BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.498 of 2018
Date of Instt. 06.12.2018
Date of Decision:11.07.2022
Suman Tuli W/o Late Sh. Rajiv Tuli Aged 46 years R/o 44 Kala Singha Road, New Guru Nanak Nagar Sai Colony Basti Guzan, Jalandhar.
..........Complainant
Versus
1. HDFC Bank Branch: Retail Loan Service Centre Plot No.911, First Floor, Near Narinder Cinema, G. T. Road, Jalandhar. Through its Manager.
2. HDFC Ergo General Insurance Company Limited Branch: 3rd Floor Eminent Mall, 261 Lajpat Nagar Near Guru Nanak Mission Chowk, Jalandhar.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Smt. Jyotsna (Member)
Sh. Jaswant Singh Dhillon (Member)
Present: Sh. Robin Budhiraja, Adv. Counsel for the Complainant.
Sh. Sushil Mehta, Adv. Counsel for OP No.1.
Sh. R. K. Sharma, Adv. Counsel for OP No.2
Order
Dr. Harveen Bhardwaj (President)
1. The instant complaint has been filed by the complainant, wherein it is alleged that the complainant has purchased one Maruti Swift Car (PB08-DV-3103) on 14.10.2017 for Rs.6,48,000/- vide Invoice No.007/VSL/17000731. At the time of purchasing of above said vehicle, the husband of the complainant had took a loan of Rs.5,50,000/- for the vehicle vide loan account no.519906335 from OP No.1. At the time of above said loan the OP No.1 had made a general insurance from OP No.2 regarding the life of Sh. Rajiv Tuli now deceased vide policy No.2999201363863001. As per terms of the above said policy in the event of death of the policy holder the loan amount will be paid by OP No.2 to OP No.1. On 28.01.2018 the husband of the complainant felt badly pain in his chest. The family members of deceased took him to NIMS Hospital where he declared to be dead. The complainant has filed claim regarding the death of her husband which has been rejected by OP No.2 through letter dated 03.05.2018. The OP No.2 has wrongly rejected the claim of the complainant on the ground that the death of the complainant is not covered under the policy. The death of the complainant is covered the policy as first heart attack. Now till date the complainant is paying all installment of Rs.8978/- till date due to harassment caused by the OPs because OPs threatened the complainant that they forfeiture the car and took the possession. The OPs have committed great negligence, deficiency and unfair trade practice and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay Rs.5,23,470/- as outstanding till today with any other charges till the decision of case to OP No.1. Further OPs be directed to issue NOC to complainant after payment received from OP No.2 and refund 9 installments of Rs.8978/- total Rs.80,802/- which has been wrongly paid by the complainant after the death of her husband and further OPs be directed to pay Rs.1,00,000/- as compensation and Rs.10,000/- as litigation expenses.
2. Notice of the complaint was given to the OPs and accordingly, OP No.1 appeared through its counsel and filed written reply and contested the complaint by taking preliminary objections that the present complaint is not maintainable as the complainant has suppressed material facts from this Commission and has relied on false documents and has relied on a false version. It is further averred that the present complaint is liable to be dismissed on the sole ground that the complainant is not a consumer. The present complaint has been filed by the complainant is nothing but an abuse of process of law and with an intention to enrich him by raising absolutely unjust and untenable claim and therefore the said complaint deserves to be dismissed on this ground alone. Sh. Rajeev Tuli in the year 2017, approached the HDFC Bank Ltd. Jalandhar and requested for grant of Auto Loan/financial assistance and also gave assurance to the HDFC Bank Ltd that he will abide by the terms and conditions on which loan may be granted by the bank. The HDFC Bank Ltd. Jalandhar in the year 2017 based on the aforesaid assurance given by the Sh. Rajeev Tuli acceded to his request and sanctioned and disbursed a auto loan of Rs.5,66,761/- vide loan account no.51906335. As per the stipulated terms and conditions as envisaged in the said loan agreement, the borrower/Rajeev Tuli was bound to repay the loan amount with interest there upon by way of 84 equated monthly installments of Rs.8978/- as per the schedule of payment mutually agreed at the time of execution of the loan agreement. Further, the borrower was bound to pay in addition of the aforesaid equated monthly installments, overdue interest & other charges. On merits, the factum with regard to taking loan for vehicle by the husband of the complainant is admitted, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
3. OP No.2 filed its separate written reply and contested the complaint by taking preliminary objections that the complaint is not maintainable against the answering OP and as such, the same is liable to be dismissed. It is further averred that the present complaint pertains to insurance claim under Sarv Suraksha Policy having policy no.2950 2019 5920 7300 000 which is valid from 23.10.2017 to 22.10.2022. the liability of the OP is always subject to the terms and conditions of the policy which was duly supplied to the deceased insured and never been disputed. As alleged in the complaint, the deceased insured suffered chest pain on 28.01.2018. The complainant has alleged that the insured died on the way to the hospital and was brought dead at NIMS Hospital. After the death of the insured, the applicant lodged a claim with the OP seeking benefits under Critical section of the policy. After lodging the claim, the OP company sent a letter dated 16.10.2017 to the complainant and requested him to send the requisite documents as mentioned in the letter. After going through the certificate issued by NIMS Hospital and others documents as submitted by the applicant it was found that the insured was declared brought dead at NIMS Hospital. It is further averred that the complainant has mentioned Heart Attack in the claim form while lodging the claim with the answering OP. It is further clarified that as per the policy, only first heart attack of specified severity is covered which includes Myocardial Infaraction and which can be ascertained only through the medical practitioner through given criteria. On merits, the factum with regard to issuance of insurance policy Sarav Suraksha in the name of Rajeev Tuli for the period 23.10.2017 to 22.10.2022 subject to terms and conditions of the insurance policy is admitted, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
4. Rejoinder not filed.
5. In order to prove their respective versions, both the parties have produced on the file their respective evidence.
6. We have heard the learned counsel for the respective parties and have also gone through the case file very minutely.
7. The husband of the complainant purchased a Maruti Swift Car for Rs.6,48,000/- as per Ex.C-1 and copy of the RC is Ex.C-5. It is admitted fact that the husband of the complainant took a loan of Rs.5,50,000/- for the vehicle from the OP No.1, vide Ex.C-2 and Ex.C-3. He had also taken a general insurance from OP No.2 regarding his life, vide Ex.C-7/OP2/1. The contention of the complainant is that on 28.01.2018, the husband of the complainant felt badly pain in his chest and when he was taken to NIMS Hospital, he was declared dead and the death certificate has been proved as Ex.C-4. It has been alleged by the complainant that when the claim form was furnished by the complainant to the OPs, the same was repudiated, vide Ex.C-6. The claim of the complainant has been rejected and repudiated on flimsy grounds. He has referred the law laid down by the Hon’ble Supreme Court, vide which the Hon’ble Supreme Court has observed that the insurance companies are refusing the claims in many cases on flimsy grounds. He has also referred the law laid down by the Hon’ble Rajasthan State Commission, in 2008(54) R. C. R. (Civil) 398 and the law laid down by the Hon’ble Supreme Court, in a case titled as “Manmohan Nanda Vs. United India Assurance Co. Ltd. & Anr.” and submitted that the Hon’ble Supreme Court has held that where there is any ambiguity in the contract of insurance or doubt, it has to be construed contra proferentem against the insurance company.
8. The OPs on the other hand have admitted that the husband of the complainant took the loan for Auto/Two Wheeler, vide Ex.O-1. Auto loan was also signed between the parties vide Ex.O-2 and the general insurance Ex.OP2/1/C-7 has also been admitted. The complaint has been contested on the ground that the claim furnished by the complainant is not covered under the policy got by the husband of the complainant. He has referred the certificate issued by the NIMS Hospital Ex.OP2/3. Perusal of this certificate shows that the doctor has certified that on 28.01.2018 at 02:00 PM patient Rajeev Tuli was having no pulse and BP with Pupils B/L fixed and Dilated & Declared Dead same time at 02:00 PM. The further contention of the counsel for the OPs is that the complainant has filled the claim form under the critical illness and the critical illness does not cover the person brought dead and as per the terms and conditions of the insurance company, the first heart attack of specified severity is included for the claim and hence this claim is not covered.
9. The bench of Hon’ble Justice M. R. Shah and Hon’ble Justice B. V. Nagarathna of Hon’ble Supreme Court in case titled as “Gurmail Singh Vs. Branch Manager, National Insurance Company” has held that the insurance companies are refusing the claims on flimsy grounds and they should not be too technical while settling the claims and ask for the documents that the insured is not in a position to produce due to circumstances beyond his control. In the present case, the OPs are claiming the certificate of critical illness, but there is no such document on the record nor could the complainant get the certificate from the doctor as he was never admitted in any hospital. Now the point to be considered is as to whether the case of the complainant is concerned under critical illness as the first heart attack with specified severity under the insurance cover or not. Perusal of the insurance policy of the husband of the complainant shows that the policy covers 8 conditions as per Ex.C-7, which are as under:-
1. Loss of Job (3 EMI)
2. Accidental Death
3. Permanent Total Disability/Permanent Partial Disability
4. Accidental Hospitalization
5. Critical Illness
6. Credit Shield Insurance
7. Garage Cash
8. Householders Coverage
The complainant has furnished the claim form, vide Ex.OP2/2 under the head of Critical Illness. The critical illness covers heat attack. Heart Attack means, the first occurrence of myocardial infarction, which means the death of a portion of the heart muscle as a result of inadequate blood supply to the relevant area. The diagnosis for this will be evidenced by all of the following criteria:
1. A history of typical clinical symptoms consistent with the diagnosis of Acute Myocardial Infarction (for e.g. typical chest pain)
2. New characteristic electrocardiogram changes
3. Evation of infarction specific enzymes, Troponins or other specific biochemical markers.
9. There is no document on the record except the certificate issued by the doctor Ex.OP2/3 and the death certificate Ex.C-4 showing that the husband of the complainant died outside NIMS Hospital. The complainant has alleged that on 28.10.2018, her husband felt badly pain in his chest and when was taken to hospital, he died. Admittedly, there is no certificate of the doctor to the effect that the complainant suffered heart attack due to which he died, but the fact remains that he was not having any disease like heart disease, BP or diabetes as per the pleadings nor the same has been alleged by the OPs nor the same has been alleged by the complainant. The husband of the complainant suffered chest pain and this itself shows that his condition was so critical that he was immediately taken to the hospital and he could not get immediate treatment which was required at home only and this critical condition of the complainant caused his death. This is sufficient to prove that he suffered heart attack and the attack was so severe that he could not survive and could not reach to the hospital for taking even first aid. Though the OP has produced on record the certificate of the doctor, where it has been certified that he was brought dead, but the OP has not produced on record any document to show that he did not die of heart attack nor the OP alleged so. Merely on the ground that he was brought dead to the hospital is not sufficient to reject the claim. The doubt could have been arisen regarding the critical condition of the husband of the complainant, if he had been suffering of any other disease, but this is not the case of the OPs. Since, the husband of the complainant died outside the hospital, therefore it is not within the control or within the reach of the complainant to get any certificate from any doctor to declare that her husband was suffering from critical illness. The OPs have taken the premium and they cannot avoid their liability merely on the ground that since he was brought dead, therefore this ailment is not covered under policy. There is no column or terms and conditions in the policy that the person who was brought dead does not allow the LRs of that deceased person entitled for the claim, therefore the repudiation letter Ex.C-6 is hereby set-aside.
10. In the light of above detailed discussion, the complaint of the complainant is partly allowed and OP No.2 is directed to pay Rs.1,00,000/-, the amount insured for Critical Illness, to the OP No.1 and the OP No.1 shall deduct the amount of insurance from the outstanding amount and to issue NOC to the complainant after clearance of the loan as per rules. Further, OPs are directed to pay a compensation of Rs.10,000/- to the complainant for causing mental tension and harassment and Rs.5000/- as litigation expenses. The entire compliance be made within 45 days from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
10. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jaswant Singh Dhillon Jyotsna Dr. Harveen Bhardwaj
11.07.2022 Member Member President
