The District Consumer Disputes Redressal Commission, Ernakulam (Kerala) bench comprising Shri D.B. Binu (President), Shri V. Ramachandran (Member), and Smt. Sreevidhia T.N. (Member), has held Future Generali India Insurance Company Ltd. accountable for service deficiency. The Insurance Company wrongly denied a legitimate medical claim under the Corona Rakshak Policy.
Here are the summarized facts: The complainant had purchased a Corona Rakshak Policy from Future Generali India Insurance Company Limited (“Insurance Company”) covering himself and his mother. Each insured person was eligible for Rs. 1,50,000/- for COVID-19 hospitalization, with a total premium of Rs. 3,025/-. Subsequently, the complainant was hospitalized at Amrita Institute of Medical Sciences and Research Centre (“AIMS”) in Kochi, where a COVID-19 Antigen Test confirmed positive on the same day of admission. The complainant incurred hospital expenses amounting to Rs. 54,982/-. Treatment was provided at AIMS’s Respiratory Medicine Department, and he was discharged on 12.12.2020.
On 21.12.2020, the complainant notified the Insurance Company about the claim and received an acknowledgment the same day. The Insurance Company requested the reimbursement claim form in the prescribed format. The complainant submitted the Health Insurance Claim form along with six documents, including the discharge summary from AIMS. On 15.01.2021, the Insurance Company acknowledged the receipt and registered the claim documents.
Nevertheless, on 18.03.2021, the Insurance Company issued a rejection letter asserting that the complainant had received all medications orally and was primarily hospitalized for investigation, evaluation, and supportive treatment. They contended that hospitalization necessitated admission to a government-designated COVID-19 treatment facility for a minimum continuous inpatient care period of seventy-two hours.
The complainant contended that he was hospitalized as an inpatient from 07.12.2020 to 12.12.2020, fulfilling the policy’s requirements. During his hospital stay, he received treatment for low blood potassium levels and was diagnosed with systemic hypertension alongside COVID-19. Thus, he argued that inpatient care was necessary. Following his recovery from COVID-19, the complainant experienced respiratory issues and fatigue, which hindered his ability to work. He was advised to observe home quarantine until 18.12.2020 and scheduled for a follow-up on 24.12.2020.
Despite submitting all necessary claim documents, the Insurance Company denied his legitimate claim. Feeling aggrieved by this decision, the complainant lodged a consumer complaint with the District Consumer Disputes Redressal Commission, Ernakulam, Kerala (“District Commission”).
Observations by the Commission:
The District Commission perused the exclusion clause of the policy which stated that inpatient care means treatment for which the insured person has to stay in a hospital continuously for more than seventy-two hours for the treatment of COVID-19. As per the available evidence, the Complainant was found in adherence to the policy clauses which entitled him to the insurance amount.
Therefore, the District Commission held that the Insurance Company wrongfully repudiated the Complainant’s claim. It was held liable for deficiency in service. The District Commission directed the Insurance Company to pay Rs. 1,50,000/- to the Complainant along with Rs. 10,000/- as compensation and Rs. 5,000/- as litigation costs.
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