Gujarat State Commission Orders Reliance General Insurance To Pay Rs. 1.5 Lakhs To The Insured For Availing Covid-19 Treatment

Brief facts of the case:

Sonesh Patel (“Complainant”) purchased a special Covid-19 insurance policy worth Rs. 2 lakhs from Reliance General Insurance Co. Ltd. (“Insurance Company”) during the pandemic. In November 2020, the complainant tested positive for Covid-19 and subsequently received treatment at a private hospital, following a referral from an urban health centre. After undergoing treatment, the complainant filed an insurance claim with the insurer, seeking the reimbursement of his medical expenses and the full claim amount specified in the policy.

However, the insurance company rejected the complainant’s claim, on the premise that the 'Covid-positive' report submitted by him was not issued by a certified laboratory, as required by the terms and conditions of the insurance policy. Dissatisfied with this rejection, the complainant filed a consumer complaint in the Bhavnagar District Consumer Dispute Redressal Commission (“District Commission”), seeking a resolution to this dispute.

The District Commission ruled in favour of the complainant and ordered the Insurance Company to pay the full claim amount of Rs 2 lakh. Following this ruling, the insurance company, appealed the decision to the Gujarat State Consumer Dispute Redressal Commission (“State Commission”).

The complainant’s primary contention was that he had contracted Covid-19 and required medical treatment, which he duly received at a private hospital, supported by medical records and case papers. He argued that he had provided a certificate from a government health officer confirming his Covid-19 infection, which should serve as sufficient evidence for his claim. Additionally, he submitted laboratory reports from a government medical college to substantiate his illness and treatment.

The insurance company's main contention was that the complainant’s 'Covid-positive' report, while supported by a government health officer's certificate, did not meet the policy's requirement of being issued by a certified laboratory. It further argued that adherence to policy terms and conditions, including the requirement for a certified laboratory report, was essential for the validation of any claim. The insurance company maintained that the complainant’s claim could not be accepted in its entirety due to the absence of a certified laboratory report, even though other supporting documents were provided.

Observations by the commission:

The State Commission recognized that the complainant had taken reasonable steps to substantiate his claim, including obtaining a certificate from a government health officer, presenting case papers from a private hospital, and providing laboratory reports from a government medical college. However, given the specific policy requirement for a certified laboratory report, the State Commission concluded that a compromise was necessary to balance the complainant’s legitimate claim for Covid-19 treatment expenses and the policy's terms and conditions. As a result, the State Commission modified the initial ruling of District Commission and directed the insurance company to pay Patel Rs 1.50 lakh, along with 7% interest from the date of filing the complaint, as a fair resolution that considered both the medical expenses incurred by Patel and the policy's requirements.

Case: Reliance General Insurance Co. Ltd vs Soneshbhai Vashrambhai Patel

Case No.: A/381/2023

Advocate for the Appellant: Ms. K.S. Pathak

Advocate for the Respondent: D.V. Trivedi

Click Here To Read/Download Order