Ernakulam District Commission Holds Future Generali India Insurance Co. Liable For Wrongful Repudiation Of Genuine Medical Claim

Brief Facts:

The Complainant took a Corona Rakshak Policy from Future Generali India Insurance Company Limited (“Insurance Company”). The insured persons under the policy were the Complainant and his mother. The sum insured for COVID-19 hospitalization was Rs. 1,50,000/- each for both insured persons, with a total premium of Rs. 3,025/-. Subsequently, the Complainant was admitted as an inpatient at Amrita Institute of Medical Sciences and Research Centre (“AIMS”) in Kochi. The COVID-19 Antigen Test conducted on the same day returned positive. The Complainant incurred Rs. 54,982/- towards hospital expenses. He was treated at the Respiratory Medicine Department at AIMS and was discharged on 12.12.2020.

The Complainant sent a claim intimation to the Insurance Company on 21.12.2020 and received an acknowledgement from them on the same day, requesting the reimbursement claim form in the prescribed format. He submitted the Health Insurance Claim form, enclosing six documents, including the discharge summary from AIMS. The Insurance Company acknowledged the receipt of the claim documents on 15.01.2021 and registered it.

However, the Insurance Company issued a repudiation letter on 18.03.2021, stating that the Complainant received all medication orally and was hospitalized mainly for investigation, evaluation, and supportive treatment. It argued that hospitalization required admission to a hospital designated for COVID-19 treatment by the Government for a minimum period of seventy-two consecutive inpatient care hours.

The Complainant argued that he was treated as an inpatient from 07.12.2020 to 12.12.2020 which fulfilled the policy's requirements. During hospitalization, his blood potassium level was low, and he received medication for it. He was also diagnosed with systemic hypertension in addition to COVID-19. Therefore, inpatient treatment was necessary. Post-COVID, the Complainant suffered from breathing issues and tiredness, preventing him from working. He was advised to remain in home quarantine till 18.12.2020 and to appear for a review on 24.12.2020. Despite receiving the claim documents, the Insurance Company repudiated his genuine claim. Feeling aggrieved, the Complainant filed a consumer complaint in 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.

Case Title: Ajaychand V. vs Future Generali India Insurance Company Ltd. and Anr.

Case No.: C.C. No. 487/2021

Advocate for the Complainant: Biju K Chacko, P. Balan, Arunkumar P.T.

Advocate for the Opposite Parties: None