Gandhinagar: Insurer made to pay Covid patients after their claims were rejected

AHMEDABAD: A consumer court ordered an insurance company to pay two claimants Rs 2.5 lakh each for their special Covid-19 cover, after it rejected their medical insurance claims on the grounds that the patients' RT-PCR reports returned negative for Covid, even though they had been hospitalized and treated for Covid.
Both cases are from Gandhinagar district. Ishwar Rawal, a resident of Sector 3, had taken the Corona Rakshak Policy with Rs 2.5 lakh assured from Future Generali India Insurance Co Ltd. The policy entailed 100% reimbusement for Covid treatment too. He was found to be Covid positive by a rapid antigen test and was admitted to SMVS Swaminarayan Hospital on December 18, 2020, for four days. The discharge summary reflected that he was treated for Covid. He paid Rs 93,000 for his treatment.
When Rawal made his claim, it was repudiated on the grounds of an RT-PCR report done on December 19. The insurance company said an RT-PCR positive report was needed for the claim, but his was negative. The company cited its CT values and said that the report showed him to be Covid negative. It said that the HRCT scan of his thorax was also normal and the conclusion that the patient was Covid-19 negative was correct and his claim had rightly been repudiated.
A resident of Kudasan, Yash Lalwani, has a similar experience with Rs 2.5 lakh cover from the same insurer. He was hospitalised at Ashka Hospital for four days with Covid symptoms in February 2021 and paid Rs 97,095 for treatment. His RT-PCR report was also found to be negative by the company. It found his HRCT scan normal and denied his claim.
Both policyholders sued the company with the Gandhinagar District Consumer Dispute Redressal Commission and furnished evidence about their being treated for Covid by placing discharge summaries and certificates from their treating doctors. After going through the documents, the commission said the rejection by the company was against the principle of natural justice and fair play and "a very niggardly and hyper technical approach has been taken with a myopic view". The company has been ordered to pay Rs 2.5 lakh to each of the policyholders with Rs 10,000 extra as compensation for the harassment caused to them.