Upholding concurrent findings that Care Health Insurance Ltd wrongly repudiated a claim arising from the death of a Gujarat resident who fell from a mango tree, the national consumer disputes redressal commission (NCDRC) has dismissed two second appeals filed by the insurer. The order, reserved on 18th September and pronounced on 7 November 2025, affirms decisions of both the district consumer commission at Valsad and the Gujarat state consumer disputes redressal commission, which had held the insurer liable for deficiency in service.
In the order earlier this month, the NCDRC bench of Dr Inder Jit Singh (presiding member) and Dr Sudhir Kumar Jain (judicial member) says, "After careful consideration of all the facts and circumstances of the case we are of the considered view that the state commission has rightly concluded that the death in the present case was on account of initially falling from the tree, which was an accidental event, on account of which the deceased was taken to the hospital, where he died, notwithstanding that the cause of death shown in the death certificate or postmortem report was heart attack. Hence, the claim is covered under the policy. The state commission has given a well-reasoned order, and we do not find any reason to interfere with its findings."
The case concerns the death of Navinbhai Bhikhubhai Karlekar, who was covered under a group care 360 – scheme VI policy issued through Baroda Gujarat Gramin Bank. His wife, Pratibhaben Navinbhai Karlekar, filed the claim after he fell from a mango tree on 10 June 2023, felt restless and was taken to Valsad Kasturba Hospital, where he was declared dead. The sum insured was Rs4 lakh and the policy specifically covered accidental death.
Care Health Insurance repudiated the claim on 13 September 2023, stating that the cause of death was 'cardio-respiratory arrest resulting from myocardial infarction', which it argued amounted to a natural death and not an accident. The insurer relied on the cause-of-death certificate and post-mortem report to substantiate its stand, contending before the fora that a heart attack cannot be considered an accident within the meaning of the policy.
However, both the district commission and the state commission examined the inquest panchnama, witness statements and circumstances surrounding the incident and held that the fall from the tree was an accidental, sudden and unforeseen event triggering the chain of events that led to the insured’s death.
The state commission noted that Mr Karlekar had no prior illness and that the fall, the onset of symptoms and the hospitalisation occurred within a short span, establishing a clear nexus between the accidental fall and the fatal outcome. It also observed that the insurer had not carried out any independent investigation to establish the absence of such a nexus.
NCDRC agreed with these findings, holding that the insurer had failed to prove that the fall was unrelated to the cardiac event. The commission referred to the policy definition of 'accident' as a sudden, unforeseen and involuntary event caused by external, visible and violent means, and noted that a fall from a tree clearly satisfies this criterion. It emphasised that, in the specific factual background, the death must be treated as falling within the policy coverage.
The bench reiterated that the scope of interference in a second appeal under Section 51(2) of the Consumer Protection Act is limited to substantial questions of law and found no reason to disturb the concurrent factual findings of the lower fora. It held that the insurer’s arguments on policy interpretation, exclusion clauses and cause of death did not raise any such substantial question.
Consequently, both second appeals filed by Care Health Insurance were dismissed, along with all pending interlocutory applications. NCDRC’s order confirms that the widow is entitled to the benefits under the accidental death cover of the group insurance policy.
(Second Appeal Nos187/188 of 2025 Date: 7 November 2025)
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