The Vadodara District Consumer Disputes Redressal Commission has directed an insurance company to pay a claim of Rs 1.41 lakh to a policyholder whose wife was treated for Covid-19 in November 2020. The insurer had rejected the claim on the grounds that the patient had suffered from tuberculosis 20 years ago, which was not disclosed while purchasing the policy.
Case Background
According to details of the case, Mukesh Shah had bought an insurance policy of Rs 5 lakh for himself and his wife from Future Generali India Insurance Company Ltd in 2020. Shah paid an additional premium because he was suffering from diabetes and hypertension, and his wife also had diabetes. In November 2020, Shah’s wife was admitted to a hospital for five days for treatment of Covid infection. Shah subsequently filed a claim of Rs 1.41 lakh, but the insurer rejected it in December 2020, arguing that the patient had suffered from pulmonary tuberculosis, which was not disclosed to the insurance firm.
Consumer Complaint
Shah filed a complaint with the Vadodara District Consumer Disputes Redressal Commission (additional) in February 2021. The insurance firm told the consumer commission that the patient had TB 20 years ago and that this fact was not disclosed in the proposal form. The consumer forum observed that it was not proved whether the patient was asked about any disease suffered 20 years ago, when she was young. If the patient had been asked, she would have definitely mentioned TB, especially since they had already paid a loading premium for pre-existing conditions.
Forum’s Observations
The forum further noted: “Even if it is believed that the patient had TB 20 years ago, the opponent has not proved that she contracted Corona due to TB. The doctor’s certificate given to the patient says that the Covid disease did not occur due to the previous TB.” The consumer commission ordered the insurance firm to pay Rs 1.41 lakh to the complainant, along with Rs 5,000 each for legal costs and mental agony.
This ruling underscores the importance of clear communication and burden of proof in insurance claims, particularly when pre-existing conditions are decades old and unrelated to the current ailment. The decision provides relief to policyholders who may face rejection of legitimate claims based on historical medical conditions that have no bearing on the current illness.
