Punjab

Ludhiana

CC/21/292

Paramjit Kaur - Complainant(s)

Versus

Bharti Axa General Ins.Co.Ltd - Opp.Party(s)

Aman Khullar Adv

30 Sep 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 292 dated 03.06.2021.                                                        Date of decision: 30.09.2022. 

 

Paramjit Kaur aged about 31 years wife of Late Sh. Harpal Singh, R/o. H. No.101, Vill. Dolon Khurd, Distt. Ludhiana.                                                                                                                              ..…Complainant

  •  
  1. ICICI Lombard Gen. Insurance Co. Ltd., 4th Floor, Plot No.149, Industrial Area, Phase-I, next to Hometel Hotel, Chandigarh (UT)-160002.
  2. Fullerton India Credit Co. Ltd., SCO-16-17, 5th Floor, Fortune Arcade, Feroze Gandhi Market, Ludhiana, through its Manager/Authorized Representative.

…..Opposite parties 

                   Complaint under Section 35 of the Consumer Protection Act.

QUORUM:

SH. K.K. KAREER, PRESIDENT

SH. JASWINDER SINGH, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Aman Khullar, Advocate.

For OP1                         :         Sh. Rajeev Abhi, Advocate.

For OP2                         :         Sh. Ashok Kumar, Advocate.

 

ORDER

PER K.K. KAREER, PRESIDENT

1.                In brief, the case of the complainant is that her husband Harpal Singh son of Baldev Singh had taken a loan from OP2 to the tune of Rs.1,00,73,925/- vide loan account No.197601310549824. In order to secure the loan amount, OP2 got the loan amount insured to the tune of Rs.35,00,000/-  vide policy No.MPI/14258475/P1/08/007011 which was valid from 30.08.2019 to 29.08.2024. The husband of the complainant paid a sum of Rs.47,412/- as premium of the said policy in which the complainant was made nominee of the insured.

2.                It is further alleged that the husband of the complainant died on 21.08.2020 as he was diagnosed with Covid positive and Pneumonia. After the death of her husband, the complainant lodged the claim with OP1 and provided all the requisite documents for the sanction of the claim.          However, OP1 vide letter dated 22.03.2021 repudiated the claim on the ground that the cause of death mentioned in the death summary was Covid-19 positive and Pneumonia which was not covered under the definition critical illness as per the policy. According to the complainant, when the insurance policy was obtained on 30.08.2019, pandemic Covid-19 was not in existence and it became one of the critical illnesses subsequently. Therefore, the repudiation of the claim is illegal and arbitrary. Non-payment of the claim amounts to deficiency of service on the part of OP1. In the end, it has been requested that the OPs be directed to pay the insurance amount of Rs.35,00,000/- along with interest @18% per annum and the OPs be further made to pay compensation of Rs.5,00,000/-.       

3.                The complaint has been resisted by OPs. In the written filed on behalf of OP1, it has been pleaded that the complaint is not maintainable. According to OP1, on receipt of the claim, it was registered and processed. It has further been pleaded that Harpal Singh had obtained Universal Protection Policy from Bharti Axa General Insurance Co. Ltd. which was valid from 30.08.2019 to 29.08.2014 which covered the critical illness as per plan 5-25CI subject to memoranda clauses, warranties and endorsement attached thereto with sum assured of Rs.35,00,000/-  and personal accident with sum assured of Rs.35,00,000/-. The critical illness cover under the policy i.e. plan 5-25CI  clearly enumerates the illnesses in the policy and death by Covid-19 and Pneumonia         is not specifically covered under the policy. That being so, the claim has been rightly repudiated as on scrutiny of documents, it was found that Harpal Singh was brought to  Guru Nanak Charitable Hospital, Model Town, Ludhiana on 18.11.2020 with complaints of breathing difficulty with known case of Type-II diabetic mellitus for the last 6-7 years and was diagnosed with  Covid-19 and Pneumonia and was also treated for the same. The cause of death was Covid-19 and Pneumonia which is not covered under the critical illnesses defined in the policy. Therefore, the repudiation of the claim is legal and valid being strictly in accordance with the terms and conditions of the policy. The other averments made in the complaint have been denied as wrong and a prayer for dismissal of the complaint has also been made.

4.                In a separate written statement filed on behalf of OP2, it has been pleaded that the complaint is not maintainable as against OP2 as no cause of action has arisen to the complainant to file the complaint against OP2. It has not been disputed that the loan of Rs.1,00,73,925/- was availed from OP1 against mortgage of the property by the complainant and her husband and the complainant was the co-borrower. The complainant was liable to pay a sum of Rs.1,03,20,969.91 as on 09.12.2021 along with future interest. The rest of the averments made in the complaint have been denied as wrong and a prayer for dismissal of the complaint has also been made.

5.                In evidence, the complainant tendered her affidavit as Ex. C1 along with documents Ex. C1 to Ex. C7 and closed the evidence.

6.                On the other hand, the counsel for the OP1 submitted affidavit ex. RA of Sh. Divyam Suri, Manager Legal of OP1 along with documents Ex. R1 to Ex. R18 and closed the evidence. OP2 did not formally evidence but affidavit Ex. RA of Sh. Ajay Kumar Sharma, Attorney of OP2 along with documents Ex. R1 and Ex. R2 are on record.  

7.                We have heard the arguments advanced by the counsel for the parties and have gone through the record.

8.                During the course of arguments, the counsel for the complainant has argued that OP2 had secured the loan to the extent of Rs.35,00,000/- by getting the borrower Harpal Singh insured from OP1 and as per the terms and conditions of the policy, OP1 was liable to pay the assured sum of Rs.35,00,000/- as per the terms and conditions of the policy. However, OP1 has repudiated the claim on false and frivolous grounds. In this regard, the counsel for the complainant has referred to the repudiation letter Ex. C5 dated 22.03.2021 wherein it has been mentioned that as per the death summary issued by Guru Nanak Charitable Hospital, Harpal Singh died of Covid-19 and Pneumonia which is not covered under the critical illness benefit. The counsel for the complainant has further contended that the repudiation of the claim is totally illegal and arbitrary. In this regard, the counsel for the complainant has referred to the instructions/guidelines dated 23.03.2020 issued by the Insurance Regulatory and Development Authority of India (IRDA) whereby the insurance companies have been directed to reimburse the claims of Covid-19 deaths. The counsel for the complainant has further referred to the IRDA instructions dated 04.03.2020 whereby also the insurance companies have been directed that whether the hospitalization is covered in a product, insurers shall ensure that the cases related to Corona virus disease (COVID-19) shall be expeditiously handled. The counsel for the complainant has further referred to another set of instructions dated 30.03.2020 again issued by IRDA whereby also the insurance companies have been asked to process the claims arising out on account of COVID-19 expeditiously. In the light of what has been stated in the aforesaid instructions, the counsel for the complainant has urged that the repudiation of the claim made by OP1 be set aside and the OPs be asked to pay the claim in accordance with the terms and conditions of the policy.

9.                On the other hand, the counsel for OP1 has argued that the claim has been rightly repudiated vide letter Ex. C5. The counsel for OP1 has further contended that as per the terms and conditions of the policy in question, the deceased Harpal Singh had taken a critical illness plan 5-25CI. The counsel for OP2 has further referred to the clause 4.1 of the policy Ex. R1 wherein all the critical illnesses in respect of plan 5-25CI obtained by Harpal Singh are enumerated. According to the counsel for OP1, COVID-19 and Pneumonia does not find mention in the list of critical illnesses mentioned in clause 4.1 of the policy. Therefore, according to the counsel for OP1, the claim has been rightly repudiated as it did not fall within the parameters and four corners of the policy.

10.              WE have weighed the contentions raised by the counsel for the parties and have gone through the record.

11.              As per the evidence available on record, Harpal Singh died of Covid-19 and Pneumonia. In the death summary Ex. R3 issued by Guru Nanak Charitable Hospital, Ludhiana, Harpal Singh was diagnosed with type-II diabetic mellitus, Covid-19 Pneumonia positive. In Ex. R4 also, it is mentioned that Harpal Sigh was a known case of diabetes mellitus for the last 6-7 years and he was admitted with complaint of difficulty in breathing and respiratory distress. Thus, it is evidence from the record that Harpal Singh died of Covid-19 and Pneumonia. As per the terms and conditions of the policy Ex. R18, the policy covered critical illnesses mentioned in clause 4.1. The policy further covered the accidental death, permanent total disability, permanent disability, children education benefit. Since Harpal Singh died of Covid-19 positive and Pneumonia, it has to be seen whether Covid-19 and Pneumonia is covered under definition of critical illnesses given in the clause 4.1 of the policy. A minute perusal of clause 4.1 of the policy terms and conditions reveals that there are as many as 25 critical diseases mentioned but Pneumonia or Covid-19 does not find mention in the list of critical illnesses mentioned in clause 4.1. Therefore, ex-facie it appears that the diseases, which Harpal Singh died of, was not covered under the policy.

12.              We have gone through the IRDA guidelines referred to by the counsel for the complainant whereby the insurance cases were exhorted to deal with and reimburse Covid-19 related claims expeditiously. However, these guidelines or instructions issued by IRDA cannot be read in addition or derogation of the terms and conditions of the insurance policy. Even otherwise, there is no mention in these instructions that Covid-19 or Pneumonia should be treated as critical illness in addition to the other critical illnesses mentioned in the insurance policies. Therefore, on the basis of IRDA instructions dated 23.03.2020, 04.03.2020 and 30.03.2020, it cannot be said that death by Covid-19 or Pneumonia should be treated as death from critical illness. A perusal of the instructions further reveals that by way of these instructions, the insurance companies were simply directed to disburse the medical claims of Covid patients as expeditiously as possible considering the fact that during the Covid period people in general were in distress and were not in position to pay the hospital expenses  due to pandemic conditions.

13.              As a result of above discussion, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

14.              Due to rush of work and spread of COVID-19, the case could not be decided within statutory period.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:30.09.2022.

Gobind Ram.

Paramjit Kaur Vs ICICI Lombard GIC                                     CC/21/292

Present:       Sh. Aman Khullar, Advocate for the complainant.

                    Sh. Rajeev Abhi, Advocate for OP1.

                   Sh. Ashok Kumar, Advocate for OP2.

 

                   Arguments heard. Vide separate detailed order of today, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

 

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:30.09.2022.

Gobind Ram.

 

 

 

 

 

 

 

 

 

 

 

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