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2022 Supreme(Ker) 970
IN THE HIGH COURT OF KERALA AT ERNAKULAM
V.G. Arun, J.
Star Health and Allied Insurance Company Ltd. – Petitioner
Versus
Avinash T. and ors. – Respondents
WP(C) NO. 29049 of 2021
Decided On : 20-12-2022
Advocate Appeared:
For the Petitioner: R.S.Kalkura, M.S.Kalesh, Harish Gopinath
For the Respondent: Nirmal.S, GP, Justine Jacob
Point of Law : ‘in-patient care’ means treatment for which the insured person has to stay in hospital continuously for more than 72 hours for treatment of COVID.
Headnote:
Company - Engaged in business Health and Allied Insurance - Claimed insurance amount - Petitioner Company is engaged in business of Health and Allied Insurance - First respondent had taken a Corona Rakshak Insurance Policy from petitioner with a coverage of Rs.1,00,000/- for period - As per terms of policy, lump sum benefit equivalent to 100% of sum assured was payable to policy holder on positive diagnosis of COVID requiring hospitalisation for a minimum continuous period of 72 hours - First respondent tested positive for COVID-19 from Government Medical College hospital, Kozhikode and was referred to a COVID First Line Treatment Centre (IFLTC) - He was admitted at CFLT Centre - After his discharge, first respondent claimed insurance amount - Claim was repudiated on the ground that insurance amount was payable only in case of hospitalisation and first respondent had only been under institutional quarantine is frivolous - As per Clause 3.6 Hospital means any institution established for in-patient care and day care treatment of disease/injuries and which has been registered as a hospital with local authorities under the Clinical Establishments (Registration and Regulation) Act, 2010 or under enactments specified under Schedule of Section 56(1) of said Act. Para 4
Finding of Court :
In order to understand whether CFLTCs are designated by the Government for COVID-19 treatment, one need only read COVID-19 advisory for patient admission to CFLTCs issued by Government as per order No.31/F2/2020/Health dated - Therein, it is specifically stated that Centre identified as COVID Health Care Centre should treat all mild and moderate symptomatic persons under surveillance and should be utilised for treating positive cases, when need arises -It is to be noted that CFLTCs are Primary Level Health Care Centres set up for providing care to less serious cases and referral of serious cases to COVID hospitals, so as to avoid crowding in COVID Hospitals and avoid wastage of resources - It can therefore be unhesitatingly held that CFLTCs are designated as hospitals for treatment of COVID-19 - Petitioner did not have any symptoms of COVID-19 and was not treated for such illness at the CFLTCs, permanent Lok Adalat relied on medical records to find that first respondent had taken treatment as outpatient at the Medical College, Kozhikode for fever, cough and mialgia - Doctor who had referred the first respondent to CFLTC had prescribed medicines and in discharge card of first respondent, it was specifically observed that he was having fever at time of admission.
Result : Writ petition is dismissed
JUDGMENT :
The petitioner Company is engaged in the business of Health and Allied Insurance. The first respondent had taken a Corona Rakshak Insurance Policy from the petitioner with a coverage of Rs.1,00,000/- for the period 25.07.2020 to 06.05.2021. As per the terms of the policy, lump sum benefit equivalent to 100% of the sum assured was payable to the policy holder on positive diagnosis of COVID requiring hospitalisation for a minimum continuous period of 72 hours.
2. The first respondent tested positive for COVID-19 on 29.09.2020 from the Government Medical College hospital, Kozhikode and was referred to a COVID First Line Treatment Centre (IFLTC). He was admitted at the CFLT Centre from 29.09.2020 to 08.10.2020. After his discharge, the first respondent claimed the insurance amount. The claim was repudiated on the ground that the insurance amount was payable only in case of hospitalisation and the first respondent had only been under institutional quarantine is frivolous. Aggrieved by the rejection of his claim, the first respondent preferred Ext.P2 original petition before the permanent Lok Adalat, Kozhikode. The petitioner defended the repudiation, contending that the CFLTC to which the first respondent was sent from the Government Medical College Hospital was an institutional quarantine facility and not a hospital. It was also contended that the medical records produced by the first respondent did not reveal that he had symptoms of COVID and was treated for COVID 19 at the CFLTC.
3. After detailed consideration, the Permanent Lok Adalat rejected the petitioner's contentions and allowed the first respondent's claim. Aggrieved, this writ petition is filed.
4. Heard Advs.R.S.Kalkura for the petitioner and Nirmal S. for the first respondent.
5. Although elaborate contentions were urged by the Counsel on either side, the short question arising for consideration is whether a COVID First Line Treatment Centre can be termed as hospital for the purpose of considering the first respondent's insurance claim. For deciding this question, it is essential to refer Clause 3.6, 3.7 and 3.8 of Ext.P1 policy. As per Clause 3.6, Hospital means any institution established for in-patient care and day care treatment of disease/injuries and which has been registered as a hospital with the local authorities under the Clinical Establishments (Registration and Regulation) Act, 2010 or under the enactments specified under Schedule of Section 56(1) of the said Act, OR complies with all minimum criteria as under:
“i. has qualified nursing staff under its employment round the clock
ii. has at least ten inpatient beds, in those towns having a population of less ten lakhs and fifteen inpatient beds in all other places
iii. has qualified medical practitioner (s) in charge round the clock
iv. has a fully equipped operation theatre of its own where surgical procedures are carried out.
v. maintains daily records of patients and shall make these accessible to the Company's authorized personnel
vi. 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.”
It is clarified in Clause 3.6.iv that, for the purpose of the policy any other set up designated by the Government as hospital for the treatment of COVID-19 shall also be considered as hospital. As per Clause 3.7, admission in a hospital designated for COVID treatment for a period of 72 consecutive 'in-patient care' hours will qualify a policy holder for the insurance coverage. Clause 3.8 makes it clear that 'in-patient care' means treatment for which the insured person has to stay in hospital continuously for more than 72 hours for treatment of COVID.
6. In order to understand whether CFLTCs are designated by the Government for COVID-19 treatment, one need only read the COVID-19 advisory for patient admission to CFLTCs issued by the Government as per order No.31/F2/2020/Health dated 24.07.2020. Therein, it is specific
