite party through second opposite party as intermediary. The prospectus of the first opposite party insurer describes the said policy as a single premium fixed benefit policy and offered lump sum benefit equal to 100% of the sum assured if the insured person is diagnosed covid positive and hospitalized for more than 72 hours following medical advice of a duly qualified medical practitioner. The complainant paid premium of Rs.1373 to the first opposite party through the second opposite party.
On 16-9-2020 the complainant was taken to general hospital, Kottayam having symptoms and on 17-9-2020 she was diagnosed as covid positive. She was hospitalized at General hospital Kottayam from 16-9-2020 to 18-9-2020 and thereafter referred to CFLTC hospital Ettumanoor and was hospitalized there for 10 days from 18-9-2020 and discharged on 27-9-2020.
The complainant lodged claim to the first opposite party on 1-10-2020 along with the documents. The additional documents required by the first opposite party were also submitted. But the first opposite party repudiated the claim stating that “the insured was asymptomatic, vitals stable, there were no co morbidities. Hence the patient could have been managed on OPD basis.
Hospitalization is not justifiable in this case.”
The opposite party illegally repudiated the genuine claim of the complainant. It is averred in the complaint that the grounds stated for the repudiation are based on newly imposed conditions and assumptions. According to the complainant the act of the opposite party amounts to unfair trade practice and deficiency in service and she had suffered huge mental agony and hardship and financial loss due to the actions of the opposite party. Hence this complaint is filed by the complainant praying for an order to direct the opposite parties to pay Rs.2.5 lakhs along with interest and to direct the opposite parties to pay penal interest @2% to the insured sum of R. 2.5lakhs with penal interest and compensation of Rs.50,000/.
Upon notice opposite parties appeared before the commission and filed separate version.
Version of the first opposite party is as follows:
The complainant was covid 19 positive asymptomatic and was managed conservatively. No treatment was given to the complainant while she was admitted. The first opposite party is liable to compensate the complainant only according to the terms and conditions of the policy. According to the policy the first opposite party is not liable make any payment under the policy, in respect of any expenses in connection with or in respect of investigation and evaluation. It is submitted in the version that from the discharge summary it is evident that the complainant was not having any symptoms nor was she administered any treatment while she was hospitalized. The complainant was admitted only for investigation and evaluation and no treatment was given to her. According to the exclusion of the policy, the first opposite party is not liable to make any payment under the policy as the admission was primarily for observation. Though the complainant was hospitalized for covid that ipso facto does not entitle the complainant to the benefits under the policy. The operative clause of the policy states that, any amount payable under the policy shall be subject to the terms of coverage, exclusion, conditions and definitions contained in the policy. In view of the operative clause and the specific exclusion clause in the policy, the benefit under the policy is available only when the complainant is hospitalized for covid
for 72 hours and does not fall within the exclusion clauses in the policy.
According to the first opposite party there was no deficiency in service or unfair trade practice on their side.
Version of the second opposite party is follows:
The first and second opposite parties are different legal entities. The second opposite party has no connection for the day to day business of the first opposite party. The contract of insurance is a contract between the policy holder and the insurance company. If the claim is payable as per the terms and conditions of the
policy and in such circumstances the first opposite party is liable to honour the claim. The second opposite party is an unnecessary party in the complaint. There is no deficiency in service on the part of the second opposite party.
Complainant filed proof affidavit in lieu of chief examination and marked exhibit A1 to A9. Vimal Nath T. who is the legal manger of the opposite party filed proof affidavit and exhibit B1 marked from the side of the opposite party. Second opposite party filed proof affidavit in lieu of chief examination. No documentary evidence from the side of the second opposite party.
On evaluation of complaint, version and evidence on record we wold like to consider the following points.
(1) Whether there is any deficiency in service or unfair trade practice on the part of the opposite party?
(2) If so what are the reliefs and costs?
For the sake of convenience we would like to consider the point number 1 and 2 together.
Point No.1 and 2
There is no dispute on the fact that the complainant had availed a Corona Rakshak health insurance policy from the first opposite party vide Exhibit B1 policy schedule . The policy was valid from 30-7-2020 to 9-2-2021. On perusal of exhibit B1 we can see that the basic sum assured was Rs.2,50,000/-. It is proved by Exhibit A6 referral letter issued by Dr. Sindhu G. Nair that the complainant had the contact with the covid positive patient on RAT it was found that she was covid Positive and was referred to CFLTC of the Govt. hospital Kottayam on 17-9-20. Complainant was admitted in the CFLTC Etumanoor which is Covid First Line treatment Centre on 17-9-20 and discharged on 27-9-20 when she became covid negative. On perusal of Exhibit A7which is the discharge card issued from the CFLTC the complainant was asymptomatic and managed conservatively and discharged on 27-9-2020.
Complaint was resisted by the opposite party, stating that the complainant was not having any symptoms nor was she administered any treatment while she was hospitalized. The counsel for the opposite party relied on clause 6 of the terms and conditions of the policy, which is reproduced hereunder,
6. Exclusions:
The Company shall not be liable to make any payment under the policy, in respect of any expenses incurred in connection with or in respect of:
6.1. Investigation & Evaluation (Code- Excl04)
i) Expenses related to any admission primarily for diagnostics and evaluation purposes.
ii) Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment
6.2. Any diagnosis which is not related and not incidental to COVID is not covered in this Policy
6.3. Testing done at a Diagnostic centre which is not authorized by the Government shall not be recognized under this Policy
6.4. Any claim with respect to COVID manifested prior to commencement date of this policy or during the waiting period.
6.4. Cover under this Policy shall cease if the Insured Person travels to any country placed under travel restriction by the Government of India.
Thus opposite party is not liable to pay for the investigation &Evaluation .
On perusal of operative clause of B1 policy we can see that, If during the policy period the Insured Person is diagnosed with COVID and hospitalized for more than seventy-two hours following Medical Advice of a duly qualified Medical Practitioner as per the norms specified by Ministry of Health and Family Welfare, Government of India, the Company shall pay the agreed sum insured towards the Coverage mentioned in the policy schedule. Here in this case it is proved by exhibit A6 that the complainant had admitted in the CFLTC after the diagnosis and advice by the doctor who was working at General Hospital, Kottayam. On perusal of exhibits A6 and A7 we cannot see that the admission of the complainant was only for the purpose of investigation and for the evaluation of the ailment which she had. It is argued by the counsel for the complainant that she was treated as per the guidelines issued by the by Ministry of Health and Family Welfare, Government of India, and Govt of Kerala at that time. It is pertinent to note that the opposite party has not produced any evidence to prove that the complainant has not treated with the guidelines and protocol which was issued by the by Ministry of Health and Family Welfare, Government of India and government of Kerala at that time.
As per Clause 4.1 of the terms conditions of the policy COVID Cover is a Lump sum benefit equal to 100% of the Sum Insured and shall be payable on positive diagnosis of COVID, requiring hospitalization for a minimum continuous period of 72 hours. The positive diagnosis of COVID shall be from a government authorized diagnostic centre. The payment will be made only on Hospitalisation for a minimum continuous period of 72 hours following positive diagnosis for COVID.
Under such circumstance, we have to keep in mind the very sound and salutary principle of “better protection of the right of the consumer” which is clearly stated in the preamble of Consumer Protection Act, 2019, and even if it is believed for the sake of argument that there was some inconsistency in reports, however, looking in to the aforesaid hospital papers as we discussed, we are of the considered opinion that complainant was suffering from Covid-19, hence repudiation is not sustainable.
Therefore, we hold that the present complainant is covered under the policy of Corona and 100% of insured amount of Rs.2,50,000/- required to be given under the policy. Therefore, we hold that letter of repudiation dt.20-11-2020 was passed against the principles of natural justice and fair play and very niggardly and hyper technical approach has been taken, with a myopic view of the opposite party in denying the claim amount. Therefore, we do not accept the ground stated in the letter of repudiation accordingly it cannot be acted upon. Thus, we are of the opinion that the said act of the 1st opposite party amounts to deficiency in service and unfair trade practice.
Moreover clause 7.4 for the terms and conditions of the policy speaks about the Claim Settlement (provision for Penal Interest). As per clause 7.4.i.the opposite party shall settle or reject a claim, as the case may be, within 30 days from the date of receipt of last necessary document. In the case of delay in the
payment of a claim, the opposite party shall be liable to pay interest from the date of receipt of last necessary document to the date of payment of claim at a rate of 2% above the bank rate. It is further stated in calsue7.4. (iv) that in case of delay beyond stipulated 45 days in clause 7.4.(iii) the opposite party shall be liable to pay interest at a rate 2% above the bank rate from the date of receipt of last necessary document to the date of payment of claim.
It is proved by Exhibit A8 that the complainant had preferred claim before the opposite party on 1-10-2020. However the opposite party repudiated the claim only on 20-11-2020 vide exhibit A9. The repudiation of the claim of the complainant was beyond 45 days from the receipt of the claim from the complainant and the opposite party is bound to pay interest @ 2% above bank rate in accordance with the clause 7.4.ii of the terms and conditions of the policy.
In the result following final order is passed.
- The complainant is entitled to recover the amount of Rs.2,50,000/-(Rupees Two Lakh Fifty Thousand only)from the 1st opposite party with the interest at the rate of 11% p.a. from the date of the filing of this complaint till realization.
- The complainant is entitled to recover an amount of Rs.25,000/- (Rupees Twenty Five Thousand Only) under the head of mental pain and suffering from the 1st opposite party.
- The complainant is entitled to recover Rs.5,000/- from the 1st opposite
party as cost to this litigation.
Aforesaid all amount to be paid to the complainant within 30 (thirty) days from the date of receiving the copy of the order , in default the compensation amount will carry further 9% interest from the date of this order.
Pronounced in the Open Commission on this the 29th day of July, 2022
Sri. Manulal V.S. President Sd/-
Smt. Bindhu R. Member Sd/-
Sri. K.M. Anto, Member Sd/-
Appendix
Exhibits marked from the side of complainant
A1 – Copy of circular dtd.26-06-2020 as guidelines on Covid standard benefit
based health policy (subject to proof)
A2 - Copy of circular dtd.04-03-2020 as guidelines on handling of claims
reported under corona virus (subject to objection)
A3 – Copy of prospectus of corona Rakshak policy issued by 1st opposite party
A4- Copy of description of policy details in Malayalam from 1st opposite party
(subject to objection)
A5 – Copy of insurance policy no.2856/61693253/00/000 from 1st opposite party
A6 – Copy of prescription dtd.16-09-2020 by Dr.Sindhu G. Nair
A7- Copy of discharge card of petitioner dtd.27-09-2020 from CFLTC,
Ettumanoor
A8-Copy of claim letter dtd.01-10-2020 by Arul P.A to 1st opposite party
A9 – Copy of claim repudiation letter dtd.20-11-2020 by 1st opposite party to Arul P.A.
Exhibits marked from the side of opposite party
B1 – Copy of policy document issued by 1st opposite party
By Order
Assistant Registrar
