'Mild Symptoms' No Ground To Repudiate Insurance Claim Of Policy Holder Hospitalised On Account Of Covid-19: Kollam Consumer Commission

The District Consumer Disputes Redressal Commission, Kollam (Kerala) recently held that the insurance claim of a Corona Rakshak Policyholder cannot be declined merely citing mildness of his symptoms.Bench comprising Smt. S.K. Sreela (President) and Sri. Stanly Harold (Member) thus held Future Generali India Insurance Company liable for wrongfully repudiating the claim of the Complainant for COVID-19 hospitalization. It held,"The Corona Rakshak Policy clearly outlines the conditions for claim eligibility, including hospitalization for a minimum of 3 continuous days. The policy does not specify the severity of symptoms or the necessity of active treatment during hospitalization. Therefore, the opposite parties' contention that the complainant's mild symptoms preclude claim eligibility is unfounded."The Commission thus directed the insurer to remit sum assured Rs. 2.5 Lakh to the Complainant alongwith Rs. 50,000 compensation for mental agony and Rs. 10,000 towards litigation cost. Brief Facts: Riyas S (“Complainant”) purchased a 'Corona Rakshak Policy' from the Future Generali Health (FGH) department of the Future Generali India Insurance Company (“Insurance Company”). The insured amount was Rs. 2,50,000/- which was payable upon a positive Covid-19 report, couple with a minimum 72 hours of hospitalization. During the validity period of the policy, the Complainant was diagnosed with COVID-19 and was subsequently admitted to Travancore Medical College Hospital, Kollam (“Hospital”) for 5 days. The total expenditure was Rs. 43,906/-. As soon as he was discharged, he informed the Insurance Company and preferred his claim before it. The Insurance Company repudiated the claim on the basis that all medication he received was in oral form and his situation could have easily been managed at home. Further, the Insurance Company interpreted the term 'hospitalization' as admission to a hospital designated for COVID-19 treatment by the Government for a minimum of 72 hours, under the policy. Feeling aggrieved, the Complainant filed a consumer complaint in the District Consumer Disputes Redressal Commission, Kollam, Kerala (“District Commission”). Observations by the Commission: At the outset, the District Commission observed that the Insurance Company had accepted the existence of the insurance policy in contention. It also acknowledged that the Complainant was indeed suffering from Covid-19 and that was the cause of his admission to the Hospital. In the Hospital, he was categorized as a Category B/Mild illness patient and had symptoms of high fever, cough and cold. The District Commission perused the T&C of the policy and held that it did not specify the severity of the symptoms or the necessity of active treatment during hospitalization. Therefore, the repudiation based on 'mild' symptoms was held to be invalid and unjustified. Adding to this, the District Commission held that the mere presence of mild symptoms does not negate the need for hospitalization, especially considering COVID-19's potential to rapidly deteriorate a patient's body. The bench also remarked that due to the callous and arrogant attitude of the Insurance Company, the Complainant had to face hardships and such acts warrant serious scrutiny. It also differentiated between 'speculation' and 'insurance' by highlighting that insurance provides a crucial layer of economic protection, unlike speculative outcomes which are based on chance and coincidence.Advocate Dheeraj Ravi argued the matter for the complainant Case Title: Riyas S vs The Managing Director, Future Generali Health and Anr.

'Mild Symptoms' No Ground To Repudiate Insurance Claim Of Policy Holder Hospitalised On Account Of Covid-19: Kollam Consumer Commission

Smita Singh

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