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2026 Supreme(Online)(SCDRC) 3862
STATE CONSUMER DISPUTES REDRESSAL COMMISSION
A. C. Raval, Presiding Member, P. R. Shah, Member
Star Health and Allied Insurance Company Ltd. – Appellant
Versus
Vishnubhai Ganeshbhai Patel – Respondent
Appeal No. 463/2024
For the Appellants/Petitioners: R. P. Raval
For the Respondents: S. J. Mansuri
An insurer cannot arbitrarily repudiate a claim by unilaterally applying a restrictive interpretation of 'grievous injury' or 'disablement' without medical expert evidence, particularly when the treating doctor's certification of temporary total disablement remains unrebutted.
Headnote:(A) Consumer Protection Act - Insurance Claim - Repudiation - Temporary Total Disablement - Insurer contended that injury was not 'grievous' as there was no fracture - Held, in the absence of a contractual definition of 'grievous injury', insurer cannot unilaterally impose a restricted interpretation - Treating doctor’s certificate stating inability to perform routine activities remains unrebutted - Repudiation held to be arbitrary and unjustified. (Paras 9.7-9.13, 9.16)
Facts of the case:
The complainant purchased an accident insurance policy from the appellant. Following a fall, the complainant suffered lower back contusion and was advised six weeks of bed rest. The insurer rejected the claim for weekly benefits, arguing the injury was not 'grievous' and lacked evidence of fracture or hospitalization. The District Commission ruled in favor of the complainant, directing payment of the claim amount with interest.
Findings of Court:
The court affirmed the lower commission's order, noting that the insurer failed to produce medical expert evidence to counter the treating doctor's assessment and that the policy's own reference to 'Home Convalescence' implied that injury recovery (even without hospitalization) was covered.
Issues: Whether the repudiation of the insurance claim for 'temporary total disablement' was legal, and whether the insurer's interpretation of 'grievous injury' was justified.
Ratio Decidendi: An insurance company cannot substitute its own assessment for that of a medical expert in the absence of contrary evidence, nor can it import narrow, restrictive definitions into policy terms that are not explicitly stated in the contract.
Result: Appeal dismissed; decision of the District Commission confirmed.
| Table of Content |
|---|
| 1. procedural status of the appeal and the impugned order. (Para 1 , 2 , 3 , 4) |
| 2. factual background and opposing contentions of the parties. (Para 5 , 6 , 7) |
| 3. the court's analysis of the evidentiary record and the insurer's internal assessment of injury. (Para 8 , 9) |
| 4. final ruling and dismissal of the appeal. (Para 10) |
| Details | DD | MM | YYYY |
|---|---|---|---|
| Date of Judgment | 25 | 03 | 2026 |
| Date of filing | 03 | 04 | 2024 |
| Duration | 22 | 11 | 01 |
Order by Hon'ble Ms. P. R. Shah, Member
1. The present appeal is filed by the appellant being aggrieved and dissatisfied with the order dated 20.01.2024 passed by the Ld. District Consumer Dispute Redressal Commission, Ahmedabad Rural in Consumer Complaint No. 370 of 2023.
2. When the matter was called out Ld. Advocate Mr. R. P. Raval for the Appellant and Ld. Advocate Mr. S. J. Mansuri for the Respondent remained present.
3. The appellant is the original opponent, respondent is the original complainant in the complaint before the Ld. District Commission and for the sake of convenience parties will be addressed with the same nomenclature.
4. Impugned Judgment
4.1 The Learned District Commission has observed that there is no evidence on record to establish that the complainant had been provided the terms and conditions of the policy by the opponent, and therefore the terms and conditions of the policy cannot become binding on the complainant. It was further observed that the complainant had availed the policy of the opponent and during the currency of the policy, the complainant fell from the shed in his house and suffered injury and had to take bed rest as per the doctor's advice. The Learned District Commission held that the complainant was entitled to benefits under the policy. Accordingly, the Learned District Commission ordered and directed the opponent to pay to the complainant Rs. 90,000 with 9% interest from the date of the complaint and Rs. 500 for mental agony and Rs. 500 as cost.
5. Facts
5.1 The facts as narrated in the complaint, in brief, are that the complainant had availed an 'Accident care individual insurance' policy of the opponent for sum assured of rupees 50 lakhs for the period 19-02-2022 to 18-02-2025. The complainant has averred that on 23-07-2022, while cleaning the shed in his residence, he slipped and fell and was taken to "Shree Rang Orthopedic and Surgical Hospital" and consulted Dr. Hetalbhai Kapasi who advised an X-ray. The complainant got the X-ray done at Kadam Diagnostics Center.
5.2 The X-ray report revealed that the complainant had sustained a contusion injury to the lower back accompanied by pain, for which the treating doctor recommended six weeks of bed rest from 23-07-2022 to 07-09-2022. The complainant averred that he incurred an expenditure of rupees 25,000 for the treatment and was entitled to rupees 15,000 per week as per the policy and accordingly claimed rupees 90,000 from the opponent by submitting all relevant documents.
5.3 The complainant further submitted that no policy terms and conditions were given to him and therefore its terms and conditions are not binding on him. The opponent rejected the claim vide letter dated 12-01-2023. Alleging deficiency in service and unfair trade practice, the complainant filed a case before the Learned District Commission.
6. Arguments of the Opponent
6.1 The learned advocate for the opponent, Mr. Ankit Solanki, for Mr.R.P. Raval, submitted that the Learned District Commission erred in passing the judgment without granting opportunity to the opponent. It was urged that this Commission should examine the rojkam to ascertain that after the complainant filed evidence, no opportunity was given to the opponent to file its evidence and only the complainant was heard before passing the order. The opponent alleged before this Commission that it was not given opportunity of filing evidence and hearing by the Learned District Commission and therefore the matter should be remanded for fresh hearing.
6.2 It was admitted that
