State Consumer Disputes Redressal Commission
Tarachand Raosaheb Chaudhari vs The Oriental Insurance Co Ltd on 21 October, 2024
1 A/619/2022
Date of filing :26.08.2022
Date of order :21.10.2024
MAHARASHTRA STATE CONSUMER DISPUTES REDRESSAL
COMMISSION,MUMBAI, BENCH AT AURANGABAD.
FIRST APPEAL NO. : 619 OF 2022
IN COMPLAINT CASE NO.: 336 OF 2021
DISTRICT CONSUMER COMMISSION : AURANGABAD.
Jayashree w/o Satish Kharote, Appellant
R/o Plot No.C 12, Prabhodhankar (Adv.M.P.Bhaskar)
Thakare Nagar, Near Mahalaxmi Temple,
N-2, CIDCO, Aurangabad.
VERSUS
1. The Oriental Insurance Company Ltd,. Respondent No.1
Through it's Divisional Manager, (Adv.S.S. Wagh)
Diviional Office II, 3 floor, ABC East
rd
Building, Beside Prozone Mall, Chikalthana,
Aurangabad.
2. MD India Health Insurance TPA Respondent No.2
Private Ltd,. (Ex-parte)
Through it's Manager,
Office at S.No.46/1, E-Space, A-2 Building,
3rd floor, Pune Nagar road,
Vadgaonsheri, Pune 411014.
CORAM : Milind.S.Sonawane, Hon'ble Presiding Member.
Nagesh C.Kumbre, Hon'ble Member.
JUDGMENT
(Delivered on 21/10/2024) Per Nagesh C.Kumbre, Hon'ble Member..
The Appellant has challenged in this appeal, impugned Judgment and order passed by the District Consumer 2 A/619/2022 Commission, Aurangabad ( in short, District Commission ) in C.C.No.336/2021 dated, 26.07.2022, wherein the present appellant is original complainant and respondent no. 1 and respondent no. 2 are the original opponent no. 1 and opponent no. 2 respectively.
2. Brief facts giving rise to this appeal are as under :-
On 22.09.2020 appellant had availed the Corona Rakshak Policy from respondent no.1 bearing policy no. 182100/48/2021/4321 valid for the period from 22.09.2020 to
03.07.2021, and paid Rs. 2580/- as a premium towards the said policy. On 09.03.2021 as per the RTPCR report, the appellant found to be infected with Corona and admitted in a Covid centre duly declared by the Aurangabad Municipal Corporation at MIT Boys Hostel from 09.03.2021 to 16.03.2021. The name of appellant was also listed in the list of corona patients issued by VRDL Laboratory, Dept. of Microbiology Government Medical College Aurangabad. Appellant intimated this fact to respondent no.1 immediately on 09.03.2021. After discharge, appellant filed insurance claim with respondent no.1 on 19.03.2021 but on 06.05.2021 respondent no.1 repudiated the claim of appellant on the ground as shown in clause no. 3.6 of insurance policy. Being aggrieved by the repudiation of claim, appellant filed consumer complaint claiming Rs. 2,50,000/- as a insurance amount with 18 % interest, Rs. 50,000/- for mental agony and financial harassment and Rs. 25,000/- for cost of litigation. In support of complaint, appellant filed copy of Corona Rakshak Policy with its terms and conditions, copy of RTPCR test report and list of corona patients, copy of discharge card along with treatment 3 A/619/2022 papers, copy of claim form with documents, copy of repudiation letter dated 06.05.2021 etc.
3. Respondent no.1 appeared before the District commission and filed written statement, thereby resisted the complaint and denies the allegations. It is submitted by respondent no.1 that as per discharge card, the treatment given to appellant was simple and there is no need for her to get admitted. There is no active line of treatment during hospitalization therefore claim is not admissible under policy exclusion clause no. 3.6 and hence rightly repudiated. The matter was proceeded ex parte against respondent no.2.
4. On hearing the counsel of both parties and considering the evidence on record, District Commission dismissed the consumer complaint.
5. Feeling aggrieved by the impugned judgment and order, complainant came to this Commission in appeal. Heard Adv. M.P.Bhaskar for appellant and Adv.S.S.Wagh for respondent no.1. The matter was proceeded ex-parte against respondent no.2.
6. Adv. Bhaskar for appellant argued and submitted through his written argument that the Commission below had not properly consider the policy terms and conditions, clause 3.6 of policy and the evidence filed by appellant and passed the impugned order which is erroneous. It is submitted that as per the Corona Rakshak Policy terms and conditions, the eligibility criteria for insurance claim is that the claimant has to be 4 A/619/2022 corona positive and has to be hospitalized for 72 hours in government hospital or hospital established under local authority, as such appellant was corona positive and hospitalized for 8 days and entitled for insurance claim. The appellant was admitted in Covid centre duly approved by the Municipal Corporation of Aurangabad therefore the claim was wrongly repudiated by respondent no.1 under clause 3.6 of policy terms and conditions. Appellant did not breach any terms and conditions of said policy. District Commission has not considered these aspects while deciding the matter and passed the impugned order which needs to be quashed and set aside.
7. Adv.Wagh for respondent no.1 argued and submitted through his written arguments that, as per discharge card, the treatment given to appellant was so simple therefore there is no need for her to get admitted. There is no active line of treatment during hospitalization therefore claim is not admissible under policy exclusion clause no. 3.6 and hence rightly repudiated. It is submitted that appellant was admitted in Covid centre which is quarantine centre and cannot be called as a hospital. As such respondent no.1 has not committed any deficiency in service towards appellant and there is no error in the impugned judgment which requires interference by this Commission.
8. We have gone through the appeal compilation, impugned judgment and order, pleading and written notes of arguments on record. In this appeal two points are there for our consideration. First, within the period of policy, weather appellant was corona positive or not and second, weather she 5 A/619/2022 was hospitalized for more than 72 hours following the advice of duly qualified Medical practitioner or not. It is not disputed that appellant had taken insurance policy named Corona Rakshak Policy valid for the period of 22.09.2020 to 03.07.2021 and paid Rs. 2,580/- towards the premium of said policy. On perusing the policy documents, terms and conditions of said policy which is on record, clause no. 2 as operative clause, clause no.4.1 as Covid cover clause is important and reproduced as, -
i) Clause no.2, operative clause - If during the policy period the insured person is diagnosed with COVID and hospitalized for more than 72 hours following medical advice of a duly qualified medical practitioner. The insurance company shall pay the agreed sum insured towards the coverage mentioned in the policy schedule.
ii) Clause 4.1 Covid cover -Lump sum benefit equal to 100% of the sum insured 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 form a government authorized diagnostic centre.
9. As per the medical treatment papers, discharge card and RTPCR test report which are on record, it appears that the appellant was infected with corona virus on 09.03.2021 and admitted in Covid centre, MIT Boys Hostel duly declared by the Aurangabad Municipal Corporation. The list issued by VRDL laboratory, Govt. Medical College Aurangabad which is on record, shows that appellant on serial no. 225 was corona positive. Letter dated 09.03.2021 and 12.04.2021 issued by Medical Officer, health department of Aurangabad Municipal 6 A/619/2022 Corporation shows that appellant was corona positive and referred her to MIT Boys Hostel Covid centre for treatment. As per the case papers, it appears that appellant having symptoms of corona and she was corona positive.
10. The claim of appellant was repudiated by respondent no.1 on the ground of clause 3.6 of policy terms and conditions. As per clause 3.6 the term hospital is explained. Clause 3.6 (vi) reproduced as, For the purpose of this policy any other set-up designated by the government as hospital for the treatment of Covid-19 shall also be considered as hospital. Due to massive spread of corona virus in state, government itself encouraging Covid centres for the treatment of Covid patients as there was lack of beds and other medical facilities in hospitals. Admittedly appellant was referred and admitted for treatment at MIT Boys Hostel which was declared as Covid centre by Aurangabad Municipal Corporation having medical practitioners and duly qualified nursing staff. Therefore we are of the view that the MIT Boys Hostel declared by Aurangabad Municipal Corporation as a Covid centre comes within the purview of clause 3.6 (vi) of policy and repudiation of claim on the said ground is deficiency in service on the part of respondent no.1. As such appellant fulfill the eligibility criteria required for the insurance benefit under the said policy. Appellant was Corona positive and hospitalized for more than 72 hours as per the advice of qualified medical practitioner and therefore entitled for benefits under the Corona Rakshak Policy. District Commission has not considered the above important facts while adjudicating the consumer complainant. Therefore, the 7 A/619/2022 impugned judgment and order passed by the District Commission deserve to be quashed and set aside.
11. In view of aforesaid facts and discussion we are of the opinion that, the District Commission has committed an error in appreciating evidence on record. The District Commission in the impugned judgment and order ignored above important facts. Hence, the impugned judgment and order are liable to be quashed and set aside. In the fact and circumstances of the appeal there is no order as to cost. Hence, we pass the following order.
ORDER.
1. The appeal is partly allowed.
2. The impugned judgment and order passed by the District Commission, Aurangabad in C.C.No.336/2021 dated 26.07.2022 is hereby quashed and set aside.
3. Respondent no.1 is directed to pay insurance amount of Rs. 2,50,000/- under Corona Rakshak Policy to the appellant with interest @ 8 % p.a. from the date of repudiation of insurance claim i.e. 06.05.2021 till its realization.
4. Respondent no.1 is directed to pay Rs. 10,000/- for mental agony, financial harassment and cost of litigation to appellant.
5. Copy of this judgment be given free of cost to both parties.
N.C.Kumbre M.S.Sonawane
Member Presiding Member
UNK
8 A/619/2022
Date of filing :26.08.2022
Date of order :21.10.2024
MAHARASHTRA STATE CONSUMER DISPUTES REDRESSAL COMMISSION,MUMBAI, BENCH AT AURANGABAD.
FIRST APPEAL NO. : 620 OF 2022 IN COMPLAINT CASE NO.: 335 OF 2021 DISTRICT CONSUMER COMMISSION : AURANGABAD.
Jayashree w/o Satish Kharote, Appellant
R/o Plot No.C 12, Prabhodhankar (Adv.M.P.Bhaskar)
Thakare Nagar, Near Mahalaxmi Temple,
N-2, CIDCO, Aurangabad.
VERSUS
1. The Oriental Insurance Company Ltd,. Respondent No.1
Through it's Divisional Manager, (Adv.S.S. Wagh)
Diviional Office II, 3 floor, ABC East
rd
Building, Beside Prozone Mall, Chikalthana, Aurangabad.
2. MD India Health Insurance TPA Respondent No.2 Private Ltd,. (Ex-parte) Through it's Manager, Office at S.No.46/1, E-Space, A-2 Building, 3rd floor, Pune Nagar road, Vadgaonsheri, Pune 411014.
CORAM : Milind.S.Sonawane, Hon'ble Presiding Member.
Nagesh C.Kumbre, Hon'ble Member.
JUDGMENT (Delivered on 21/10/2024) Per Nagesh C.Kumbre, Hon'ble Member..
The Appellant has challenged in this appeal, impugned Judgment and order passed by the District Consumer 9 A/619/2022 Commission, Aurangabad ( in short, District Commission ) in C.C.No.335/2021 dated, 26.07.2022, wherein the present appellant is original complainant and respondent no. 1 and respondent no. 2 are the original opponent no. 1 and opponent no. 2 respectively.
2. Brief facts giving rise to this appeal are as under :-
On 22.09.2020 appellant had availed the Corona Rakshak Policy from respondent no.1 bearing policy no. 182100/48/2021/4321 valid for the period from 22.09.2020 to
03.07.2021, and paid Rs. 2580/- as a premium towards the said policy. On 09.03.2021 as per the RTPCR report, the appellant found to be infected with Corona and admitted in a Covid center duly declared by the Aurangabad Municipal Corporation at MIT Boys Hostel from 09.03.2021 to 16.03.2021. The name of appellant was also listed in the list of corona patients issued by VRDL Laboratory, Dept. of Microbiology Government Medical College Aurangabad. Appellant intimated this fact to respondent no.1 immediately on 09.03.2021. After discharge, appellant filed insurance claim with respondent no.1 on 19.03.2021 but on 06.05.2021 respondent no.1 repudiated the claim of appellant on the ground as shown in clause no. 3.6 of insurance policy. Being aggrieved by the repudiation of claim, appellant filed consumer complaint claiming Rs. 2,50,000/- as a insurance amount with 18 % interest, Rs. 50,000/- for mental agony and financial harassment and Rs. 25,000/- for cost of litigation. In support of complaint, appellant filed copy of Corona Rakshak Policy with its terms and conditions, copy of RTPCR test report and list of corona patients, copy of discharge card along with treatment 10 A/619/2022 papers, copy of claim form with documents, copy of repudiation letter dated 06.05.2021 etc.
3. Respondent no.1 appeared before the District commission and filed written statement, thereby resisted the complaint and denies the allegations. It is submitted by respondent no.1 that as per discharge card, the treatment given to appellant was simple and there is no need for her to get admitted. There is no active line of treatment during hospitalization therefore claim is not admissible under policy exclusion clause no. 3.6 and hence rightly repudiated. The matter was proceeded ex-parte against respondent no.2.
4. On hearing the counsel of both parties and considering the evidence on record, District Commission dismissed the consumer complaint.
5. Feeling aggrieved by the impugned judgment and order, complainant came to this Commission in appeal. Heard Adv. M.P.Bhaskar for appellant and Adv.S.S.Wagh for respondent no.1. The matter was proceeded ex-parte against respondent no.2.
6. Adv. Bhaskar for appellant argued and submitted through his written argument that the Commission below had not properly consider the policy terms and conditions, clause 3.6 of policy and the evidence filed by appellant and passed the impugned order which is erroneous. It is submitted that as per the Corona Rakshak Policy terms and conditions, the eligibility criteria for insurance claim is that the claimant has to be 11 A/619/2022 corona positive and has to be hospitalized for 72 hours in government hospital or hospital established under local authority, as such appellant was corona positive and hospitalized for 8 days and entitled for insurance claim. The appellant was admitted in Covid centre duly approved by the Municipal Corporation of Aurangabad therefore the claim was wrongly repudiated by respondent no.1 under clause 3.6 of policy terms and conditions. Appellant did not breach any terms and conditions of said policy. District Commission has not considered these aspects while deciding the matter and passed the impugned order which needs to be quashed and set aside.
7. Adv.S.S.Wagh for respondent no.1 argued and submitted through his written arguments that, as per discharge card, the treatment given to appellant was so simple therefore there is no need for her to get admitted. There is no active line of treatment during hospitalization therefore claim is not admissible under policy exclusion clause no. 3.6 and hence rightly repudiated. It is submitted that appellant was admitted in Covid centre which is quarantine centre and cannot be called as a hospital. As such respondent no.1 has not committed any deficiency in service towards appellant and there is no error in the impugned judgment which requires interference by this Commission.
8. We have gone through the appeal compilation, impugned judgment and order, pleading and written notes of arguments on record. In this appeal two points are there for our consideration. First, within the period of policy, weather appellant was corona positive or not and second, weather she 12 A/619/2022 was hospitalized for more than 72 hours following the advice of duly qualified Medical practitioner or not. It is not disputed that appellant had taken insurance policy named Corona Rakshak Policy valid for the period of 22.09.2020 to 03.07.2021 and paid Rs. 2,580/- towards the premium of said policy. On perusing the policy documents, terms and conditions of said policy which is on record, clause no. 2 as operative clause, clause no.4.1 as Covid cover clause is important and reproduced as, -
i) clause no.2, operative clause - If during the policy period the insured person is diagnosed with COVID and hospitalized for more than 72 hours following medical advice of a duly qualified medical practitioner. The insurance company shall pay the agreed sum insured towards the coverage mentioned in the policy schedule.
ii) Clause 4.1 Covid cover -Lump sum benefit equal to 100% of the sum insured 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 form a government authorized diagnostic centre.
9. As per the medical treatment papers, discharge card and RTPCR test report which are on record, it appears that the appellant was infected with corona virus on 09.03.2021 and admitted in Covid centre, MIT Boys Hostel duly declared by the Aurangabad Municipal Corporation. The list issued by VRDL laboratory, Govt. Medical College Aurangabad which is on record, shows that appellant on serial no. 225 was corona positive. Letter dated 09.03.2021 and 12.04.2021 issued by Medical Officer, health department of Aurangabad Municipal 13 A/619/2022 Corporation shows that appellant was corona positive and referred her to MIT Boys Hostel Covid centre for treatment. As per the case papers, it appears that appellant having symptoms of corona and she was corona positive.
10. The claim of appellant was repudiated by respondent no.1 on the ground of clause 3.6 of policy terms and conditions. As per clause 3.6 the term hospital is explained. Clause 3.6 (vi) reproduced as, For the purpose of this policy any other set-up designated by the government as hospital for the treatment of Covid-19 shall also be considered as hospital. Due to massive spread of corona virus in state, government itself encouraging Covid centres for the treatment of Covid patients as there was lack of beds and other medical facilities in hospitals. Admittedly appellant was referred and admitted for treatment at MIT Boys Hostel which was declared as Covid centre by Aurangabad Municipal Corporation having medical practitioners and duly qualified nursing staff. Therefore we are of the view that the MIT Boys Hostel declared by Aurangabad Municipal Corporation as a Covid centre comes within the purview of clause 3.6 (vi) of policy and repudiation of claim on the said ground is deficiency in service on the part of respondent no.1. As such appellant full-fill the eligibility criteria required for the insurance benefit under the said policy. Appellant was corona positive and hospitalized for more than 72 hours as per the advice of qualified medical practitioner and therefore entitled for benefits under the Corona Rakshak Policy. District Commission has not considered the above important facts while adjudicating the consumer complainant. Therefore the 14 A/619/2022 impugned judgment and order passed by the District Commission deserve to be quashed and set aside.
11. In view of aforesaid facts and discussion we are of the opinion that, the District Commission has committed an error in appreciating evidence on record. The District Commission in the impugned judgment and order ignored above important facts. Hence, the impugned judgment and order are liable to be quashed and set aside. In the fact and circumstances of the appeal there is no order as to cost. Hence, we pass the following order.
ORDER.
1. The appeal is partly allowed.
2. The impugned judgment and order passed by the District Commission, Aurangabad in C.C.No.335/2021 dated 26.07.2022 is hereby quashed and set aside.
3. Respondent no.1 is directed to pay insurance amount of Rs.2,50,000/- under Corona Rakshak Policy to the appellant with interest @ 8 % p.a. from the date of repudiation of insurance claim i.e. 16.04.2021 till its realization.
4. Respondent no.1 is directed to pay Rs. 10,000/- for mental agony, financial harassment and cost of litigation to appellant.
5. Copy of this judgment be given free of cost to both parties.
N.C.Kumbre M.S.Sonawane
Member Presiding Member
UNK
15 A/619/2022
Date of filing :26.08.2022
Date of order :21.10.2024
MAHARASHTRA STATE CONSUMER DISPUTES REDRESSAL COMMISSION,MUMBAI, BENCH AT AURANGABAD.
FIRST APPEAL NO. : 621 OF 2022 IN COMPLAINT CASE NO.: 334 OF 2021 DISTRICT CONSUMER COMMISSION : AURANGABAD.
Tarachand s/o Raosaheb Chaudhari, Appellant R/o Plot No.18, S.No.156,, (Adv.M.P.Bhaskar) Harsool, Aurangabad.
VERSUS
1. The Oriental Insurance Company Ltd,. Respondent No.1 Through it's Divisional Manager, (Adv.S.S. Wagh) Diviional Office II, 3 floor, ABC East rd Building, Beside Prozone Mall, Chikalthana, Aurangabad.
2. MD India Health Insurance TPA Respondent No.2 Private Ltd,. (Ex-parte) Through it's Manager, Office at S.No.46/1, E-Space, A-2 Building, 3rd floor, Pune Nagar road, Vadgaonsheri, Pune 411014.
CORAM : Milind.S.Sonawane, Hon'ble Presiding Member.
Nagesh C.Kumbre, Hon'ble Member.
JUDGMENT (Delivered on 21/10/2024) Per Nagesh C.Kumbre, Hon'ble Member..
The Appellant has challenged in this appeal, impugned Judgment and order passed by the District Consumer Commission, Aurangabad ( in short, District Commission ) in 16 A/619/2022 C.C.No.334/2021 dated, 26.07.2022, wherein the present appellant is original complainant and respondent no. 1 and respondent no. 2 are the original opponent no. 1 and opponent no. 2 respectively.
2. Brief facts giving rise to this appeal are as under :-
On 23.02.2021 appellant had availed the Corona Rakshak Policy from respondent no.1 bearing policy no. 182100/48/2021/7972 valid for the period from 23.02.2021 to 04.12.2021, and paid Rs. 2580/- as a premium towards the said policy. On 01.04.2021 as per the RTPCR report, the appellant found to be infected with Corona and admitted in a Covid centre duly declared by the Aurangabad Municipal Corporation at Samajkalyan Boys Hostel Covid centre Kille Ark from 03.04.2021 to 14.04.2021. The name of appellant was also listed in the list of corona patients issued by VRDL Laboratory, Dept. of Microbiology Government Medical College Aurangabad. Appellant intimated this fact to respondent no.1 immediately on
03.04.2021. After discharge, appellant filed insurance claim with respondent no.1 on 14.04.2021, but on 06.05.2021 respondent no.1 repudiated the claim of appellant on the ground as shown in clause no. 3.6 of insurance policy. Being aggrieved by the repudiation of claim, appellant filed consumer complaint claiming Rs. 2,50,000/- as a insurance amount with 18 % interest, Rs. 50,000/- for mental agony and financial harassment and Rs. 25,000/- for cost of litigation. In support of complaint, appellant filed copy of Corona Rakshak Policy with its terms and conditions, copy of RTPCR test and list of corona patients, copy of discharge card along with treatment papers, 17 A/619/2022 copy of claim form with documents, copy of repudiation letter dated 06.05.2021 etc.
3. Respondent no.1 appeared before the District commission and filed written statement, thereby resisted the complaint and denies the allegations. It is submitted by respondent no.1 that as per discharge card, the treatment given to appellant was simple and there is no need for her to get admitted. There is no active line of treatment during hospitalization therefore claim is not admissible under policy exclusion clause no. 3.6 and hence rightly repudiated. The matter was proceeded ex parte against respondent no.2.
4. On hearing the counsel of both parties and considering the evidence on record, District Commission dismissed the consumer complaint.
5. Feeling aggrieved by the impugned judgment and order, complainant came to this Commission in appeal. Heard Adv. M.P.Bhaskar for appellant and Adv. S.S.Wagh for respondent no.1. The matter was proceeded ex parte against respondent no.2.
6. Adv. Bhaskar for appellant argued and submitted through his written argument that the Commission below had not properly consider the policy terms and conditions, clause 3.6 of policy and the evidence filed by appellant and passed the impugned order which is erroneous. It is submitted that as per the Corona Rakshak Policy terms and conditions, the eligibility criteria for insurance claim is that the claimant has to be 18 A/619/2022 corona positive and has to be hospitalized for 72 hours in Government hospital or hospital established under local authority, as such appellant was corona positive and hospitalized for 12 days and entitled for insurance claim. The appellant was admitted in Covid centre duly approved by the Municipal Corporation of Aurangabad therefore the claim was wrongly repudiated by respondent no.1 under clause 3.6 of policy terms and conditions. Appellant did not breach any terms and conditions of said policy. District Commission has not considered these aspects while deciding the matter and passed the impugned order which needs to be quashed and set aside.
7. Adv.Wagh for respondent no.1 argued and submitted through his written arguments that, as per discharge card, the treatment given to appellant was so simple therefore there is no need for her to get admitted. There is no active line of treatment during hospitalization therefore claim is not admissible under policy exclusion clause no. 3.6 and hence rightly repudiated. It is submitted that appellant was admitted in Covid centre which is quarantine centre and cannot be called as a hospital. As such respondent no.1 has not committed any deficiency in service towards appellant and there is no error in the impugned judgment which requires interference by this Commission.
8. We have gone through the appeal compilation, impugned judgment and order, pleading and written notes of arguments on record. In this appeal two points are there for our consideration. First, within the valid period of policy, weather appellant was corona positive or not and second weather she 19 A/619/2022 was hospitalized for more than 72 hours following the advice of duly qualified Medical practitioner or not. It is not disputed that appellant had taken insurance policy named Corono Rakshak Policy valid for the period of 23.02.2021 to 04.12.2021 and paid Rs. 2,580/- towards the premium of said policy. On perusing the policy documents, terms and conditions of said policy which is on record, clause no. 2 as operative clause, clause no.4.1 as Covid cover clause is important and reproduced as,
i) clause no.2, operative clause - If during the policy period the insured person is diagnosed with COVID and hospitalized for more than 72 hours following medical advice of a duly qualified medical practitioner. The insurance company shall pay the agreed sum insured towards the coverage mentioned in the policy schedule.
ii) Clause 4.1 Covid cover -Lump sum benefit equal to 100% of the sum insured 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 form a government authorized diagnostic centre.
9. As per the medical treatment papers, discharge card and RTPCR test report which are on record, it appears that the appellant was infected with corona virus on 01.04.2021 and admitted in Covid centre, Samajkalyan Boys Hostel Covid centre Kille Ark, duly declared by the Aurangabad Municipal Corporation. The list issued by VRDL laboratory, Govt. Medical College Aurangabad which is on record, shows that appellant on serial no. 22 was corona positive. Letter, discharge card issued by Medical Officer, health department of Aurangabad Municipal Corporation shows that appellant was corona 20 A/619/2022 positive and referred her to Samajkalyan Boys Hostel Covid centre for treatment. As per the case papers, it appears that appellant having symptoms of corona and he was corona positive.
10. The claim of appellant was repudiated by respondent no.1 on the ground of clause 3.6 of policy terms and conditions. As per clause 3.6 the term hospital is explained. Clause 3.6 (vi) reproduced as, For the purpose of this policy any other set-up designated by the government as hospital for the treatment of Covid-19 shall also be considered as hospital. Due to massive spread of corona virus in state, government itself encouraging Covid centres for the treatment of Covid patients as there was lack of beds and other medical facilities in hospitals. Admittedly appellant was referred and admitted for treatment at Samajkalyan Boys Hostel Covid centre Kille Ark which was declared as Covid centre by Aurangabad Municipal Corporation having medical practitioners and duly qualified nursing staff. Therefore we are of the view that the Samajkalyan Boys Hostel Covid centre declared by Aurangabad Municipal Corporation as a Covid centre comes within the purview of clause 3.6 (vi) of policy and repudiation of claim on the said ground is deficiency in service on the part of respondent no.1. As such appellant fulfill the criteria required for the insurance benefit under the said policy. Appellant was corona positive and hospitalized for more than 72 hours as per the advice of qualified medical practitioner and therefore entitled for benefits under the Corona Rakshak Policy. District Commission has not considered the above important facts while adjudicating the consumer complainant. Therefore the impugned judgment and order 21 A/619/2022 passed by the District Commission deserve to be quashed and set aside.
11. In view of aforesaid facts and discussion we are of the opinion that, the District Commission has committed an error in appreciating evidence on record. The District Commission in the impugned judgment and order ignored above important facts. Hence, the impugned judgment and order are liable to be quashed and set aside. In the fact and circumstances of the appeal there is no order as to cost. Hence, we pass the following order.
ORDER.
1. The appeal is partly allowed.
2. The impugned judgment and order passed by the District Commission, Aurangabad in C.C.No.334/2021 dated 26.07.2022 is hereby quashed and set aside.
3. Respondent no.1 is directed to pay insurance amount of Rs. 2,50,000/- under Corona Rakshak Policy to the appellant with interest @ 8 % p.a. from the date of repudiation of insurance claim i.e. 06.05.2021 till its realization.
4. Respondent no.1 is directed to pay Rs. 10,000/- for mental agony, financial harassment and cost of litigation to appellant.
5. Copy of this judgment be given free of cost to both parties.
N.C.Kumbre M.S.Sonawane
Member Presiding Member
UNK
22 A/619/2022
Date of filing :26.08.2022
Date of order :21.10.2024
MAHARASHTRA STATE CONSUMER DISPUTES REDRESSAL COMMISSION,MUMBAI, BENCH AT AURANGABAD.
FIRST APPEAL NO. : 622 OF 2022 IN COMPLAINT CASE NO.: 375 OF 2021 DISTRICT CONSUMER COMMISSION : AURANGABAD.
Omprakash s/o Laxminarayan Dhoot, Appellant R/o Flat No.12, Pushkaraj Apartment, (Adv.M.P.Bhaskar) Near Prakash Kirana Stores, Rokadiya Hanuman colony, Aurangabad.
VERSUS
1. The Oriental Insurance Company Ltd,. Respondent No.1 Through it's Divisional Manager, (Adv.S.M.Jondhale) Diviional Office II, 3 floor, ABC East rd Building, Beside Prozone Mall, Chikalthana, Aurangabad.
2. MD India Health Insurance TPA Respondent No.2 Private Ltd,. (Ex-parte) Through it's Manager, Office at S.No.46/1, E-Space, A-2 Building, 3rd floor, Pune Nagar road, Vadgaonsheri, Pune 411014.
CORAM : Milind.S.Sonawane, Hon'ble Presiding Member.
Nagesh C.Kumbre, Hon'ble Member.
JUDGMENT (Delivered on 21/10/2024) Per Nagesh C.Kumbre, Hon'ble Member..
The Appellant has challenged in this appeal, impugned Judgment and order passed by the District Consumer 23 A/619/2022 Commission, Aurangabad ( in short, District Commission ) in C.C.No.375/2021 dated, 26.07.2022, wherein the present appellant is original complainant and respondent no. 1 and respondent no. 2 are the original opponent no. 1 and opponent no. 2 respectively.
2. Brief facts giving rise to this appeal are as under :-
On 29.07.2020 appellant had availed the Corona Rakshak Policy from respondent no.1 bearing policy no. 182100/48/2021/2467 valid for the period from 29.07.2020 to 09.05.2021, and paid Rs. 5185/- as a premium towards the said policy. On 07.03.2021 as per the RTPCR report, the appellant found to be infected with Corona virus and admitted in a Covid centre duly declared by the Aurangabad Municipal Corporation at Covid-19 care centre, Government Engineering Collage from 07.03.2021 to 15.03.2021. Appellant intimated this fact to respondent no.1 immediately on 07.03.2021. After discharge, appellant filed insurance claim with respondent no.1 on 16.03.2021 but on 15.04.2021 respondent no.1 repudiated the claim of appellant on the ground as shown in clause no. 3.7 of insurance policy. Being aggrieved by the repudiation of claim, appellant filed consumer complaint claiming Rs. 2,50,000/- as a insurance amount with 18 % interest, Rs. 50,000/- for mental agony and financial harassment and Rs. 25,000/- for cost of litigation. In support of complaint, appellant filed copy of Corona Rakshak Policy with its terms and conditions, copy of RTPCR test, copy of discharge card along with treatment papers, copy of claim form with documents, copy of repudiation letter dated 15.04.2021 etc. 24 A/619/2022
3. Respondent no.1 appeared before the District commission and filed written statement, thereby resisted the complaint and denies the allegations. It is submitted by respondent no.1 that as per discharge card, the treatment given to appellant was simple and there is no need for him to get admitted. Appellant failed to file medical bills, prescription, diagnostic and pathology reports in support of her contention. The appellant has not hospitalized in government authorized hospital. There is no active line of treatment during hospitalization therefore claim is not admissible under policy exclusion clause no. 3.7 and hence rightly repudiated. The matter was proceeded ex parte against respondent no.2.
4. On hearing the counsel of both parties and considering the evidence on record, the District Commission dismissed the consumer complaint.
5. Feeling aggrieved by the impugned judgment and order, complainant came to this Commission in appeal. Heard Adv. M.P.Bhaskar for appellant and Adv. S.M.Jondhale for respondent no.1. The matter was proceeded ex parte against respondent no.2.
6. Adv. Bhaskar for appellant argued and submitted through his written argument that the Commission below had not properly consider the policy terms and conditions, clause 3.7 of policy and the evidence filed by appellant and passed the impugned order which is erroneous. It is submitted that as per the Corona Rakshak Policy terms and conditions, the eligibility criteria for insurance claim is that the claimant has to be 25 A/619/2022 corona positive and has to be hospitalized for 72 hours in Government hospital or hospital established under local authority, as such appellant was corona positive and hospitalized for 9 days and entitled for insurance claim. The appellant was admitted in Covid centre duly approved by the Municipal Corporation of Aurangabad therefore the claim was wrongly repudiated by respondent no.1 under clause 3.7 of policy terms and conditions. Appellant did not breach any terms and conditions of said policy. District Commission has not considered these facts while deciding the matter and passed the impugned order which needs to be quashed and set aside.
7. Adv.Jondhale for respondent no.1 argued and submitted through his written arguments that, as per discharge card, the treatment given to appellant was so simple therefore there is no need for her to get admitted. Doctor has not advice her to hospitalize as appellant suffering from mild infection. There is no active line of treatment during hospitalization therefore claim is not admissible under policy exclusion clause no. 3.7 and hence rightly repudiated. It is submitted that appellant was admitted in Covid centre which is quarantine centre and cannot be called as a hospital. As such respondent no.1 has not committed any deficiency in service towards appellant and there is no error in the impugned judgment which requires interference by this Commission.
8. We have gone through the appeal compilation, impugned judgment and order, pleading and written notes of arguments on record. In this appeal two points are there for our consideration. First, within the valid period of policy, weather 26 A/619/2022 appellant was corona positive or not and second weather she was hospitalized for more than 72 hours following the advice of duly qualified Medical practitioner or not. It is not disputed that appellant had taken insurance policy named Corona Rakshak Policy valid for the period of 29.07.2020 to 09.05.2021 and paid Rs. 5158/- towards the premium of said policy. On perusing the policy documents, terms and conditions of said policy which is on record, clause no. 2 is as operative clause, clause no.4.1 is as Covid cover clause is important and reproduced as,
i) Clause no.2, operative clause - If during the policy period the insured person is diagnosed with COVID and hospitalized for more than 72 hours following medical advice of a duly qualified medical practitioner. The insurance company shall pay the agreed sum insured towards the coverage mentioned in the policy schedule.
ii) Clause 4.1 Covid cover -Lump sum benefit equal to 100% of the sum insured 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 form a government authorized diagnostic centre.
9. As per the medical treatment papers, discharge card and RTPCR test report which are on record, it appears that the appellant was infected with corona virus on 07.03.2021 and admitted at Government Engineering Collage Covid centre, duly declared by the Aurangabad Municipal Corporation. Letter dated 07.03.2021 and discharge card issued by Medical Officer, health department of Aurangabad Municipal Corporation shows that appellant was corona positive and referred him to Government Engineering Collage Covid centre for treatment. As 27 A/619/2022 per the case papers, it appears that appellant having symptoms of corona and she was corona positive.
10. The claim of appellant was repudiated by respondent no.1 on the ground of clause 3.7 of policy terms and conditions. As per clause 3.7 the term hospitalization means admission in a hospital designated for Covid-19 treatment by Government, for a minimum period of 72 consecutive ' in patient care' hours. In policy terms and conditions, hospital is explained under clause 3.6. Clause 3.6 (vi) reproduced as, For the purpose of this policy any other set-up designated by the government as hospital for the treatment of Covid-19 shall also be considered as hospital. Due to massive spread of corona virus in state, Government itself encouraging Covid centres for the treatment of Covid patients as there was lack of beds and other medical facilities in hospitals. Admittedly appellant was referred and admitted for treatment at Government Engineering Collage Covid centre which was declared as Covid centre by Aurangabad Municipal Corporation, having medical practitioners and duly qualified nursing staff. Therefore we are of the view that the Government Engineering Collage Covid centre declared by Aurangabad Municipal Corporation as a Covid centre comes within the purview of clause 3.6 (vi) of policy and repudiation of claim on the ground under clause 3.7 of policy was deficiency in service on the part of respondent no.1 towards appellant. As such appellant fulfill the eligibility criteria required for the insurance benefit under the said policy. Appellant was corona positive and hospitalized for more than 72 hours as per the advice of qualified medical practitioner and therefore entitled for benefits under the Corona Rakshak Policy. District Commission has not 28 A/619/2022 considered the above important facts while adjudicating the consumer complainant. Therefore the impugned judgment and order passed by the District Commission deserve to be quashed and set aside.
11. In view of aforesaid facts and discussion we are of the opinion that, the District Commission has committed an error in appreciating evidence on record. The District Commission in the impugned judgment and order ignored above important facts. Hence, the impugned judgment and order are liable to be quashed and set aside. In the fact and circumstances of the appeal there is no order as to cost. Hence, we pass the following order.
ORDER.
1. The appeal is partly allowed.
2. The impugned judgment and order passed by the District Commission, Aurangabad in C.C.No.375/2021 dated 26.07.2022 is hereby quashed and set aside.
3. Respondent no.1 is directed to pay insurance amount of Rs. 2,50,000/- under Corona Rakshak Policy to the appellant with interest @ 8 % p.a. from the date of repudiation of insurance claim i.e. 15.04.2021 till its realization.
4. Respondent no.1 is directed to pay Rs. 10,000/- for mental agony, financial harassment and cost of litigation to appellant.
5. Copy of this judgment be given free of cost to both parties.
N.C.Kumbre M.S.Sonawane
Member Presiding Member
UNK
29 A/619/2022
Date of filing :26.08.2022
Date of order :21.10.2024
MAHARASHTRA STATE CONSUMER DISPUTES REDRESSAL COMMISSION,MUMBAI, BENCH AT AURANGABAD.
FIRST APPEAL NO. : 623 OF 2022 IN COMPLAINT CASE NO.: 374 OF 2021 DISTRICT CONSUMER COMMISSION : AURANGABAD.
Trupti w/o Omprakash Dhoot, Appellant
R/o Flat No.12, Pushkaraj Apartment, (Adv.M.P.Bhaskar)
Near Prakash Kirana Stores,
Rokdiya Hanuman colony, Aurangabad.
VERSUS
1. The Oriental Insurance Company Ltd,. Respondent No.1
Through it's Divisional Manager, (Adv.S.M.Jondhale)
Diviional Office II, 3 floor, ABC East
rd
Building, Beside Prozone Mall, Chikalthana, Aurangabad.
2. MD India Health Insurance TPA Respondent No.2 Private Ltd,. (Ex-parte) Through it's Manager, Office at S.No.46/1, E-Space, A-2 Building, 3rd floor, Pune Nagar road, Vadgaonsheri, Pune 411014.
CORAM : Milind.S.Sonawane, Hon'ble Presiding Member.
Nagesh C.Kumbre, Hon'ble Member.
JUDGMENT (Delivered on 21/10/2024) Per Nagesh C.Kumbre, Hon'ble Member..
The Appellant has challenged in this appeal, impugned Judgment and order passed by the District Consumer Commission, Aurangabad ( in short, District Commission ) in C.C.No.374/2021 dated, 26.07.2022, wherein the present 30 A/619/2022 appellant is original complainant and respondent no. 1 and respondent no. 2 are the original opponent no. 1 and opponent no. 2 respectively.
2. Brief facts giving rise to this appeal are as under :-
On 29.07.2020 appellant had availed the Corona Rakshak Policy from respondent no.1 bearing policy no. 182100/48/2021/2467 valid for the period from 29.07.2020 to 09.05.2021, and paid Rs. 5185/- as a premium towards the said policy. On 08.03.2021 as per the RTPCR report, the appellant found to be infected with Corona virus and admitted in a Covid centre duly declared by the Aurangabad Municipal Corporation at Covid-19 care centre, Government Engineering Collage from 08.03.2021 to 16.03.2021. The name of appellant was also listed in the list of corona patients issued by VRDL Laboratory, Dept. of Microbiology Government Medical College Aurangabad. Appellant intimated this fact to respondent no.1 immediately on 08.03.2021. After discharge, appellant filed insurance claim with respondent no.1 on 16.03.2021 but on 08.07.2021 respondent no.1 repudiated the claim of appellant on the ground as shown in clause no. 3.6 of insurance policy.
Being aggrieved by the repudiation of claim, appellant filed consumer complaint claiming Rs. 2,50,000/- as a insurance amount with 18 % interest, Rs. 50,000/- for mental agony and financial harassment and Rs. 25,000/- for cost of litigation. In support of complaint, appellant filed copy of Corona Rakshak Policy with its terms and conditions, copy of RTPCR test along with list of corona positive patient, copy of discharge card along with treatment papers, copy of claim form with documents, copy of repudiation letter dated 08.07.2021 etc. 31 A/619/2022
3. Respondent no.1 appeared before the District commission and filed written statement, thereby resisted the complaint and denies the allegations. It is submitted by respondent no.1 that as per discharge card, the treatment given to appellant was simple and there is no need for her to get admitted. Appellant failed to file medical bills, prescription, diagnostic and pathology reports in support of her contention. The appellant has not hospitalized in government authorized hospital. There is no active line of treatment during hospitalization therefore claim is not admissible under policy exclusion clause no. 3.6 and hence rightly repudiated. The matter was proceeded ex parte against respondent no.2.
4. On hearing the counsel of both parties and considering the evidence on record, the District Commission dismissed the consumer complaint.
5. Feeling aggrieved by the impugned judgment and order, complainant came to this Commission in appeal. Heard Adv. M.P.Bhaskar for appellant and Adv. S.M.Jondhale for respondent no.1. The matter was proceeded ex parte against respondent no.2.
6. Adv. Bhaskar for appellant argued and submitted through his written argument that the Commission below had not properly consider the policy terms and conditions, clause 3.6 of policy and the evidence filed by appellant and passed the impugned order which is erroneous. It is submitted that as per the Corona Rakshak Policy terms and conditions, the eligibility 32 A/619/2022 criteria for insurance claim is that the claimant has to be corona positive and has to be hospitalized for 72 hours in Government hospitals or hospital established under local authority, as such appellant was corona positive and hospitalized for 9 days and entitled for insurance claim. The appellant was admitted in Covid centre duly approved by the Municipal Corporation of Aurangabad therefore the claim was wrongly repudiated by respondent no.1 under clause 3.6 of policy terms and conditions. Appellant did not breach any terms and conditions of said policy. District Commission has not considered these aspects while deciding the matter and passed the impugned order which needs to be quashed and set aside.
7. Adv.Jondhale for respondent no.1 argued and submitted through his written arguments that, as per discharge card, the treatment given to appellant was so simple therefore there is no need for her to get admitted. Doctor has not adviced her to hospitalize as appellant suffering from mild infection. There is no active line of treatment during hospitalization therefore claim is not admissible under policy exclusion clause no. 3.6 and hence rightly repudiated. It is submitted that appellant was admitted in Covid centre which is quarantine centre and cannot be called as a hospital. As such respondent no.1 has not committed any deficiency in service towards appellant and there is no error in the impugned judgment which requires interference by this Commission.
8. We have gone through the appeal compilation, impugned judgment and order, pleading and written notes of arguments 33 A/619/2022 on record. In this appeal two points are there for our consideration. First, within the period of policy, weather appellant was corona positive or not and second weather she was hospitalized for more than 72 hours following the advice of duly qualified Medical practitioner or not. It is not disputed that appellant had taken insurance policy named Corona Rakshak Policy valid for the period of 29.07.2020 to 09.05.2021 and paid Rs. 5158/- towards the premium of said policy. On perusing the policy documents, terms and conditions of said policy which is on record, clause no. 2 as operative clause, clause no.4.1 as Covid cover clause is important and reproduced as,
i) Clause no.2, operative clause - If during the policy period the insured person is diagnosed with COVID and hospitalized for more than 72 hours following medical advice of a duly qualified medical practitioner. The insurance company shall pay the agreed sum insured towards the coverage mentioned in the policy schedule.
ii) Clause 4.1 Covid cover -Lump sum benefit equal to 100% of the sum insured 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 form a government authorized diagnostic centre.
9. As per the medical treatment papers, discharge card and RTPCR test report which are on record, it appears that the appellant was infected with corona virus on 08.03.2021 and admitted at Government Engineering Collage Covid centre, duly declared by the Aurangabad Municipal Corporation. The list issued by VRDL laboratory, Govt. Medical College Aurangabad which is on record, shows that appellant on serial no. 20 was 34 A/619/2022 corona positive. Letter and discharge card issued by Medical Officer, health department of Aurangabad Municipal Corporation shows that appellant was corona positive and referred her to Government Engineering Collage Covid centre for treatment. As per the case papers, it appears that appellant having symptoms of corona and she was corona positive.
10. The claim of appellant was repudiated by respondent no.1 on the ground of clause 3.6 of policy terms and conditions. As per clause 3.6 the term hospital is defined. Clause 3.6 (vi) reproduced as, For the purpose of this policy any other set-up designated by the government as hospital for the treatment of Covid-19 shall also be considered as hospital. Due to massive spread of corona virus in state, government itself encouraging Covid centres for the treatment of Covid patients as there was lack of beds and other medical facilities in hospitals. Admittedly appellant was referred and admitted for treatment at Government Engineering Collage Covid centre which was declared as Covid centre by Aurangabad Municipal Corporation having medical practitioners and duly qualified nursing staff. Therefore we are of the view that the Government Engineering Collage Covid centre declared by Aurangabad Municipal Corporation as a Covid centre comes within the purview of clause 3.6 (vi) of policy and repudiation of claim on the said ground is deficiency in service on the part of respondent no.1 towards appellant. As such appellant fulfill the criteria required for the insurance benefit under the said policy. Appellant was corona positive and hospitalized for more than 72 hours as per the advice of qualified medical practitioner and therefore entitled for benefits under the Corona Rakshak Policy. District 35 A/619/2022 Commission has not considered the above important facts while adjudicating the consumer complainant. Therefore the impugned judgment and order passed by the District Commission deserve to be quashed and set aside.
11. In view of aforesaid facts and discussion we are of the opinion that, the District Commission has committed an error in appreciating evidence on record. The District Commission in the impugned judgment and order ignored above important facts. Hence, the impugned judgment and order are liable to be quashed and set aside. In the fact and circumstances of the appeal there is no order as to cost. Hence, we pass the following order.
ORDER.
1. The appeal is partly allowed.
2. The impugned judgment and order passed by the District Commission, Aurangabad in C.C.No.374/2021 dated 26.07.2022 is hereby quashed and set aside.
3. Respondent no.1 is directed to pay insurance amount of Rs. 2,50,000/- under Corona Rakshak Policy to the appellant with interest @ 8 % p.a. from the date of repudiation of insurance claim i.e. 08.07.2021 till its realization.
4. Respondent no.1 is directed to pay Rs. 10,000/- for mental agony, financial harassment and cost of litigation to appellant.
5. Copy of this judgment be given free of cost to both parties.
N.C.Kumbre M.S.Sonawane
Member Presiding Member
UNK
36 A/619/2022