Punjab

StateCommission

A/254/2015

HDFC Ergo General Insurance Company Limited - Complainant(s)

Versus

Gurdeep Kaur - Opp.Party(s)

Sandeep Suri

15 Jul 2016

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB, DAKSHIN MARG, SECTOR 37-A, CHANDIGARH.

 

                                                    First Appeal No.254 of 2015

                                                                                                                         Date of institution :       03.03.2015 

Date of decision    :                15.07.2016

 

1. HDFC Ergo General Insurance Company, Corporate Office 6^th Floor, Leela Business Park, Andheri Kurla Road, ANDHERI (East), Mumbai 400 059 through its MD/Chairman/authorized Signatory.
2. HDFC Ergo General Insurance Company, Branch Office-Basement under HDFC Bank, Kaula Park, Sangrur 148 001 through its Branch Manager/authorized signatory.

                                        …Appellants/Opposite Party No.1 & 2

 

                                               Versus

1. Gurdeep Kaur wife of Late S. Daljit Singh R/o H.No.B/4/548, Nanakpura Mohalla, VPO Chhahar, Near Dhandori Bus Standi, Tehsil Sunam, Distt. Sangrur. 

                                                        ..…Respondent/Complainant.

2. HDFC Bank, Kaula Park, Sangrur 148 001 through its Branch Manager.

                                                  ….Respondent/Opposite Party No.3         

 

First Appeal against the order dated 19.11.2014 passed by the District Consumer Disputes Redressal Forum, Sangrur.

 

         Quorum:-   

  

                         Mrs. Surinder Pal Kaur, Presiding Member.

 

Present:-

 

For the appellants               :        Sh. Sandeep Suri, Advocate

For respondent No.1 :        Sh. Ashok Suri, Advocate

For respondent No.2 :        Sh. Sunil Narang, Advocate

 

 

 

 

MRS. SURINDER PAL KAUR, PRESIDING MEMBER:-                                             

ORDER

 

          The appellant/Opposite Party has filed the present appeal against the order dated 19.11.2014 passed by District Consumer Disputes Redressal Forum, Sangrur (hereinafter referred as “District Forum”) in Consumer Complaint No.347 dated 18.6.2014 vide which complaint of the complainant was allowed and OPs were directed to pay Rs.1 lac as insured amount alongwith interest 9% per annum from the date of filing the present complaint i.e. 18.06.2014 till realization. It was further directed to pay Rs.10,000/-, compensation  for mental tension and harassment and Rs.5500/- as litigation costs. The above said order to be complied within 30 days from the receipt of the   copy of the order. 

2.                As per averments made in the complaint by the complainant, Deceased Life Assured (DLA)   had taken a loan of Rs.2,95,000/- from OP No.3 for purchase of  a second  hand car. OP No.3 insisted him to purchase a policy in order to get the loan at earlier.  Accordingly, under pressure, he purchased the policy in question from OP No.3 in the name and style of HDFC cargo General Insurance Company and the same was having bearing No.295020376626200000.  She is nominee under the policy. The policy in question was also covering the critical illness of the insured to the tune of Rs.1 lac   including accidental hospitalization, accidental death, permanent total disability/ partial disability etc. Policy terms and conditions were not supplied to the insured. However, cover note was issued to him. In the month of July/August 2013, deceased felt some physical problem, therefore, he approached PGI, Chandigarh for medical checkup and was diagnosed to be suffering from critical Kidney disease.  He took treatment from PGI, Chandigarh and also from Sibia Health Care Private Ltd, Sangrur. He got admitted in Sibia Health Care Private Ltd, Sangrur from 25.01.2014 to 28.01.2014.  He was also undergoing Homodialysis in the above said hospital. Unfortunately, he died due to his long and critical illness on 13.02.2014. Thereafter,   complainant being the nominee, immediately informed and submitted all the documents to OP No.2 but it refused to accept the same and suggested her to forward all the documents to OP No.1.  Accordingly, she forwarded all the documents to OP No1 but OPs failed to  release  the  insured  amount rather demanded some more documents vide letter dated 26.03.2014 which were also supplied to them. She also got served a legal notice dated 23.05.2014 to OPs but all in vain.  The above said act of the OPs amounts to deficiency in service; as a result of which she suffered harassment and mental agony. She prayed for issuance of the directions to pay insured amount alongwith interest at the rate of 18% per annum from the date of  death  till realization and also to pay Rs.50,000/-, as compensation for mental tension and harassment and Rs. 22,000/- as litigation costs.

3.                The complaint was contested by the OPs by filing written reply before the District Forum.  While denying the other allegations made in the complaint they pleaded that   policy was issued through OP No 3, on the request of deceased for the period so mentioned in the complaint. Under the policy critical illness was covered to the tune of Rs 1,00,000/-. As per the record of PGIMER, Chandigarh he was patient of Chest Infection since childhood.  He was got admitted in PGI on 07.08.2013 with Chronic Kidney failure stage-V which clearly shows that before getting the policy he was critical ill. Vide letter dated 26.03.2014 complainant was asked to supply other additional documents i.e.

i. First Consultation and investigation records when the symptoms were first noticed. 

ii.      Certify from treating doctor starting the exact duration of the onset of Kidney failure. 

          iii.      Certify from treating doctor starting the exact cause of                death.

 She failed to supply the same and ultimately claim of the complainant was repudiated vide letter dated 28.04.2014 due to non supply of requisite documents. The said documents were very much necessary for ascertaining their liability. No claim is payable of previous ailment under terms and conditions of the policy. She is herself guilty of her own act and conduct for not supplying the requisite documents. There was no deficiency in their service and prayed for dismissal of the complaint with costs of Rs.25,000/-.

4.                The parties produced evidence in support of their respective averments before the District Forum, which after going through the same and hearing learned counsel on their behalf, allowed the complaint, vide aforesaid order.

5.                We have heard learned counsel both the parties and have carefully gone through the record of the District Forum.

6.                It was submitted by the learned counsel for the OPs that the District Forum failed to consider that complainant has failed to supply the documents. History recorded by PGI that DLA was patient of Chest Infection. Four years ago, he was admitted in the hospital for two weeks. Since, he was having health problem and was admitted in PGI on 07.08.2013 with chronic Kidney failure stage-V which clearly shows that before getting the policy he was critically ill.  She instead of proving the necessary documents has filed the present complaint to injure their reputation. He prayed for acceptance of the appeal and set aside the impugned order.  

 7.               On the other hand, it was submitted by the learned counsel for the complainant that DLA was not suffering from any pre-existing disease. Without any proof repudiation of the claim is not justified. Correct findings were recorded by the District Forum. He prayed for dismissal of the appeal.

8.                The complainant proved on record her affidavit Ex.C-1 in which she deposed all the facts stated in the complaint.  She deposed that in the month of July-August 2013 her husband felt some physical problem and after medical examination at PGI, Chandigarh he was diagnosed to be suffering from critical kidney disease. The treatment of her husband was continued at PGI, Chandigarh and when he felt some difficulty to go to Chandigarh then he taking the treatment at Sibia Health Care Pvt. Sangrur and he got admitted there from 25.04.2014 to 28.01.2014.  Unfortunately, her husband died on 13.02.2014 due to his long and critical illness.  He further deposed that on the instructions of OP No.2, she forwarded the papers to OP No.1 but in spite of received the documents OPs had failed to release the policy amount rather demanded some more documents, vide letter dated 26.03.2014, and the documents were supplied by her.  This affidavit was duly rebutted by affidavit of Pankaj Kumar, Authorized Signatory HDFC ERGO, General Insurance Company Ltd., (Ex.OP1-2/1).  He deposed that complainant was failed to submit the documents i.e:-

i.       First Consultation and investigation records when the symptoms were first noticed. 

ii.      Certify from treating doctor starting the exact duration of the onset of Kidney failure. 

iii.     Certify from treating doctor starting the exact cause of      death. 

 The complainant deposed in the affidavit that her husband was diagnosed to be suffering from critical kidney disease and from 07.08.2013 he was under treatment, PGI Chandigarh. After the death of the DLA, she was required to prove the document for proving her claim. Some queries were made from her and for furnishing the documents, which had not been furnished along with claim form but she failed to give the clarification about the queries made from her. She only deposed in her affidavit that all the documents were submitted to OPs. If she submitted all the documents, she should have stated so in the complaint by disclosing on which date she furnished the documents to the opposite parties. As per the Regulations issued by the IRDA, it was supposed to decide the claim within six months. The complainant was to wait for the decision of her claim before proceeding against the insurance company. Moreover, in the absence of demanded documents the OPs was justified to close her claim.  In these circumstances, conclude that the complaint against the OPs is premature and is liable to be dismissed on that ground. 

9.                Accordingly the appeal is allowed the order passed by the District Forum is set aside and complainant is directed to submit the documents within two months from the receipt of the copy of this order, if complainant failed to submit the documents within time than the OPs are directed to settle the claim on the documents which are already submitted by the complainant within one month and in case the complainant feels aggrieved by that decision, she shall have the liberty to file the fresh complaint challenging the same. 

10.              The Appellant/OP had deposited a sum of Rs.25,000/  at the time of filing of the appeal. It further deposited a sum of Rs.48,383/- on 31.03.2015. Both these amounts along with interest which had accrued thereon, if any, shall be remitted by the registry to the appellant/OP No.1  by way of a crossed cheque/ demand draft after the expiry of 45 days of the sending of certified copy of the order to the parties subject to stay if any by any higher Fora/ Court.

11.              The arguments in this appeal were heard on 12.07.2016 and the order was reserve­d. Now, the order be communicated to the parties as per rules.

12.           The appeal could not be decided within the statutory period due to heavy pendency of court cases.

 

   

 

July  15 ,   2016                                       (SURINDER PAL KAUR)

SK                                                            PRESIDING MEMBER