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STATE CONSUMER DISPUTES REDRESSAL COMMISSION
ICICI Lombard Gen Ins Co.Ltd – Appellant
Versus
Jagrut Nagarik - P V Moorjani – Respondent
SC/24/A/103/2023
Key Points: - The appellate court upheld the District Commission’s conclusion that the claim for COVID-19–related death falls within the policy coverage, as discussed in para 13, 27, 28, and 49. (!) (!) - The policy provides a list of Major Medical Illness and Procedures, including "First Heart Attack" and certain conditions, with COVID-19 not explicitly listed; the District Commission linked COVID-19 illness to cardiac events in its reasoning. (!) (!) (!) - Insurance company repudiated the claim citing absence of Major Medical Illness as defined in the policy; this was deemed deficient by the District Commission and affirmed on appeal. (!) (!) - The respondent argued that death certificate shows Acute Cardio Respiratory Arrest caused by COVID-19, which is connected to the insured’s death and should be covered under the policy terms. (!) (!) (!) - The Appellant relied on medical literature to distinguish between heart conditions and COVID-19–related death but the court found the District Commission’s interpretation reasonable. (!) (!) - The appeal is dismissed and the District Commission’s order confirming liability and directing payment is upheld. (!) (!) - The policy terms and specific coverage (Major Medical Illness & Procedure) are laid out in the policy schedule, including items under "First Heart Attack" and other illnesses; the interpretation of these terms is central to the dispute. (!) - The court noted the definitions of COVID-19, cardiac arrest, myocardial infarction, respiratory arrest, and heart attack to interpret the cause of death in context. (!) (!) (!) (!) (!) (!) - The order includes directions regarding cost, deposit verification, and transmission of copies to involved parties. (!)
IN THE STATE CONSUMER DISPUTES REDRESSAL COMMISSION GUJARAT STATE COURT NO.2 First Appeal no.103 of 2023
Details
DD MM YYYY
Date of Judgment
26
10
2023
Date of filing
07
10
2022
Duration
19
00
01
1. ICICI Lombard Gen. Insurance Co. Ltd.
2nd Floor, 204,205,206 Golden Icon, Bird Circle, Opp: BSNL, Vadodara – 390007 …Appellant VS
1. Jagrut Nagrik (A voluntary Consumer Association)
through its Managing Trustee -P.V.Moorjani Opp: LBS Vidyalaya, Nr. Prerna School, Sangam, Karelibaug, Vadodara.
2. Mrs. Kajal M. Gaekwad
19, Nageshwar Society, Harni Road, Vadodara- 390 006.
3. ICICI Bank Ltd ICICI Bank Tower, Nr. Chakli Circle, Old Padra Roda, Vadodara – 390006 …Respondents APPEARANCE: Mr. N. S. Dave, Ld. Adv. for the Appellant.
Mr. P. V. Moorjani, Ld. Representative for the Respondent.
CORUM: Hon’ble Ms. Archana Raval, Presiding Member Order by Hon’ble Ms. Archana Raval, Presiding Member
1. The appellant/original Opponent no.2 has filed this appeal under section 15 of the Consumer Protection Act, being aggrieved by and dissatisfied with the order dated 07.10.2022 passes by the Ld. District Consumer Disputes Redressal Forum Vadodara (Addn.) (hereinafter referred to as “ Learned District Commission”) in Consumer Complaint No.670 of 2022. For the sake of convenience, the parties to the proceedings will be addressed as per their original nomenclature in the complaint.
2. Heard Ld. Adv. Mr. N.S. Dave for the Appellant and Ld. representative Mr. P. V. Moorjani for the Respondent were present.
3. Facts of the case:
3.1 It is the case of the complainant that the complaint and her late husband Mr. Mehulkumar Gaekwad had jointly took loan for flat no. 504, tower-A, Yagyapurush Residency, Harini, Vadodara from ICICI bank Limited on 17.11.2015. Where ICICI bank Limited approved total loan amount of Rs.15,00,00 and loan account no. BRD00002510018 was created, for term of 20 years payable into 240 instalments. After that, in the year 2018, complainant and her late husband have jointly took another loan for flat number 103 first floor tower B Orchid Calisto, Nr. Sama-Dumad-Vemali Chokdi, Vadodra from the same bank on 19.04.2018 whereas the ICICI bank Ltd. approved total of Rs. 22,00,000/- and loan A/C no. LBBRD00004411852 was created for 20 years payable in 240 installments. Further, the bank made it compulsory to obtain insurance policy from its sisters concern ICICI general insurance Company Limited, policy premium was paid Rs.1,47,115/-, that amount was also sanctioned by the bank as a loan. The total loan amount sanctioned was Rs. 23,47,115/-. After borrowing both the loans from ICICI bank limited, the complainant and her husband purchased above stated both the houses.
3.2 For the first loan, the premium amount of RS. 25,865/34 was paid for the period from 11.01.2016 to 10.01.2021 and after completion of 5 years of the said policy, ICICI bank Ltd. had issued another policy for the period from 21.01.2021 to 20.01.2026, against same loan i.e. 1st loan of Rs. 10,00,000/- with premium amount Rs. 14,632/-. Further, for 2nd loan of Rs. 22,00,000/-,the premium amount paid was Rs. 1,18,325/79 for the period from 31.05.2018 to 30.05.2023. The personal health benefits of the policy are mentioned in section B, of the terms and conditions, where the payment made for treatment of critical illness was made reimbursable clause 2.1.
3.3 Both the policies were issued in the name of the husband of the complainant Mr. Mehulkumar C. Gaekwad. Husband of the complainant was admitted in Radha Multi Specialty Hospital on 29.03.2021 and passed away on 02.04.2021 due to Acute Crdio Respi. Arrest in Covid-19 Pneumonia + LRTI + Septicemia. The complainant lodged 2 separate claims for reimbursement of treatment amount and closure of loan accounts. Both the claim of the complainant were rejected by the insurance company vide its letter dated 26.08.2021 and 27.08.2021. The reason given in both the repudiation letters was that upon verification there was no evidence of any
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