Punjab

Ludhiana

CC/21/302

Shimla Devi - Complainant(s)

Versus

DCB Bank Ltd - Opp.Party(s)

Anand Sabharwal

02 Aug 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                             Consumer Complaint No:302 dated 15.06.2021.                               Date of decision: 02.08.2024.

 

Shimla Devi wife of Late Shri Jiwan Kumar, resident of B-36/1011, Guru Amardass Nagar, Near Lodhi Club, Rajguru Nagar, Near Juneja Bakery, Sunet, Ludhiana.                                                                                                                                                                                          ..…Complainant

                                                Versus

1. DCB Bank Limited, having its Branch Office at: Feroze Gandhi Market, Ferozepur Road, Ludhiana-141001, through its Branch Manager.   
2. DCB Bank Limited, having its Registered Office & Corporate Office at: 6^th Floor, Tower-A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai-400013, through its Managing Director.   
3. ICICI Lombard General Insurance Company Limited, having its Branch Office at: TF 1-5, 3^rd Floor, Kunal Towers, 88, The Mall, Ludhiana-141001, through its Branch Manager.                  
4. ICICI Lombard General Insurance Company Limited, having its Registered & Corporate Office at: ICICI Lombard House, 414, Veer Savarkar Marg, Near Sidhi Vinayaka Temple, Prabhadevi, Mumbai-400025, through its Managing Director.                                                                                                                     …..Opposite parties 

Complaint Under section 35 of the Consumer Protection Act, 2019.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Anand Sabherwal, Advocate.

For OP1 and OP2          :         Exparte.

For OP3 and OP4          :         Sh. Rajeev Abhi, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Shorn of unnecessary details, the facts of the case are that the complainant along with her husband Late Shri Jiwan Kumar took loan from DHFL. In May 2017, the representatives of OP1 and OP2 Bank approached them to get their loan transferred from DHFL to their Bank, upon which the complainant and her husband transferred the loan with OP1 and OP2. The officials of OP1 and OP2 took signatures of the complainant and her husband on blank papers but no loan agreement or any other loan document was provided to them despite their repeated requests. Loan of Rs.25,00,000/- was sanctioned vide loan account No.DRBLLUD00428934 to the complainant and her husband to be repaid in monthly installments of Rs.28,415/- each. The complainant stated that OP1 and OP2 asked her and her husband to get the loan insured from OP3 and OP4 ICICI Lombard General Insurance Company by getting insurance policy towards any untoward incident in future and in case of death of the insured person during the policy period the outstanding loan amount will be adjusted and closed. On the assurance of the OPs, the complainant and her husband agreed to take insurance and the OPs deducted insurance premium of Rs.25,000/- at the time of disbursal of loan. The complainant and her husband regularly paid the loan installments without any default.

                   The complainant further stated that on 26.08.2020, her husband fell from the stairs at home and he was taken to Shree Raghunath Hospital, Aggar Nagar, Ferozepur Road, Ludhiana where he was declared brought dead. The OPs were intimated regarding death of Shri Jiwan Kumar but they did not tell her to get the postmortem conducted nor the hospital authorities told her to get the postmortem conducted. The complainant approached the OPs and filed her claim for insurance amount by providing all the required documents. Then the complainant shocked to know that the OPs have insured the amount of Rs.8,89,350/- in policy No.4005/M/DCB/131947102/00/000 instead of total amount of Rs.25,00,000/-. Moreover, the OPs adjusted Rs.7057/- out of Rs.25,000/- premium deducted from their account towards another policy No.4013/H/DCB/131953468/00/000 with regard to burglary, fire and special perils and earthquake without consent of the complainant and her husband. The complainant further stated that when she enquired from the officials of the OPs they threatened her and her family members to reject their claim. Vide letter dated 22.11.2020, OP3 and OP4 rejected the claim of the complainant on the false and frivolous ground that “on verification of the claim documents, it is evident that ate Jiwan Kumar expired due to medical illness. On further verification, there is no evidence of accidental injuries involved leading to the death of the insured.” However, Sh. Jiwan Kumar died due to fall from stairs in his house and all the documents and proofs were provided to them. The complainant approached the local office of the OPs number of times with request to reimburse the amount and to adjust the sum assured amount towards the outstanding loan amount but they dilly delayed the matter on one pretext or the other. Even the officials of OP1 and OP2 are threatening her to pay the loan amount and in case of failure on the part of the complainant to take possession of the mortgaged property forcible and illegally. The complainant sent legal notice dated 13.01.2021 upon the OPs to which OP1 and OP2 sent a false and frivolous reply. Hence this complaint, whereby the complainant has prayed for issuing direction to the OPs to pay the amount of policy Rs.25,00,000/- and to adjust the total outstanding loan account and also to pay compensation of Rs.1,00,000/- and Rs.11,000/- as litigation expenses.

2.                Notice to OP1 and OP2 sent through registered post was received with report of refusal and as such, OP1 and OP2 were proceeded against exparte vide order dated 04.10.2021.

3.                Upon notice, OP3 and OP4 appeared and filed joint written statement and by taking preliminary objections, assailed the complaint on the ground of its maintainability; the complainant being estopped by her own act and conduct; the complainant not come to the Commission with clean hands; concealment of material facts; lack of jurisdiction; complaint is bad for non-joinder of necessary parties etc. OP3 and OP4 stated that on receipt of the claim, it was duly registered, entertained and processed. The complainant obtained the Group Personal Accident Policy No.4005/M/DCB/131947102/00/000 valid from 12.06.2017 to 11.06.2022 from them. Insurance policy is a contract in itself and the parties are bound by the terms and conditions of the policy. The policy conditions under the head Benefits and Other Extension Table is reproduced

Sr. No.	Policy Condition	Clause(s)
1.	Policy certificate Part I of the schedule, Benefit table; Policy wordings part II of the schedule under General Definitions	The policy covers 'Death resulting from Accident' and 'Permanent Total Disability resulting from accident only.  The term 'Accident' is defined as "A sudden, unforeseen, uncontrollable and unexpected physical event to the insured person caused by external, violent and visible means occurring under the circumstances described in a hazard applicable to that person. It does not include the cumulative result of a series of small incidents.”

 

Further as per policy wording Part II of the Schedule the term “Accident” is defined as “A sudden, unforeseen and undesirable physical event caused by external violent and visible means beyond the control of the insured person.” OP3 and OP4 further stated that the complainant lodged the claim regarding death of Sh. Jiwan Kumar under PA Death Claim of the insurance policy. M/s. JD Health Care Services, Garden Colony, Kharar was appointed to investigate the accident claim of Sh. Jiwan Kumar who made thorough investigation recorded the statements, took the documents and after preparing his report submitted the same with OP3 and OP4. Thereafter, OP3 and OP4 vide letters dated 22.09.2020 followed with reminder dated 10.10.2020, 23.10.2020 and 07.11.2020 called upon the complainant to submit the documents required for processing of the claim, out of which the complainant submitted certain documents but failed to supply the requisite demanded documents with them. OP3 and Op4 further stated that after scrutinizing the documents of claim file and after applying their mind, their officials repudiated the claim as no claim vide letter dated 22.11.2020 on the ground that Shri Jiwan Kumar had died of medical illness and not due to accidental injuries. Even the said fact is mentioned in repudiation letter dated 22.11.2020 with remarks, reproduced as under:-

“On verification of the claim documents, it is evident that late Jiwan Kumar expired due to medical illness. On further verification there is no evidence of accidental injury involved leading to the death of insured”.

 

OP3 and OP4 further stated that the claim does not fall within the ambit of Group Personal Accident Policy and as such, the claim has been rightly repudiated as no claim on legal, valid and enforceable grounds as per terms and conditions of the policy.

                    On merits, OP3 and OP4 reiterated the crux of averments made in the preliminary objections. However, OP3 and OP4 stated that they have not received any amount of Rs.25,000/- either from the deceased Jiwan Kumar or from the complainant or from OP1 and OP2. No policy has been obtained by Jiwan Kumar or complainant or OP1 and OP2 from them whereby the loan repayment is secured any untoward incident. Sh. Jiwan Kumar obtained two insurance policies from OP3 and OP4 i.e. Group Personal Accident Policy No.4005/M/DCM/131947102/00/000 valid from 12.06.2017 to 11.06.2022 with a sum insured of Rs.8,89,350/- for a period of five years commencing from 13.06.2017 on payment of total premium of Rs.17,943/- and second policy i.e. Home Insurance Policy bearing No.401/H/DCB/131953468/00/000 valid from 12.06.2017 to 11.06.2022 on payment of premium of Rs.7,057/- having coverage, which is reproduced as under:-

Sr. No.	Coverage	Sum Insured (Rs.)	Premium
1.	Contents – Burglary	355740	3335.06
2.	Contents – Fire and Special Peril	355740	667.01
3.	Structure – Fire and Special Peril	889350	667.53
4.	Contents – Earthquake	355740	133.4
5.	Structure – Earthquake	889350	333.51

 

OP3 and OP4 further averred that a claim was lodged on account of death of Jiwan Kumar under Group Policy No.4005/M/DCB/131947102/00/000, which was repudiated as no claim vide letter dated 22.11.2020 on the grounds that Jiwan Kumar expired due to medical illness and there was no evidence of accidental injuries involved leading to death of the insured. Further as per both policies, there is no coverage whereby the loan account would be adjusted and the nominee and the legal heirs will not have to pay any outstanding loan amount to OP1 and OP2 or the loan account would  be adjusted and closed from the insurance payment from OP3 and OP4 i.e. one policy is Group Personal Accident Policy whereby only personal accident death is covered and another policy is Home Insurance Policy where fire and special perils is covered. Even the claim was lodged after death of Jiwan Kumar and after his cremation. No documents were provided relating to accidental death of Jiwan Kumar. The policy was issued for the sum insured of Rs.8,89,350/- at the instance of Jiwan Kumar and DCB Bank Ltd. for which premium was paid only qua the accidental death of Shri Jiwan Kumar alone. The repudiation of the claim is in accordance of policy terms and conditions. OP3 and OP4 have denied that there is any deficiency of service and have also prayed for dismissal of the complaint.

4.                In support of her claim, the complainant tendered her affidavit Ex. CA in which she reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 is the copy of repudiation letter dated 22.11.2020, Ex. C2, Ex. C3 is the copy of Risk Assumption Letter dated 13.06.2017, Ex. C4 is the copy of death certificate of Jiwan Kumar, Ex. C5 is the copy of certificate dated 09.09.2020 of Dr. Mohanjeet Kaur of Shree Raghunath Hospital, Ex. C6 is the copy of receipt dated 09.09.2020, Ex. C7 is the copy letter dated 18.12.2020, Ex. C8 is the copy of legal notice dated 13.01.2021, Ex. C9 to Ex. C12 are the copies of postal receipts, Ex. R13 is the copy of reply dated 01.02.2021 to legal notice dated 02.07.2020, Ex. C14 is the copy of Loan Account Detail from 31.05.2017 to 03.06.2021, Ex. C15 is the copy of Aadhar Card of the complainant, Ex. C16 to Ex. C18 are the copies of the receipts and closed the evidence.

5.                On the other hand, counsel for OP3 and OP4 tendered affidavit Ex. RA of Sh. Rohan Mishra, Manager Legal of OP3 and OP4 along with documents Ex. R1 is the copy of Risk Assumption Letter dated 13.06.2017 along with Policy Certificate-Group Personal Accident, Ex. R2 is the copy of General Definitions, Ex. R3 is the copy of Claim Form, Ex. R4 is the copy of loan account statement for 31.05.2017 to 20.10.2020, Ex. R5 is the copy of death certificate of Jiwan Kumar, Ex. R6 is the copy of loan account detail for 31.05.2017 to 28.09.2020, Ex. R7 is the copy of passbook of the complainant, Ex. R8 is the copy of cancelled cheque, Ex. R9 is the copy of letter dated 22.09.2020, Ex. R10 is the copy of reminder letter dated 10.10.2020, Ex. R11 is the copy of reminder letter dated 23.10.2020, Ex. R12 is the copy of letter dated 07.11.2020, Ex. R13 is the copy of repudiation letter dated 22.11.2020, Ex. R14 is the copy of questionnaire for treating doctor and closed the evidence.

6.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written reply along with affidavit and documents produced on record by both the parties.

7.                One Jiwan Kumar, deceased husband of the complainant and the complainant availed loan from DHFL. In May 2017, they opted out from said loan and availed loan facility of Rs.25,00,000/- from OP1 and OP2 bank. They also availed two insurance policies from OP3 and OP4 insurance company. One was “Group Personal Accidental Policy” having validity from 12.06.2017 to 11.06.2022 for a sum insured of Rs.8,89,350/- Ex. C2, C3 = Ex. R1 for a period of five years commencing from 13.06.2017. The another policy known as “Home Loan Insurance policy” extended coverage with regard to burglary, fire and special peril, earthquakes. On 26.08.2020, Jiwan Kumar was declared brought dead by the doctors of Shree Raghunath Hospital, Aggar Nagar, Ludhiana. The complainant preferred the death claim Ex. R3 under Group Personal Accidental policy upon which M/s. JD Health Care Services, Kharar was appointed by OP3 and OP4 to investigate the accidental claim of Sh. Jiwan Kumar. The investigator issued letters dated 22.09.2020 (Ex. R9) followed by reminder dated 10.10.2020 (Ex. R10), reminder dated 23.10.2020 (Ex. R11) and letter dated 07.11.2020 (Ex. R12) calling upon the complainant to submit certain documents but the complainant failed to supply the requisite documents. Finally on 22.11.2020, vide repudiation letter Ex. C1 = Ex. R13, OP3 and OP4 repudiated the claim of the complainant. Operative part of Ex. C1 = Ex. R13 is reproduced as under:-

“Refer the claims documents submitted by you for the above-mentioned claim number. On scrutiny of the documents, we regret to inform you that the claim stands rejected for the following reason(s) as per the policy terms & conditions.

Sr. No.	Policy Condition	Clause(s)
1.	Policy certificate Part I of the schedule, Benefit table; Policy wordings part II of the schedule under General Definitions	The policy covers 'Death resulting from Accident' and 'Permanent Total Disability resulting from accident only.  The term 'Accident' is defined as "A sudden, unforeseen, uncontrollable and unexpected physical event to the insured person caused by external, violent and visible means occurring under the circumstances described in a hazard applicable to that person. It does not include the cumulative result of a series of small incidents.”
Remarks	On verification of the claim documents it is evident that Late Jiwan Kumar expired due to Medical Illness. On further verification there is no evidence of accidental injuries involved leading to death of the insured.

 

8.                Now the point of determination arises whether the death of Jiwan Kumar was due to a bodily injury resulting solely and directly from an accident caused by external, violent and visible means and whether OP3 and OP4 were justified in repudiating the claim?

9.                As per definition of accident as contained in “General Definitions” of Part II of Schedule of Ex. R2, the word “Accident”, “Bodily injury” and “Disease” has been defined as follows:-

“Accident – means a sudden, unforeseen, uncontrollable and unexpected physical event to the insured person caused by external, violent and visible means occurring under the circumstances described in a hazard applicable to that person. It does not include the cumulative result of a series of small incidents.”

“Bodily injury – means an illness or disease proximately ceased by accident but it excludes disease from natural causes.”

“Disease – means an illness or affliction of the body having a defined and recognized pattern of symptom(s) which causes more than temporary indisposition and which illness or affliction first manifested itself and was contracted under the circumstances described in a Hazard.”

 

Conjoint reading of the aforesaid definitions would make it crystal clear that insured must suffer some bodily injury resulting solely and directly from the accident which should be sudden, unforeseen and involuntary event caused by sudden unforeseen and violent means. But the disease from other natural causes has been excluded.

10.              It is a specific case of the complainant that the deceased Jiwan Kumar fell down from the stairs in the house which resulted in his death and he was declared brought dead by the doctors of Shree Raghunath Hospital. The complainant has not mentioned date, time and place when Jiwan Kumar allegedly fell from the stair case. The complaint as well as affidavit is also silent about the facts whether Jiwan Kumar sustained any visible injuries on his person. Further at the time of alleged accident whether any family member or the friend was standing nearby him or rescued him when he allegedly fell. The complainant is not able to disclose how the deceased was shifted to the hospital and by whom. Dr. Mohanjeet Kaur stated to have been attended patient Jiwan Kumar and vide certificate Ex. C5 declared Jiwan Kumar to be brought dead. Even details of injuries sustained by Jiwan Kumar has not been mentioned in the hospital record or certificate. During the investigation of the claim, a questionnaire for treating doctor was presented before Dr. Ramneek Kaur of Shree Raghunath Hospital, Aggar Nagar, Ludhiana. In all, total 15 questions were put to her in order to ascertain factum of accidental death but her responses to the questions were vague and repetitive with the words ‘brought dead’, ‘No’ and ‘NA’. The questionNo.6, 7 and 13 are reproduced as under:-

“6. Dear Sir, whether final diagnosis is due to any medical illness or due to any trauma?

Ans. NO.

7. Dear sir, was there any History of accident/trauma noted in insured?

Ans. NO.

13. Dear sir, kindly confirm whether insured died due to medical ailment.

Ans. NA.”

From the perusal of the answers, it is clear that no postmortem was got conducted nor the police was informed regarding alleged accident. So it cannot be concluded that Jiwan Kumar died due to accidental death case.

11.              In this regard, reference can be made to Smt. Alka Shukla Vs Life Insurance Corporation of India (2019) 6 SCC 64 whereby the Hon’ble Supreme Court of India in para No.12 of its judgment has made the following observations:-

“12. In the present case, there is no evidence to show that any bodily injuries were suffered due to the fall from the motorcycle or that they led to the assured suffering a heart attack. There is no evidence to show that the accident took place as a result of any outward, violent and visible means. The assured died as a result of heart attack which was not attributable to the accident.”

Further the Hon’ble Supreme Court of India in its recent judgment dated 08.02.2023 passed in Civil Appeal No.4769 of 2022 in National Insurance Company Ltd. Vs The Chief Electoral Officer & Others 2023 LiveLaw (SC) 90 has made the following observations:-

“Insurance Law – Accidental death – Death due to sun stroke during election duty will not come under the scope of the clause “death only resulting solely and directly from accident caused by external violent and any other visible means” – proximate casual relationship between the accident and the body injury is a necessity – plain reading of the clauses is the guiding to interpret insurance contracts.”

So by applying ratio of the above said citations and keeping in view the facts and circumstances of the case, it is crystal clear that OP3 and OP4 were justified in repudiating the claim of the complainant. As such the complaint is not maintainable and the same deserves dismissal.

12.              As a result of above discussion, the complaint is hereby dismissed being devoid of any merits. 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.      

13.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)                                (Sanjeev Batra)

Member                                                President         

 

Announced in Open Commission.

Dated:02.08.2024.

Gobind Ram.