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The district consumer disputes redressal commission (DCDRC) in Ahmedabad city overruled an insurance company’s decision to reject a claim for Covid-19 treatment on the ground that the patient had pre-existing heart conditions. DCDRC ordered the insurer to pay the claim amount with interest and compensation.
The complainant, Paldi resident Fenil Shah, was admitted to CIMS Hospital for five days–from November 28 to December 2, 2020–for Covid-19 treatment and had incurred an expense of Rs 1.90 lakh. He had filed his claim with Max Bupa Health Insurance Co Ltd, which not only rejected the claim but also revoked the policy on the ground of non-disclosure of pre-existing heart disease.
However, DCDRC, in an order dated June 20, noted that at the time of the policy subscription in 2020, a medical test was done and the certificate had already mentioned the pre-existing heart condition, along with the line of treatment and medication. The order said the insurer had covered Shah’s risk after accepting the medical certificate. “…there is no reason to believe that the complainant has suppressed the fact of his health issues,”
DCDRC observed.
“…we find no direct nexus between Covid and heart diseases. The issue of heart disease would not be a material fact for Covid. The opponent has not produced any medical literature that shows any direct nexus between Covid and heart diseases. The opponent has not proved that due to the pre-existing heart diseases, the complainant suffered from Covid and hence, the risk of the complainant was not covered,” the Commission noted.
Hence, the commission held that the insurer’s cancellation policy “is absolutely illegal” and “has committed an unfair trade practice” by revoking the policy as well as “repudiating a genuine claim”. The insurer “has miserably failed to accept their contractual liability towards the complainant,” it said.
Shah’s counsel Sunil Chhabria had submitted before DCDRC that his policy entitled him to Rs 2,000 per day of hospitalisation, thus making him eligible for a payment of Rs 10,000.
The commission directed Max Bupa Health Insurance to pay Rs 1,90,619, as claimed by Shah, and an additional Rs 10,000, which was payable under the policy clause as hospitalisation cash per day, along with interest at the rate of 6 per cent per annum from the date of the complaint until its payment within one month from now, failing which, the interest rate would be hiked to 8 per cent.
The commission also directed an additional Rs 10,000 to be paid to Shah for “mental agony and stress”, in addition to Rs 2,000 towards expenses of the complaint. It also ordered the restoration of the policy.
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