Rajkot: The District Consumer Dispute Redressal Commission , Rajkot, has held a private insurance company liable for deficiency in service and ordered it to pay an insurance cover amount of Rs 39.70 lakh along with 6% interest.The forum delivered the verdict in favor of the complainant after the company rejected his critical illness claim stemming from a severe road accident.The bench, comprising commission president P C Raval and member M S Bhatt directed the insurer to deposit the awarded sum —calculated with 6% interest from the complaint filing date of July 31, 2024, until realization — directly into the complainant’s home loan account in two months.According to the complaint filed through advocate K P Mavadiya and supported by Rama Mavani of the Rajkot city district consumer protection board, The complainant had secured a mediclaim cover of Rs 39.70 lakh for critical illness tied to a Rs 40 lakh home loan.On Aug 3, 2023, while traveling on his motorcycle from Rajkot to Jasdan amid heavy rain, the two-wheeler skidded at a speed breaker near Virnagar. A passing heavy truck ran over his right hand, crushing his palm muscles and fracturing bones. He underwent fasciotomy surgery and extensive treatment from Aug 3 to Sept 15, 2023, incurring medical expenses of Rs 5.89 lakh and suffering amputation of all fingers.Medical certificates confirmed that he had lost the ability to perform six daily activities, while a disability certificate from Rajkot Govt Hospital assessed a 42% permanent disability.“According to the terms and conditions of the policy, if the insured person suffered critical illness and wasn’t able to perform certain activities because of this critical illness, they were eligible to get the entire sum assured,” Mavadiya said.The insurance company, ICICI Prudential, had rejected the claim, contending that the injury did not fall under the definition of “critical illness” or “loss of independent existence” under the policy terms.Dismissing the insurer’s contentions, the commission observed that the policy fell under the ‘Classic Package’ and covered critical illnesses. It noted that the insurance company failed to present independent, neutral expert evidence under the Evidence Act, pointing out that its panel doctor had given an opinion without conducting a physical examination of the patient.
