Insurance Claim Dispute Dismissed: Court Upholds Concurrent Findings in Critical Illness Case.


25 November 2024 Civil Revision >> Civil & Consumer Law   |   Consumer Protection Act >> Consumer Rights   |   Insurance Claim/Money Rejected >> Insurance  

The National Consumer Disputes Redressal Commission (NCDRC) recently dismissed Revision Petition of Mukesh Kumar Kaushal Vs ICICI Lombard General Insurance Co. Ltd. & Another., thereby upholding the concurrent orders of the Punjab State Consumer Disputes Redressal Commission and the District Consumer Disputes Redressal Forum, Jalandhar. The petitioner, who had filed a complaint seeking Rs. 10 lakh in critical illness coverage, saw his plea rejected after the lower forums found his medical condition did not meet the policy's defined criteria.

The petitioner had obtained a critical illness insurance policy for Rs. 10 lakh, paying a premium of Rs. 17,393. He was later admitted to Dayanand Medical College, Ludhiana, with chest pain and diagnosed with Coronary Artery Disease (Single Vessel Disease). After being discharged against medical advice, he filed a claim, which the insurer repudiated, stating his condition did not fall under the policy's critical illness coverage.


 

 

The District Forum dismissed the complaint, noting the petitioner had accepted a full and final settlement of Rs. 13,624, which covered his hospital expenses. The forum also highlighted that the petitioner's condition, Single Vessel Disease, was not listed as a covered critical illness in the policy. The State Commission upheld this decision, emphasizing the policy's specific definitions of critical illnesses and the petitioner's acceptance of the settlement amount.

In the revision petition, the complainant argued that his condition, Acute Anterior Wall Myocardial Infarction (heart attack), qualified as a critical illness under the policy. He also alleged procedural lapses by the insurer, including the non-provision of complete policy terms and conditions and the failure to present expert medical testimony.

However, the NCDRC, in its ruling, reiterated the limited scope of its revisional jurisdiction. It emphasized that it could only intervene in cases of jurisdictional errors, material irregularities, or perversity in the lower forums' orders. The Commission found no such errors in the concurrent findings, which were based on a thorough examination of the evidence and policy terms.

The NCDRC highlighted established legal precedents, quoting Supreme Court rulings that restrict the revisional jurisdiction of consumer commissions. It stressed that it cannot interfere with concurrent findings based on the appreciation of evidence.

The NCDRC concluded that the petitioner's condition, as evidenced by medical records, did not align with the policy's definition of a critical illness. It also affirmed that the petitioner's acceptance of the settlement amount precluded further claims. The petition was dismissed, with no order as to costs.

This case underscores the importance of understanding the precise terms and conditions of insurance policies, particularly regarding critical illness coverage. It also reaffirms the limited scope of revisional jurisdiction in consumer disputes, emphasizing the weight given to concurrent findings of lower forums.


Section 13, Consumer Protection Act - 1986  

Section 21, Consumer Protection Act - 1986  

Consumer Protection Act, 1986