Haryana

Panchkula

CC/133/2017

DURGAWATI DEVI PAL. - Complainant(s)

Versus

HDFC ERGO GEN.INSURANCE COMPANY LTD. - Opp.Party(s)

ANKUSH GUPTA

19 Apr 2018

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,  PANCHKULA.

                                                                  

Consumer Complaint No	:	133 of 2017
Date of Institution	:	7.7.2017
Date of Decision	:	19.4.2018

1. Durgawati Devi Pal wife of Late Sh. Ramdhani Pal, aged 55 years.
2. Amit Pal son of Late Sh. Ramdhani Pal aged about 23 years.
3. Samita Pal daughter of Late Sh. Ramdhani Pal aged about 22 years.
4. Gaurav Pal son of Late Sh. Ramdhani Pal aged about 19 years.

 

All resident of H.No.2154-P-3, Basant Vihar Colony, Kalka, District Panchkula.

                                                                        ….Complainants

Versus

1. HDFC ERGO General Insurance Company Ltd. through its Manager/Authorized Representative having head office at 6^th Floor, Leela Business Park, Andheri Kurla Road, Andheri (East) Mumbai-400059.

 

IInd Address:- Registered Office: Raman House, H.T.Parekh Marg, 169, Backby Reclamation, Mumbai-400020.

 

2. Housing Development Finance Corporation Ltd. (HDFC) through its Manager/Authorized Representative Branch office at Mansa Devi Complex, Panchkula.

 

IInd Address:- Registered Office: Raman House, H.T.Parekh Marg, 169, Backby Reclamation, Mumbai-400020.

 

….Opposite Parties

COMPLAINT UNDER SEC. 12 OF THE CONSUMER PROTECTION ACT, 1986.

 

 

Before:              Mr.Dharam Pal, President.

Mr.Jagmohan Singh, Member.

 

 

For the Parties:   Mr. Ankush Gupta, Advocate for complainant. 

                        Mr. Nitesh Singhi, Advocate for OP No.1.

                        Mrs. Rupali Sherkhar Verma, Advocate for OP No.2.

 

 

ORDER

(Dharam Pal, President)

1.     This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by Durgawati Devi Pal and Others, complainants against HDFC ERGO General Insurance Company Ltd. and another, the opposite parties.

2.     It is stated in the complaint by the complainants that they are legal heirs of Late Sh. Ramdhani Pal son of Sh. Kanta Parsad, who died on 28.6.2015 due to major medical illness & Procedures and all the complainants are the dependant of Late Sh. Ramdhani Pal and have no source of income. Late Sh. Ramdhani Pal taken Home Loan from the OP No.2 for raising construction over the plot 2142/5, House No.2154/PB, Khasra 320/102,337/100, Khatta 1/1, Mouja Kurari, Basant Vihar Colony, Kalka and agreement between Late Sh. Ramdhani Pal and OP No.2 had been executed at Panchkula on 23.5.2013 and Home Loan sanctioned to Late Sh. Ramdhani Pal vide Loan Account No.608319837 and term of repayment of Home Loan was provided to Late Sh. Ramdhani Pal as per schedule. Late Sh. Ramdhani Pal taken Home Suraksha Plus Policy from the OP No.1 through OP No.2 by paying one time premium of Rs. 81,966/- vide which sum of Home Loan Account is insured as per policy and risk is covered. Policy issued to Late Sh. Ramdhani Pal vide policy No.2918200509053300000 dated 27.5.2013. As per policy, complainant was entitled to claim Rs.10,81,990/- and if any miss-happening would be happened to the insured, the OP No.1 is under obligation to pay the insured sum to OP No.2 on behalf of Late Sh. Ramdhani Pal. At the end of life of Late Sh. Ramdhani Pal got his treatment from Civil Hospital Kalka from Dr. Anil Dass from where he was referred to PGI Chandigarh for further treatment and remain admitted till 28.6.2015 and on the same day, he declared naturally death by the doctors due to immediate cause of refractory septic shock and antecedent cause due to pneumonia with septicemia acute kidney injury etc. Thereafter, heirs of complainants intimated about the death of Late Sh. Ramdhani Pal to OPs and also supplied all the documents as per requirement of OPs and lodged the claim. As per requirement submitted documents i.e all hospitalization treatment paper, all medical investigation report, affidavits of all legal heirs and photo identity and address proof of the legal heirs. But, OPs pressurized complainant to pay the premium of Home Loan. Finally, claim of the complainants was repudiated by the OPs in toto manner illegally and arbitrary vide letter dated 19.10.2015. However, repudiation of claim of complainant was totally illegal by wrongly coded by the OP No.2 that these aliments did not fall within the policy purview. It was also wrongly mentioned by OP No.2 that in connivance with OP No.1 that these aliment did not fall within the policy purview and major medical illness and procedure. But OPs rejected the claim of the complainants arbitrary and illegally. Complainant No.1 make her best effort to clear the debts and for these borrow some money from her relatives and paid some Home Loan amount of Rs. 5,01,994/- through cheque bearing No.163345 dated and 16.11.2015 and amount of Rs.4,01,064/- through cheque bearing No.163346 dated 11.1.2016. Complainant was also paying EMI of Home Loan on time of the balance loan amount. As per clause of policy, the OP No.1 liable to assigned the amount to the OP No.2 immediately from the date of death of Late Sh. Ramdhani Pal i.e. 28.6.2016. The complainant No.1 already paid the excessive amount of Rs. 2,15,729/- till May, 2017 to OP No.2. So, the OP No.2 is liable to reimburse the excessive amount with interest to the complainant. The complainant sent legal notice through counsel to both the OPs, but no response.  Hence, this complaint.

3.     Upon notice, OPs No.1 and 2 have appeared and contested the complaint by filing their separate written statement taking preliminary objections. The OP No.1 has stated that the insurance claim under Major Medical Illness and procedure coverage provided to Mr. Ramdhani Pal  by the OP No.1 subject to the terms and conditions of the insurance policy, which was never disputed by the complainant. The OP No.1 scrutinized the documents submitted by the complainant in support of her claim, in which it was found that according to the Medical Certificate cause of death, was not found to be payable, as the same aliment is not covered under the coverage’s mentioned under the Major Medical Illness. The major medical illness and procedures section of this policy covers listed critical illness only. So, the claim of the complainant repudiated as per terms and conditions of the policy. Bare reading of the policy wording clarify that end stage renal means a stage where regular renal dialysis is carried out and in the present case the insured/deceased first suffered from acute renal failure and secondly regular dialysis as required under the policy was not carried out, which was perquisite of the policy. So, the OP No.1 had rightly repudiated the claim. It is a settled principle of law that insurance is a concept based on the principle of good faith and its benefit should be delivered to the person who needs it. The OP No.1 had acted as per the agreed terms and conditions of the insurance policy. The benefits under the policy are subject to the policy terms and conditions and any benefit can-not be given to the complainants, which is over and above the terms and conditions of the policy as the policy was purchased by the policy holder after going through the terms and conditions of the policy and only after being fully satisfied he had submitted the required documents for the issuance of the policy. The OP No.1 had provided each and every information with regard to the policy in question to the insured and all the policy documents, along with the terms and conditions of the policy were sent to the complainant well within time, to which the insured had never objected nor raised any complaint with regard to the policy in question and as such the policy was accepted as it was  by the policy holder. So, the complainants could not raise any objection with regard to the policy in question.

4.     In the written version, the OP No.2 has stated that OP No.2 is an independent entity in law and having no control over the affairs and business operations of OP No.1. The complainant No.1 along with her husband availed a housing loan from the OP No.2 and it was to be repaid as per agreed terms of loan agreement. The complainant was not paying monthly installment regularly and even as on date the account was in default. No cause of action has arisen in favour of the complainant qua the OP No.2. Therefore, in view of the facts and circumstances mentioned above, there is no deficiency in service on the part of answering OPs and as such, the complaint of the complainant is liable to be dismissed with costs. 

5.     The learned counsel for complainant placed on record his affidavit as Annexure C-A along with documents Annexure C-1 to C-17 and thereafter closed the evidence. On the other hand, the learned counsel for OP No.1 has placed on record the affidavits as Annexure R-1/A and R-1/B along with documents Annexure R-1/1 to R-1/9 and has closed the evidence. Learned counsel for OP No.2 has also closed the evidence after tendering the affidavit Annexure R2/A along with document Annexure R2/1.

6.     We have heard learned counsel for both the parties and have gone through the record carefully.

7.     There is no dispute that late Sh. Ramdhani Pal had availed the housing loan of Rs.21,81,990/- on 23.5.2013 from OP No.2 and an agreement was executed in this regard (Annexure C-3). The said housing loan was insured by late Sh. Ramdhani Pal from OP No.1 vide Home Suraksha Plus Policy bearing No. 2918200509053300001 for the period from 27.5.2013 to 26.5.2018 and paid one time premium of Rs. 81,966/-. The ensured amount was Rs.10,81,990/- by the OP No.1 and policy was issued to the deceased on 27.5.2013 (Annexure R1/1). The Home Suraksha Plus Policy provided coverage like:-

        (i) Fire & Allied Perils

        (ii) Burglary & Theft

        (iii) (Major Medical illnesses & Procedures

        (iv) Personal Accident

        (v) Loss of Job.

8.     The copy of Death Certificate (Annexure C-1) shows that he died on 28.6.2015. The deceased Ramdhani Pal suffered from fever on 7.6.2015 for which he got his treatment from Civil Hospital Kalka and thereafter from PGI, Chandigarh. However, on 28.6.2015 Sh. Ramdhani Pal died and the cause of death shown in the Medical Certificate as Refractory Septic Shock and antecedent cause Pneumonia with Septicemia Acute Kidney injury (Annexure C-7). The complainants being the legal heirs of the deceased filed the claim with the OP No.1 and supplied all the necessary documents (Annexure R-1/4). However, the OP No.1 repudiated the claim on 19.10.2015 (Annexure C-9). The contents of said letter are as under:-  

“We refer to the above claim lodged by you and all the documents received at our end for reconsideration. As per the Case Summary received; Late MR RAMDHANI PAL died due to Refactory Septic shock, Pneumonia, Septicemia, and Acute kidney injury. However, these ailments do not fall within the policy purview. Kindly note that Major Medical Illness & Procedures section of this policy covers listed Critical Illness only.

Please refer to diseases covered under Major Medical Illness & Procedure section of policy-

1. Kidney Failure
2. Cancer
3. Multiple Sclerosis
4. Major Organ Transplant
5. Heart Value Replacement
6. Coronary Artery Bypall Graft
7. Stroke
8. Paralysis
9. Myocardial Infarction

 

                Kidney Failure (End Stage Renal Failure)

End stage renal disease presented as chronic irreversible failure of both kidneys to function, as a result of which either regular renal dialysis (hemodialysis or peritoneal dialysis) is ins# tuted or renal transplanta#on is carried out.

Since the losses claimed under Critical illness are not covered as per above policy wording, we treat the claim as “NO Claim”.

In case of any query you may contact our toll free number which is mentioned below.”

9.     On perusal of the case file, it reveals that while issuing the policy in question the OP No.1 issued a letter dated 27.5.2013 (Annexure C-5) sending the insurance policy in question and intimated the deceased that Home Suraksha Plus Policy provides coverage like:-

        (i) Fire & Allied Perils

        (ii) Burglary & Theft

        (iii) (Major Medical illnesses & Procedures

        (iv) Personal Accident

        (v) Loss of Job.

They also sent the policy schedule (Annexure C-6) to the deceased along with the above said letter shows that total sum insured was Rs. 10,81,990/-. Since Sh. Ramdhani Pal died on 28.6.2015. The material question that arises for consideration is whether OP No.1 is liable to make the payment of insured amount.

10.    From the perusal of the Death certificate, deceased died due to Refractory Septic Shock and antecedent cause Pneumonia with Septicemia Acute Kidney injury, which is covered under the policy supplied by the OP No.1 to the deceased. We are unable to agree with the OP No.1 that the claim of the complainant is not covered under the terms and conditions of the policy, which never brought to the notice of the deceased at the time of issuing the insurance policy. However, as per policy Section 3 of Major Medical illness and procedure company’s liability under insured event in relation to insured shall mean any illness, medical event or surgical procedure as specifically defined, whose signs and symptoms first commence more than 90 days after the commencement of period of insurance and shall only include—Kidney failure (end stage renal failure), end stage renal disease presented as chronic irreversible failure of both kidneys as a result of which either regular renal dialysis is instituted or renal transplantation is carried out.

11.    As per medical certificate cause of death is acute kidney injury is also being contributed to cause of death, which is covered under policy as the chances of dialysis and transplantation of kidney could not happen as the deceased died before that stage. The genuine claim of the complainant cannot be repudiated on the technical ground.

12.    From the above, we are of the opinion that the OP No.1 is liable to pay the insured amount. In view of the above, the OPs No.1 is directed as under:-

1. To pay the insured amount to the complainant along with 9% interest per annum from the date of repudiation.  
2. To pay Rs.10,000/- to the complainant towards compensation for mental agony, physical harassment.
3. To pay Rs.5,000/- to the complainant towards cost of litigation.

13.    The complaint qua OP No.2 is dismissed. This order shall be complied with by the OP No.1 within a period of 30 days from the date of receipt of certified copy of the order. A copy of this order be sent to the parties free of costs and file be consigned to record room after due compliance.

Announced

19.4.2018                  JAGMOHAN SINGH                  DHARAM PAL

                                        MEMBER                              PRESIDENT

 

 

Note: Each and every page of this order has been duly signed by me.

 

                                       

                                                DHARAM PAL 

                                                PRESIDENT