COVID claim denied, Health insurance company ordered to pay Rs 1.6 lakh

The case dates back to 2020, when the complainant, a resident of Radhapuri, Hapur, admitted his wife to a private hospital in Ghaziabad with Covid-19 on September 16. She had undergone four days of treatment and was discharged on September 20. The medical bill exceeded Rs 2 lakh.

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Since both the complainant and his wife were covered under the Super Surplus Floater Revised Mediclaim Policy worth Rs 15 lakh purchased from Star Health and Allied Insurance Co Ltd, he submitted the required documents, including bills and prescriptions, to claim the expenses. The policy was valid from July 20, 2020, to July 19, 2021.

However, the insurance company rejected the claim in May 2024, claiming that his wife had a pre-existing disease that wasn’t disclosed before taking the policy. Following this, he approached the commission.

Before the commission, he argued that his wife had no such illness before Covid and that they had to go to a private hospital because there were no beds available in Hapur hospitals.

"Before testing positive for COVID-19, my wife never had the virus or any other life-threatening disease. We had to admit her to a private hospital in Ghaziabad because no beds were available in Hapur hospitals," said the coplainant as reported by TOI. 

After hearing the arguments, the commission sided with the complainant and directed the insurer to pay Rs 1.5 lakh towards hospital expenses and pay Rs 5,000 as compensation for mental stress.

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