Date of filing:- 21/06/2021.

Date of Order:-27/05/2024.

DISTRICT CONSUMER DISPUTE REDRESSAL COMMISSION

B A R G A R H (ODISHA).

Consumer Complaint No. 31 of  2021.

            Nibedita Biswal, aged about 38(thirty eight) years, wife of Late Ashok Kumar Biswal, Occupation- House wife, resident of Dang (Behind Rani Sati Temple), Po. Bardol, Ps. Bargarh, Dist. Bargarh.                          .....            ....     .....           Complainant.

-: V e r s u s :-

1. The HDFC ERGO General Insurance Company Limited represented through its Legal Head, 1^st Floor, HDFC House, 165-166 Backbay Reclamation, H.T. Parekh Marg, Churchgate, Mumbai-400020 (Maharastra)
2. The HDFC ERGO General Insurance Company Limited represented through its Legal Manager, 6^th Floor, Leela Business Park, Andheri-Kurla Road, Andheri(E), Mumbai-400059 (Maharastra).
3. The Branch Manager, HDFC ERGO General Insurance Company Limited, 2^nd Floor, Platinum Chamber, Budharaja Marg, Sambalpur, Po. Budharaja, Dist. Sambalpur, Pin-768004 (Odisha).
4. The Branch Manager, HDFC Bank, Bargarh Branch, At- N.H. 6, Bargarh, Po. Bargarh, Dist. Bargarh-768028(Odisha).
5. Amit Kumar Sahu, aged about 40(forty) years, Consultant (DSA), HDFC Bank, Rinda Complex, Old N.H. 6, In front of Super Market, Bargarh, Po. Bargarh, Dist. Bargarh-768028 (Odisha).                 .....            .....       .....   Opposite Parties.

Counsel for the Parties:-

For the Complainant :-            Sri M.K.Ratha, Advocate with associates.

For the Opposite Party No.1(one),     

No. 2(two) and No.3(three) :- Sri A.K.Dash, Advocate with associates.

For the Opposite Party No.4(four)

and No.5(five)                         :-          Ex-parte.

                                                            -: P  R  E  S  E  N  T :-

Smt. Jigeesha Mishra               .....       .....       .....       .....       .....       P r e s i d e n t.

Smt. Anju Agrawal             .....            .....       .....       .....       .....       M e m b e r (W).

Dt.27/05/2024.                                 -: J   U  D   G  E  M  E  N  T:-

Presented by Smt. Anju Agrawal, Member(w):-   

1)         The case of the Complainant is that the Complainant's deceased husband had purchased a Maruti Suzuki Swift Dzire ZDI car bearing Regd. No.OD-02-BC-0628, Engine No. D13A-3470867 and Chassis No. MA3CZF03SKB490143 in the year 2019 and the aforesaid vehicle was financed by Opposite Party No.4(four) under loan Account No. 66568267, the EMI was of ₹17,985/-(Rupees seventeen thousand nine hundred eighty five)only per month. The Opposite Party No.1(one) is the HDFC ERGO General Insurance Company Limited, Opposite Party No.2(two) is the customer service provider of Opposite Party No.1(one) and Opposite Party No.3(three) is the Branch Office of Opposite Party No.1(one). The Complainant's husband has insured with Opposite Party No.1(one) under “Sarva Suraksha Policy” vide Policy No. 2950 2027 2002 2000 000, the period was from Dt.29-03-2019 to 28-03-2024 and key feature and benefit of the plan is that in the event of death due to illness the full sum assured to be paid to the nominee of the policy holder. The Complainant further admitted that the nominee due to typographical error has been mentioned “Ninedita Biswal” instead of “Nibedita Biswal”. On dt.01-11-2020, the husband of the Complainant died due to illness (Covid-19) at Sum Hospital, Bhubaneswar, Khordha and as per terms and conditions of the policy on dt.03-12-2020, the Complainant being nominee claimed for death and other benefits under claim No. RP-PA20-12160406 before Opposite Party No.2(two) with the help of Opposite Party No.5(five) along with relevant documents. Finally on Dt. 03-12-2020 the Opposite Party No.2(two) asked for some additional documents and on Dt. 11-02-2021, the Opposite Party No.2(two) repudiated the claim of the Complainant with the reason that “the claim for Accidental Death does not meet the requirements for its eligibility as per Policy terms and conditions”. In spite of all efforts the Opposite Parties repudiated the claim which amounts to deficiency in service on the part of Opposite Parties for which the Complainant filed this complaint before this Commission praying that the Opposite Party No.3(three) be directed to pay death benefit of worth ₹5,00,000/-(Rupees five lakh)only with interest accrued and ₹1,00,000/-(Rupees one lakh)only towards compensation and waive out the EMIs including interest accrued and other charges calculated.

2)         The case of the Opposite Parties are that the Opposite Party No.1(one), No.2(two) and No.3(three) have jointly filed their version and submitted that in the present complaint it is admitted fact that the insured was diagnosed as “Covid-19 Positive” and died due to the complications of Covid-19. Hence, the death is not accidental in nature. As the said ailment (Covid-19) is not within the purview of the coverages under critical illness coverage, the sum insured under Critical Illness is not payable to the Complainant. The insured died due to Covid-19 and not under accident as the “The term “Accident” or “Accident” means a sudden unforeseen and involuntary event caused by external, visible and violent means. The Opposite Parties have cited three number of decision (1) Saroj Juneja Vrs National Insurance Company Limited, State Consumer Redressal Commission, West Bengal, S.C.Case No. FA/516/2009 (2) New India Assurance Co. Ltd Vrs Kamal Nayan, National Consumer Disputes Redressal Commission, New Delhi, Appeal No. 81 and 201 of 1999 Decided on 27-01-2006 (3) Jagadam Bhairava Murthy Vrs Oriental Insurance Co. Ltd., National Consumer Disputes Redressal Commission, New Delhi Decided on 24-08-2007 in favour of their case. There lies no deficiency in service on the part of the Opposite Parties the complaint to be dismissed against the Opposite Parties.

3)         The case of the Opposite Party No.4(four) and No.5(five) are that both the Opposite Party No.4(four) and No.5(five) did not appear before this Commission, hence, Opposite Party No.4(four) and No.5(five) are set ex-parte.

4)         Perused the documents filed by the Parties and following issues are framed.

Issues

1. Whether the Opposite Parties are deficient in their service ?
2. What relief the Complainant is entitled for ?         

Issue No.1(one)

5)         It is an admitted fact that the Complainant's husband was admitted at the Sum Hospital for Covid-19 and the Complainant's husband died on 29-10-2020. As per the policy terms and conditions the insured was duly covered under the “Critical Illness” but in the category of Critical Illness “Covid-19” is not included.  In the handbook of clinical  neurology 2021, “Critical Illness” is defined as any life threatening condition that required pharmacological or mechanical support of vital organ function without which death would be imminent.

            Covid-19 pandemic has a tremendous impact on global health, where all the world has come to a stand still. The Complainant's husband was also effected with Covid-19 and unfortunately be died. The Opposite Party No.2(two) have repudiated the claim that the “Accident Death” does not come under the terms and conditions of the policy. The circumstances during the Covid-19 clearly reflects about the situation people faced and the loss accured therefrom. As the policy was valid the Complainant's claim repudiation was not just and proper accordingly the Opposite Party No.1(one), No.2(two) and No.3(three) are deficient in its service by not settling the insurance claim and Complainant got harassed. For the deficiency in service by the Opposite Party No.1(one) , No.2(two) and No.3(three) the Opposite Party No.4(four) and No.5(five) can not be liable.

            The issue is answered accordingly.  

Issue No.2(two)

6)           As per supra discussion, the Complainant is entitled for relief claimed.

                        Accordingly the order is passed.

                                                            O  R  D  E  R

7)         The Complaint is allowed on contest against Opposite Party No.1(one), Opposite Party No.2(two) and Opposite Party No.3(three) and dismissed ex-parte against Opposite Party No.4(four) and No.5(five). The Opposite Party No.1(one), No.2(two) and  No.3(three) are  jointly and severally directed to settle the insurance claim vide Claim No. RP-PA20-12160406 vide Policy No.  2950 2027 2002 2000 000 and pay ₹ 5,00,000/-(Rupees five lakh)only along with ₹40,000/-(Rupees forty thousand)only for deficiency in service and ₹10,000/-(Rupees ten thousand)only towards litigation expenses to the Complainant within one month of this Order. Failing which the entire order shall carry 12%(twelve percent) interest per annum till realization.

8)         Accordingly the order is pronounced in the open Commission to-day i.e.  Dt.27/05/2024 and the case is allowed against the Opposite Party No.1(one), Opposite Party No.2(two) and Opposite Party No.3(three) and disposed off.

                                                                                             Typed to my dictation

                                                                                              and corrected by me.

                                    I agree,                                               ( Smt. Anju Agrawal)

                                                                                                     M e m b e r(w).

                       (Smt. Jigeesha Mishra)

                              P r e s i d e n t.