Haryana

StateCommission

A/658/2016

HDFC ERGO GEN.INSURANCE CO. - Complainant(s)

Versus

BABITA BANSAL - Opp.Party(s)

INDERJIT SIN

03 Jan 2017

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeal No  :    658 of 2016

Date of Institution:    18.07.2016

Date of Decision :     03.01.2017

 

HDFC ERGO General Insurance Company Limited, 6^th Floor, Leela Business Parte, Andheri Kurla Road, Andheri, Mumbai through its authorised signatory Pankaj Kumar, Manager Legal, available at Stellar IT Park, Tower-1, 5^th Floor, C-25, Sector-62, Noida-201301 (UP).

                                      Appellant-Opposite Party No.2

Versus

 

1.      Smt. Babita Bansal wife of late Anil Bansal, Resident of 3/66, Gali No.2, Barahi Road, near Hanuman Mandir, Bahadurgarh, Tehsil Bahadurgarh, District Jhajjar.

Respondent-Complainant

2.      HDFC Bank Limited, Shyam Ji Complex, Bahadurgarh, Tehsil Bahadurgarh, District Jhajjar, through authorised person.

                                      Respondent-Opposite Party No.1

 

CORAM:             Hon’ble Mr. Justice Nawab Singh, President.

                             Shri B.M. Bedi, Judicial Member.

                             Shri Diwan Singh Chauhan, Member   

 

Argued by:          Shri Inderjit Singh, Advocate for appellant.

                             Shri Saurabh Dalal, Advocate for respondent No.1.

                             Shri Sunil Narang, Advocate for respondent No.2.

 

                                                   O R D E R

 

B.M. BEDI, JUDICIAL MEMBER

 

          HDFC ERGO General Insurance Company Limited–Opposite Party No.2, is in appeal against the order dated May 31^st, 2016 passed by District Consumer Disputes Redressal Forum, Jhajjar (for short ‘the District Forum’) whereby complaint filed by Babita Bansal-complainant (respondent No.1 herein) seeking insurance benefits with respect to the insurance policy obtained by her husband-Anil Kumar Bansal (hereinafter referred to as ‘the insured’) was accepted and the Insurance Company was directed as under:-

“……it is observed that there is deficiency in service on the part of the respondent No.2 who did not make the payment of genuine claim to the complainant. Therefore, it is directed that the respondent No.2 insurance company shall make the payment of a sum of Rs.1,00,000/- to the complainant for critical illness, Rs.5,00,000/- for credit shield insurance benefits on account of death of her husband namely Mr. Anil Kumar Bansal insured under policy in question which is Ex.P-4 along with an interest @ 9% p.a. from the date of death of Anil Kumar Bansal i.e. 26.4.2014 till realization of final payment to the complainant. The complainant is also entitled for a sum of Rs.5500/- on account of litigation expenses for the present unwanted and unwarranted litigation only due to the deficiency in service on the part of the respondent No.2. The complaint stands disposed of accordingly.”

 

2.                Anil Kumar Bansal (since deceased) was owner of car bearing registration No.HR-13G-9398. The car was insured with Royal Sundaram Alliance Insurance Company Limited vide Insurance Policy Exhibit R-6. The car was purchased by its owner after raising loan from HDFC Bank Limited-Opposite Party No.1, so in order to secure the loan amount, HDFC Bank got the owner insured with HDFC ERGO General Insurance Company Limited (for short ‘the Insurance Company’)–Opposite Party No.2, vide Sarv Suraksha Policy (Exhibit P-4) for the period May 2^nd, 2013 to May 1^st, 2018. The details with respect to the coverage and benefits of the policy are as under:-

Sr.No.	Loss of Job (3 EM)	Premium	Sum Assured
1.	Loss of Job (3EM)	473	1,00,000
2.	Accidental Death	547	5,00,000
3.	Permanent Total Disability/Permanent Partial Disability	729	5,00,000
4.	Accidental Hospitalization	365	1,00,000
5.	Critical illness	1276	1,00,000
6.	Credit Shield Insurance	912	5,00,000
7.	Garage Cash	821	3,50,000
8.	Householders Coverage	607	1,50,000

 

3.                During the subsistence of the policy, the insured fell ill and died on 26^th April, 2014 due to critical illness. Claim being filed, the Insurance Company vide letter dated 27^th June, 2014 (Exhibit R-16) repudiated stating therein as under:-

“As per the case summary received, late Mr. Anil Kumar Bansal started having complaints of Fever, Anorexia and Sweating on 09.04.2014 and he expired on 26.04.2014.  

For Critical illness to be admissible under our Policy, the insured person has to survive a period of 30 days from the time he was diagnosed for illness. The said condition is not fulfilled in the current case because of which, the claim is being repudiated.

SPECIFIC EXCLUSIONS APPLICABLE TO SECTION 1

If the Insured Person named in the schedule is diagnosed as suffering from a Critical illness which first occurs or manifests itself during the Policy Period, and the insured survives for a minimum of 30 days from the date of diagnosis, the Company shall pay the Critical Illness Benefit.

Since the losses Claimed under Critical Illness are not covered as per above policy wording, we treat the claim as “No Claim”.

4.                Alleging it a case of deficiency in service on the part of the Insurance Company, the complainant filed complaint under Section 12 of the Consumer Protection Act, 1986.

5.                The Opposite Parties No.1 and 2 contested the complaint by filing their respective written submissions. The Opposite Party No.1 – HDFC Bank in its written submission took the plea that the complainant had not informed the bank with respect to the death of her husband. Thus, the opposite party No.1 denied any kind of deficiency in service on its part and prayed for dismissal of the complaint.

6.                The Opposite Party No.2 – Insurance Company in its written submission stated that the insured suffered from fever, Anorexia and Sweating on 9^th April, 2014 and died due to critical illness on 26.04.2014. As per Section-1 of the policy, for benefits arising due to critical illness to be admissible under the policy, the insured has to survive for a period of 30 days from the time he was diagnosed for illness. Therefore, the complainant was not entitled for any insurable benefits.

7.                The Opposite Party No.3 did not appear despite service and was proceeded exparte.

8.                The parties led evidence in support of their respective claims. After evaluating the pleadings and evidence of the parties, the District Forum vide impugned order allowed complaint and issued direction to the opposite party No.2-appellant, as detailed in paragraph No.1 of this order.

9.                Learned counsel for the appellant has assailed the order of the District Forum raising plea that the insured died due to critical illness and as per the terms and conditions of the policy, the insured was to survive for a period of 30 days from the time he was diagnosed for illness. Since, the insured did not survive for 30 days from the date he was diagnosed having been suffering from critical illness; therefore, the Insurance Company was not liable to pay any amount to the complainant.

10.              The contention raised is tenable. Undisputedly, the insured purchased the Insurance Policy which commenced from 2^nd May, 2013. It had coverage as per policy (Exhibit P-4) the details of which have been given in paragraph No.2 of this order.

11.              The insured was diagnosed having been suffering from critical illness on 10^th April, 2014 vide report Exhibit P-6 and died on 26^th April, 2014. The coverage for critical illness was available in the event of the insured surviving for a minimum period of 30 days after being diagnosed from critical illness. The critical illness has been defined in Section-1 of the policy as under:-

                   “SECTION 1: CRITICAL ILLNESS

If the Insured Person named in the schedule is diagnosed as suffering from a Critical Illness which first occurs or manifests itself during the Policy Period and the Insured survives for a minimum of 30 days from the date of diagnosis, the Company shall pay the Critical Illness Benefit as shown in the schedule.

CRITICAL ILLNESS COVERAGE

1)      First Heart Attack (Myocardial Infarction)

Diagnosis by a Physician, of the death of a portion of heart muscle, as a result of inadequate blood supply to the relevant area. The diagnosis will be evidenced by all of the following criteria

• History or clinical presentation consistent with the diagnosis of Myocardial Infarction
• New and recent electrocardiographic changes indicating myocardial infarction.
• Elevation of infarction specific enzymes.
• Non-ST segment elevation myocardial infarction (NSTEMI) with elevation of Troponin I or T is excluded. Specific Exclusion. Angina or chest pain.”

 

12.              The details of coverage, exclusions have been given in Section 5 of the policy. The Credit Shield was only available in the event of accidental death or permanent disability and not otherwise. The accident or accidental death has also been clearly defined in Section 5 as under:

“4.     “Accident” or “Accidental” means a sudden unintended and fortuitous external and visible event.”

13.              In view of the above, it is established that the insured did not survive for a period of 30 days from the time he was diagnosed for illness to become eligible for the benefits to the beneficiary and even the Credit Shield coverage was not available as his death was not accidental. Thus, the District Forum fell in error in allowing the complaint and as such the impugned order cannot be allowed to sustain.

14.              As a sequel to the foregoing discussion, the appeal is allowed, the impugned order is set aside and the complaint is dismissed.

15.              The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the appellant against proper receipt and identification in accordance with rules, after the expiry of period of appeal/revision, if any.

 

Announced 03.01.2017

(Diwan Singh Chauhan) Member

(B.M. Bedi) Judicial Member

(Nawab Singh) President

CL