BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 339 of 2022
Date of Institution : 11.05.2022.
Date of Decision : 24.04.2024.
Paramjit Kaur, aged about 53 years wife of late Shri Lakhbir Singh, resident of village Nakora, Tehsil Rania, District Sirsa (Haryana).
……Complainant.
Versus.
1. HDFC Ergo General Insurance Company Ltd. 6th Floor, Leela Business Park, Andheri Kurla Road, Andheri (East), Mumbai- 400059, through its Officer Incharge/ authorized signatory.
2. HDFC Ergo General Insurance Company Ltd., 5th Floor, Tower-1, Steller IT Park, C-25, Sector 62, Noida (UP)- 201304, through its Officer Incharge/ authorized signatory.
3. Branch Manager/ Officer Incharge, HDFC Ergo General Insurance Company Ltd. Branch Office at Wason Complex, Subhash Colony, near Railway Line, Dabwali Road, Sirsa, District Sirsa.
4. HDFC Bank, Home Loans, Royal Diamond Complex, shop no. 265 A Ist Floor, Opposite LIC Building, Sirsa, Tehsil and District Sirsa, through its Officer Incharge/ authorized signatory.
...…Opposite parties.
Complaint under Section 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR …………PRESIDENT
MRS.SUKHDEEP KAUR………………MEMBER.
Present: Sh. Sandeep Kumar, Advocate for complainant.
Sh. H.S. Raghav, Advocate for opposite parties no.1 to 3.
Sh. Sandeep Chaudhary, Advocate for opposite party no.4.
ORDER
The present complaint has been filed by complainant under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred as OPs).
2. In brief, the case of the complainant is that husband of complainant namely Shri Lakhbir Singh son of Shri Sardul Singh had applied for Home Loan from the HDFC Bank and accordingly his request/ application was accepted and Bank approved and sanctioned Home Equity Loan to the tune of Rs.17,00,000/- at the interest rate of @9.90% on variable rate basis and it was to be paid within 15 years in 180 monthly installments. That as per terms and conditions of the loan, the husband of complainant (loanee) had to get himself insured with the aforesaid insurance company for safe return of the loan amount alongwith interest thereon. Accordingly the said loanee had purchased one health insurance policy from the ops no.1 to 3 vide policy No. 2999202171784400000 valid for the period from 30.10.2018 to 29.10.2023 with certificate no. 2918202748615900 covering Major Medical Illness and procedures for the sum insured of Rs.18,11,833/- against total premium of Rs.1,11,831/-. The complainant is the wife and nominee of the above insured Lakhbir Singh. It is further averred that husband of complainant paid the premium amount and at that time, the ops’ company had got conducted the medical examination of her husband and after fully satisfying with his health, they had issued the insurance policy. That after some time of issuance of above said policy, the husband of complainant was tested positive for MND/ paralysis disease and he took treatment from Aadhar Health Hospital, Hisar where he remained admitted from 13.08.2021 to 17.08.2021 and he also got treatment from Jindal Hospital, Hisar and PGI Hospital, Chandigarh, however, ultimately after long and best treatment from the higher Institutes, he died on 15.11.2021 due to above said disease. The complainant gave intimation about death of her husband to ops no.3 and 4 and on their asking submitted claim alongwith required documents to the op no.2 which sent the papers/ case to op no.1 but company repudiated her claim vide letter dated 01.02.2022 alleging therein that claim is not admissible and losses not payable and claim was closed as No Claim and it was mentioned that as per documents submitted, insured suffered from motor neuron disease, paralysis since 2016 before the first inception of the policy (30.10.2018) and insured had not disclosed the ailment while purchasing the policy and there is non disclosure of material facts. It is further submitted that even as per the insurance policy, the medical problems with its details i.e. major medical illness and procedures, personal accident, accidental death, permanent total disablement, dependent child education benefit (maximum two child), loss of job (No. of EMIs) etc. are covered but the claim has been wrongly and illegally repudiated by the ops’ company. The ops’ company has ignored the fact that before issuing the policy to the insured got conducted medical examination of the insured and after being satisfied with the medical examination the policy was issued to him and nothing was concealed while purchasing the policy. That complainant met the officers/ official of the insurance company and requested them to admit her claim and even got issued a legal notice dated 23.03.2022 to the ops but to no effect. It is further averred that after the death of Lakhwinder Singh, the op no.4 was deducting EMI from his account illegally which is required to be returned to the complainant with interest thereon since the date of unlawful deduction and op no.4 is to be restrained from making future deduction of any amount from the account of her husband. Hence, this complaint seeking direction to the ops no.1 to 3 either to make payment of insurance amount of Rs.18,11,833/- alongwith interest to the complainant or to pay the aforesaid amount to the bank in connection with loan amount and also to pay all other benefits under the policy and to pay an amount of Rs.1,00,000/- as compensation for harassment and litigation expenses.
3. On notice, ops appeared. Ops no.1 to 3 filed written version raising certain preliminary objections that complainant is not entitled to any relief since she has not approached with clean hands and is guilty of concealing material facts and based on non disclosure of material facts at the time of availing the policy, the claim was repudiated by the insurance company. That further it is clearly mentioned on the very page of the policy schedule itself that under Major Medical Illnesses & Procedures Section, following illnesses are covered (i) Cancer (2) End State Renal Failure (3) Multiple Sclerosis, (4) Major Organ Transplant (5) Heart Valve Replacement (6) Coronary Artery Bypass Graft (7) Stroke (8) Paralysis (9) Myocardial Infarction. It is further submitted that present complaint is liable to be dismissed in view of the settled proposition of law that the contracts of insurance are contracts of Uberrima fides – utmost good faith and every material fact must be disclosed, otherwise there is a good ground for recession of the contract. Evidently, the insured had concealed material facts and had falsely stated the fact of his health in the proposal form. That claim has been filed under the Heading “Major Medical Illness and Procedures” which is defined in Section 3 of the terms and conditions and as per the same for the purposes of this Section and the determination of the company’s liability under it, the insured event in relation to the insured, shall mean any illness, medical event or surgical procedure as specifically defined in Section 3 whose signs or symptoms first commence more than 90 days after commencement of period of insurance and shall only include only the medical conditions mentioned in Section 3 of the terms and conditions. It is further submitted that none of the medical conditions for which insured was taking treatment is covered under in Section 3 of the terms and conditions and as such, the claim is also liable to be rejected being not covered under the terms and conditions. That the ailment for which the insured was under treatment are not mentioned in the list of Major Medical Illness under Home Credit Assure Policy and liability of ops is restricted and limited to the policy terms and conditions. It is further submitted that complainant has not submitted any treating doctor’s certificate or medical documents with the answering ops or with this Commission that death of the insured is due to any of the medical illness which are mentioned in Section 3 of Major Medical Illness in the policy and as such complaint deserves dismissal on this ground alone. That as per Section 35 of the policy, the policy shall be void and all premium paid thereon shall be forfeited to the company in the event of misrepresentation, mis description or non disclosure of any material fact by the policy holder. 4. On merits, it is submitted that on 13.12.2021, a claim was received from complainant under the head “Major Medical Illness” which was registered vide claim No. RR-CI21-12753980 and various query letters were sent to the complainant and in reply complainant submitted few of the documents. That the claim was also sent for investigation and during the investigation, it was noted that the treating doctor in the progress notes has confirmed that patient is a known case of HCV related CLD since 2016 and Motor Neuron Disease (MND), paralysis since 2016. It is further submitted that documents were reviewed and it was noted from the progress notes that insured had a history of HCV related CLD since 2016 and Motor Neuron Disease (MND), paralysis since 2016 and hence due to the non disclosure of the HCV related CLD since 2016 and Motor Neuron Disease (MND), paralysis since 2016, the reimbursement claim was rejected. Remaining contents of complaint are also denied and prayer for dismissal of complaint made.
5. Op no.4 also filed written version raising certain preliminary objections regarding maintainability and jurisdiction. It is submitted that grievance of complainant is mainly against the insurance company for settlement of death claim of her deceased husband and not against answering op. That no cause of action has arisen against answering op as complainant being co-borrower alongwith her husband had availed loans from answering op one Home Equity loan and another insurance premium funding. The answering op had sanctioned the loan with pre-condition that the borrowers are required to avail the policy in order to mitigate the risk in lending. It is further submitted that now after the death of the co-borrower, the complainant is trying to avoid her legal liability and answering op being a secured creditor has every right to recover the dues. As on 04.06.2022, a sum of Rs.13,60,619/- in loan account No. 636379845 and Rs.46,998/- in loan account no. 636853297 is outstanding in the loan accounts. It is further submitted that loan accounts are in default as on date and also there is public money involved in form of these loans. Remaining contents of complaint are also denied and prayer for dismissal of complaint qua op no.4 made.
6. The complainant in evidence has tendered her affidavit Ex.C1 and copies of documents Ex. C2 to Ex.C11.
7. On the other hand, op no.4 bank has tendered in evidence copies of documents Ex.R1 to Ex.R17.
8. Ops no.1 to 3 have tendered affidavit of Sh. Vivek Yadav, Senior Manager as Ex.R18 and documents Ex.R19 to Ex.R31.
9. We have heard learned counsel for the parties and have gone through the case file carefully.
10. There is no dispute of the fact that husband of complainant namely Lakhbir Singh availed home loan of the amount of Rs.17,00,000/- from op no.4 bank during his life time and as per policy of the op no.4 bank in order to secure the loan amount, the husband of complainant (loanee) purchased health insurance policy from the ops no.1 to 3 for the period 30.10.2018 to 29.10.2023 covering Major Medical Illness and procedures for the sum insured amount of Rs.18,11,833/-. The amount of Rs.1,11,831/- as one time premium amount was also paid by the husband of the complainant to ops no.1 to 3 and said amount was also got financed by op no.4 and above said facts are also proved from the certificate of insurance Ex.C4 and loan agreement Ex.R2. It is also proved on record that on 15.11.2021 i.e. during the period of above said policy Lakhbir Singh died due to ailment of Paralysis which he suffered on 13.08.2021. According to the complainant as her husband died on 15.11.2021 during the period of policy i.e. 30.10.2018 to 29.10.2023 and as loan amount of Rs.17,00,000/- was secured by ops no.1 to 3 through op no.4 bank as per policy of op no.4 bank by insuring the loanee, therefore, complainant is not liable to pay the remaining loan amount to the op no.4 bank and ops no.1 to 3 are liable to reimburse the loan amount to op no.4. It is proved on record that deceased suffered with the disease of Paralysis as is evident from prescription slip of PGI, Chandigarh placed on record and as per policy documents and even as per written version of ops no.1 to 3, the disease of Paralysis is covered in the policy in question. From the policy certificate Ex.C4, it is evident that for Major Medical Illness and Procedures, the sum insured was Rs.18,11,833/-. However, the ops no.1 to 3 have repudiated the claim of the complainant on the ground that HCV related CLD since 2016 and Motor Neuron Disease (MND), paralysis since 2016 and this fact was not disclosed by the insured at the time of availing insurance policy in question. In this regard, ops have relied upon photostat copy of progress note of Aadhar Hospital (Ex.R30) in which it is mentioned that HCV related CLD since 2016 against the date 14.08.2021. However, the ops have not proved on record that what is the disease of HCV related CLD. The ops have not proved the said document by leading cogent and convincing evidence and have not placed on file any certificate/ affidavit of the doctor or any concerned person that how he has mentioned the above said disease since 2016 and that who told to him that said Lakhbir Singh is suffered from said disease since 2016. Only placing of a photostat copy of progress note is not sufficient to prove that Lakhbir Singh was actually suffering from HCV related to CLD disease since 2016 as in the whole treatment record placed on file, it has come that said Lakhbir Singh suffered from MND/ paralysis in the month of August, 2021 only. Moreover, the husband of the complainant Lakhbir Singh insured, now deceased was got medically examined before issuance of the policy in question by the ops no.1 to 3 and paralysis is not such a disease which can be concealed from the doctors as such disease is itself apparent from the human body and is not concealable disease and as insured was got medically examined before issuance of the policy, therefore, now ops no.1 to 3 cannot take the plea of existing disease or concealment about health status by the insured. Since the death of deceased insured on 15.11.2021 i.e. during the period of policy was due to Major Medical Illness i.e. Paralysis which is covered in the policy and as the loan amount was got secured by op no.4 from ops no.1 to 3 through insurance policy in question, therefore, complainant being nominee of deceased insured is not liable to pay remaining loan amount to the op no.4 and only ops no.1 to 3 are liable to reimburse the remaining loan amount of the insured to the op no.4 bank. As per outstanding loan amount sheet Ex.R4 placed on file by op no.4 bank, as on 04.06.2022 the amount of Rs.13,60,619/- is outstanding against the loanee and this amount is to be paid by ops no.1 to 3 to op no.4 being insurer of the loan amount of the insured. However, it has also come on record that premium amount of Rs.1,11,833/- was also paid to ops no.1 to 3 by op no.4 bank as husband of complainant also availed loan facility in this regard from op no.4 bank and as per statement of account Ex.R5, as on 04.06.2022 an amount of Rs.46,998/- is outstanding towards this loan facility of premium amount, the complainant only is entitled to pay the said amount of Rs.46,998/- to the op no.4 bank.
11. In view of our above discussion, we allow the present complaint and direct the opposite parties no.1 to 3 to pay the balance outstanding loan amount of Rs.13,60,619/- alongwith interest, if any to the op no.4 bank and op no.4 bank is directed not to raise demand of this amount from complainant. We further direct the ops no.1 to 3 to pay a sum of Rs.20,000/- as composite compensation for harassment and litigation expenses to the complainant. However, complainant is directed to pay the above said amount of Rs.46,998/- to the op no.4 bank as early as possible and on payment of this amount, the op no.4 bank will redeem the mortgage deed of the house of the complainant and will hand over the papers/ documents of the house to the complainant and will also issue no dues certificate to the complainant. Further in case it is found that op no.4 bank has deducted any EMI from the account of husband of complainant after his death i.e. 15.11.2021, then op no.4 will adjust the said EMI amounts towards the above said amount of Rs.46,998/- and will make refund of any excess amount to the complainant. The ops no.1 to 3 are directed to comply with this order within a period of 45 days from the date of receipt of copy of this order, failing which further interest of the outstanding loan amount will also be recovered from ops no.1 to 3 whereas compensation amount of Rs.20,000/- will be recoverable with interest @6% per annum from the date of this order till actual payment. The op no.4 bank will also make compliance of this order within above said period of 45 days from the date of receipt of copy of this order. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced: Member President,
Dated:24.04.2024. District Consumer Disputes
Redressal Commission, Sirsa.
