IN THE CONSUMER DISPUTES REDRESSAL COMMISSION GUJARAT STATE, AHMEDABAD.

Court No. 1 First Appeal No. 236/2023 TATA AIG Gen. Ins. Co. Ltd.

A-501, 5^th floor, Building no.4 Infinity IT Park, Dindoshi, Malad (E)-400097, Maharastra. …Appellant Vs Jyotshnaben Budhabhai Rana Res at:- C-205, Shiv Residency, Chhani-Dumad Road, Chhani, District- Vadodara-391740. …Respondent APPEARANCE: Mr. R. P. Raval, Ld. Adv. for the appellant Mr. V. M. Pancholi, Ld. Adv. for the respondent CORAM: Hon’ble Justice Mr. V. P. Patel, President Hon’ble Ms. P. R. Shah, Member Order by Hon’ble Ms. P. R. Shah, Member.

1. The present appeal is filed by the appellant being aggrieved by and dissatisfied with the order passed by the Ld. District Consumer Disputes Redressal Commission of Vadodara dated 03/11/2022 in complaint no.582/2021.

2. Heard Ld. Adv. Mr. R. P. Raval for the appellant and Ld. Adv. Mr. V.

M. Pancholi for the respondent. Perused the records.

Impugned Order

3. The Ld. District Commission has directed the opponent insurance company to pay Rs.10,31,480/- to the complainant with all the available benefits as per the terms and conditions of the policy in question with 9% interest from the date of rejection of claim till it’s actual payment. The Ld. District Commission has further directed the opponent to pay Rs.50,000/- as mental agony and Rs.

50,000/- as litigation cost.

Facts of the case

4. It is submitted by the complainant that in 2017 her husband had taken a loan of Rs.9,00,000/-. from Axis Bank to purchase a flat. The opponent issued a policy against the loan amount of Rs.9,00,000/- vide policy no. 02350000840000340000 for the period 22/06/2017 to 21/06/2022. The said policy was issued in the name of the deceased Budhabhai Rana husband of the complainant. It is also stated by the complainant that she is the widow of the deceased and in that way she is the legal heir of the deceased as well as nominee under the policy obtained from the opponent insurance company. It is the case of the complainant that the premium of the policy of Rs.70,745/- was paid directly by the Bank debiting the account of the deceased as against the policy.

5. It is the case of the complainant that her husband was infected with covid-19 virus and during the treatment at home, he could not recover and expired on 27/11/2020 due to sudden cardio respiratory arrest. It is further the case of the complainant that after the death of her husband Budhabhai Rana being legal heir and also being the widow of the deceased, she informed the opponent about the death of her husband due to corona and lodged the claim for reimbursement of the amount of Rs.10,31,480/- as per policy. The opponents repudiated the claim of the complainant on 23/02/2021 stating the reason that the insured died due to covid-19 positive and this ailment is not covered under the critical illness as per the policy. The complainant therefore filed the complaint before the Ld. District Commission to claim the amount of Rs.10,31,480/- with interest from the opponent.

Arguments of the appellant

6. It is argued by the Ld. Adv. for the appellant that the impugned order is illegal, unjust, improper and arbitrary to the provision of law as well as settled principle of law. That the complainant has not established the deficiency of service on the part of insurance company. That defence taken by the insurance company has not been dealt with by the Ld. District Commission.

6.1 The appellant has contended that the Ld. District Commission has failed to appreciate that the insured’s illness does not fall under the listed critical illness coverage as per Section1 of the policy and therefore the claim was rightly repudiated. It is also contended that the insured has suppressed his previous medical condition. It is further submitted that based on the claim form and the treatment records submitted by the insured, the insured died due to covid-