Complainant Rajwinder Kaur through the present complaint filed under Section 12 of the Consumer Protection Act, 1986 (for short, ‘the Act’) has prayed that the opposite parties be directed to make the payment of the Insurance Claim to her and they also be burdened with a cost of Rs.5,000/- as litigation expenses. Complainant has also claimed Rs.10,000/- for mental harassment and torture and prayed that opposite parties be directed to pay the same to her in the interest of justice.
- The case of the complainant in brief is that the husband of the complainant namely Surjit Singh deceased was serving as Veterinary Inspector in Animal Husbandry Department at Kapurthala and during his life time he along with his wife i.e. complainant approached the opposite party No.1 for borrowing a personal loan. It is pleaded that at the time of advancement of said loan the employees of the opposite party No.1 told the complainant and her husband that under the said loan scheme which was given to deceased Surjit Singh, his life would also be insured for the sum of Rs.1,00,000/- and the said employees also told to him that policy documents would be provided by the Insurance Company at his address. But during the life time of deceased Surjit Singh said policy documents were not delivered to him at his address and as such the husband of the complainant hired the services of the opposite parties and their consumer. It was further pleaded that unfortunately on 08.05.2015 husband of the complainant died and complainant approached the opposite party No.1 submitted all the required documents with the opposite party but her claim was repudiated by the opposite party No.2 on the ground that as per the case summary which was received by them Late Surjit Singh had a sudden heart attack on 08.05.2015 with no prior related symptoms and he expired on the same day whereas the fact on account of which the claim of the complainant was repudiated did not disclose to the concerned party at any point of time. It was also pleaded that complainant number of times requested the opposite parties to consider her claim but they did not consider the same and finally refused to do so and this act of the opposite parties amounts to deficiency in service. It was next pleaded that the cause of action has arisen to the complainant to file the present complaint on 08.05.2015 when her husband Surjit Singh died and a few days back when opposite parties had refused to pay the insured claim amount to the complainant, hence this complaint.
- Notice of the complaint was served upon the opposite parties who appeared through their counsels. Opposite party No.1 filed their written reply stating therein that it was admitted that opposite party No.1 at the request of Sh.Surjit Singh i.e. husband of the complainant sanctioned to him a loan of Rs.2,10,000/- on 03.11.2014. It was stated that opposite party No.1 is a Banking Company and not an Insurance Company and as such opposite party No.1 is totally separate from opposite party No.2 and no insurance of Surjit Singh was ever done by opposite party No.1 i.e. HDFC Bank. It was further stated that insurance was got done by the husband of the complainant with opposite party No.2 out of his own free will and as such liability to pay the insured amount if any was of opposite party No.2 i.e. Insurance Company only. Opposite party No.l has no concern and no liability in the contract of Insurance entered between the husband of the complainant and opposite party No.2. It was also stated that husband of the complainant was an educated person who got the insurance from opposite party No.2 out of his own free will and fully knew the implications of Insurance. It was next stated that strict onus of proof lies upon the complainant to prove and substantiate her allegations against opposite party No.1. All other averments made in the complaint have been denied and prayed for dismissal of the complaint with costs.
4. Opposite party No.2 also filed their written reply by taking the preliminary objections that complainant has no cause of action to file the present complaint. That the insured deceased was covered under “Sarv Surakasha Policy” which was issued by the opposite party on the request and proposal of the deceased and the said coverage was subject to the terms and conditions of the policy which forms the part and parcel of the policy schedule and the said documents were duly supplied and brought to the knowledge of the deceased. It was stated that said terms and conditions were never disputed by the deceased and claim had been repudiated on the basis of the said terms and conditions of the policy and there was no deficiency in services on the part of the Insurance Company. It was further stated that the claim of the complainant was repudiated vide letter dated 8 October, 2015 and as per the case summary Surjit Singh had a sudden attack on 08.05.2015 and as per the terms and conditions of the policy for critical illness to be admissible under the policy, the insured person had to survive for a period 30 days from the time he was diagnosed for illness. The specific exclusion applicable to section-I. “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 30 days from the date of diagnosis, the company shall pay the critical illness benefit”. As such loss claimed under critical illness were not covered as per policy wording and the claim had been made as “No Claim” and both the parties bound with it and the claim had rightly been repudiated. On merits, it was admitted that deceased was insured under the policy i.e. “Sarv Surakasha Policy” but the claim was repudiated as the same was not covered under the said policy. It was stated that the claim had been filed but the same had been repudiated as Surjit Singh died due to Sudden heart attack on 08.05.2015 which was not covered under Critical Illness Clause of the policy. All other averments made in the complaint have been denied and prayed for dismissal of the complaint with costs.
5. Complainant had tendered into evidence her own affidavit Ex.C-1 along with documents Ex.C2 to Ex.C-5 and closed her evidence.
6. Counsel for the opposite party No.1 had tendered into evidence affidavit of Sh.Hardyal Kohli Officer Ex.OP-1/1 and closed the evidence on behalf of opposite party no.1.
7. Counsel for the opposite party No.2 had tendered into evidence affidavit of Sh.Pankaj Kumar Manager-Legal and authorized signatory Ex.OP-2/1 along with documents Ex.OP-2/2 to Ex.OP-2/11 and closed the evidence on behalf of opposite party no.2.
8. We have carefully examined all the documents/evidence produced on record and have also judiciously considered and perused the arguments duly put forth by the learned counsels along with the incidental scope of adverse inference for some documents that have been somehow ignored to be produced by the contesting litigants. We observe that the prime dispute has prompted from the OP’s claim repudiation of 08.10.2015 (Ex.C3/ Ex.Op2/2) in response to the complainant’s insurance claim (Ex.OP2/3) filed as a result of the sudden death Ex.C4 of the DLA (Deceased Life Assured) on 08.05.2015 in his office, itself; having suffered an acute heart-attack. The prime reason for repudiation as put forth by the OP2 insurers has been that as per the policy terms ‘Critical illness to be admissible under the policy, the insured person has to survive a period of 30 days from the time he was diagnosed for illness; whereas, the DLA Surjit Singh had a sudden Heart Attack on 08.05.2015 with no prior related symptoms and he expired on the same day.’ Further, the OP insurers have duly admitted in the written statement & also in its affidavit (Ex.OP2/1) that the impugned insurance claim Ex.OP2/3 was repudiated in terms of the policy coverage applicable for the benefit of ‘critical-illness’ only implied thereby that the claim was not considered for the other benefits covered under the policy. We find that the OP insurers’ produced document exhibited as: Ex.OP2/6 provides policy coverage and benefits on five number of mentioned counts with ‘critical illness’ at # ‘4’ and also ‘accidental death’ at # 2 along with the other three counts comprised of: Accidental Hospitalization, Permanent Total Disability/Permanent Partial Disability and Credit Shield Insurance at # 1, 3 and 5, respectively. We are of the considered opinion that the DLA’s sudden demise caused by the least unexpected Heart Attack falls under the category ‘2’ of accidental death. The OP insurers have failed to disclose as to what prevented them to consider impugned claim under the prescribed ‘coverage and benefits’ of ‘Accidental Death’ as per the provisions of the policy. The herewith filed-in claim Ex.OP2/3 can surely be optimally considered for settlement under the ‘Accidental Death’ category. Again, Ex.OP2/8 mentions the exactly same category of coverage & benefits but numbered differently for neither any obvious nor any explained logic/reason except to create confusion that duplication and ambiguity usually cause. We deprecate the same. Further, the OP produced Policy Wording (Ex.OP2/11) has defined (as applicable to section 7) ‘Accident or Accidental’ means a sudden, unforeseen and involuntary event caused by external, visible and violent means.’ Also, under Coverage Parts: 2.1 Coverage: Part A: Death; 2.1.1 The company will pay the sum insured in the event of Accidental Bodily Injury causing the insured’s death within 12 months of the accidental bodily injury being sustained, where after this policy shall expire.’
9. To remove all ambiguity, it shall be pertinent here to mention that by the time it has become part of the trite law (by virtue of the apex court judgments duly followed by the other courts) that ‘death’ caused by sudden ‘heart attack’ shall be for all purposes shall be an ‘accidental-death’ with no history of associated ailments. Thus, the complainant here has been entitled for settlement of her ‘insurance claim’ with all the coverage benefits of ‘accidental death’ under the related policy. To sum it up all, the OP insurers have failed to produce any cogent evidence to support the above grounds/basis of repudiation and in its absence these shall amount to ‘bald’ statements, only. Thus, the OP2 insurers’ impugned repudiation of the insurance claim does not entail legality under the applicable law and need be set-aside.
10. In the light of the all above, we partly allow the present complaint and thus ORDER the OP2 insurers to pay the impugned insurance claim under the category of ‘accidental death’ to the complainant besides to pay her Rs.10,000/- as compensation (for the harassment inflicted) and Rs.5,000/- as cost (of litigation) within 30 days of the receipt of the copy of these orders otherwise the aggregate awarded amount shall attract interest @ 9% PA form the date of the orders till actual payment.
11. Copy of the order be communicated to the parties free of charges. File is ordered to be consigned to the record room.
(Naveen Puri)
President.
ANNOUNCED: (Jagdeep Kaur)
MAY 15, 2017 Member.
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