The Additional District Consumer Disputes Redressal Commission in Ahmedabad, Gujarat, has held Iffco Tokio General Insurance Co. Ltd. liable for wrongly repudiating a valid claim made by a policyholder, Mr. Amrutlal Thakkar. The policy in question was a ‘Corona Kavach’ policy with a sum assured of Rs. 5 Lakh. Mr. Thakkar had undergone treatment for COVID-19 at Aartham Hospital, incurring an expenditure of Rs. 2,01,512/-. However, when he submitted a claim to the insurance company, they only disbursed Rs. 1,55,378/-, deducting the remaining amount without a valid cause.
The insurance company justified the deduction by citing the ‘Ayushman Maharashtra’ circulars, which they claimed allowed them to limit the payment to the approved package rates. However, the commission disagreed with this interpretation, stating that the circulars were not intended to override the terms of the policy. Instead, they were meant to ensure affordable treatment for the economically weaker sections who did not have insurance coverage.
The commission observed that the insurance company had arbitrarily deducted part of the claim, which was unjustified. They directed the insurance company to pay the remaining Rs. 46,134/-, along with Rs. 3,000/- as compensation and Rs. 2,000/- as legal costs to the complainant. The complaint against the hospital was dismissed, as the contractual obligation was solely with the insurance company.
The commission’s decision emphasizes that insurance companies cannot use government guidelines as an excuse to deny legitimate claims of policyholders. The ‘Ayushman Maharashtra’ circulars are intended to provide affordable treatment to those who cannot afford it, not to limit the payments to insured individuals. The case highlights the importance of insurance companies adhering to the terms of their policies and not misinterpreting government guidelines to their advantage.
The case, Amrutlal T. Thakkar vs Iffco Tokio General Insurance Co. Ltd. and Anr., is a significant precedent for consumers who have been wrongfully denied claims by insurance companies. It emphasizes the need for insurance companies to act in good faith and honor their contractual obligations. The decision also underscores the role of consumer courts in protecting the rights of policyholders and ensuring that insurance companies are held accountable for their actions.