View 4067 Cases Against Hdfc Ergo
Gian Chand filed a consumer case on 02 May 2024 against HDFC Ergo General Ins.Co.Ltd in the Ludhiana Consumer Court. The case no is CC/20/154 and the judgment uploaded on 03 May 2024.
DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.
Complaint No: 154 dated 21.08.2020. Date of decision: 02.05.2024.
Gian Chand @ Gian Chand Gambhir son of Shri Chaudhary Ram, resident of House No.966/3, Street No.5, Harbanspura, Ludhiana. ..…Complainant
Versus
…..Opposite parties
Complaint Under Section 35 of the Consumer Protection Act, 2019.
QUORUM:
SH. SANJEEV BATRA, PRESIDENT
MS. MONIKA BHAGAT, MEMBER
COUNSEL FOR THE PARTIES:
For complainant : Sh. Sunil Sharma, Advocate.
For OP1 and OP2 : Sh. Vyom Bansal, Advocate.
For OP3 and OP4 : Sh. Rahul Rajput, Advocate.
ORDER
PER SANJEEV BATRA, PRESIDENT
1. Briefly stated, the facts of the case are that Deepak Gambhir, son of the complainant checked online to purchase a car on loan. OP1 contacted and induced son of the complainant for having best finance option and on his allurements, son of the complainant got financed from OP1 his purchased car No.PB-09Z-0707 vide loan No.61376206. The said vehicle was also got insured from Liberty General Insurance Limited vide policy No.2011-200501-18-8000257-00-000 from 23.09.2018 to 22.09.2019, which was got renewed from National Insurance Company Ltd. Vide policy No.8800200106399274 w.e.f. 04.01.2020 to 03.01.2021 having coverage of personal accident of owner driver. The complainant stated that his son Deepak Gambhir was already having personal accident insurance policy in respect of his vehicle as such, there was no need for him to avail another similar policy from any other company. Rather at the time of availing the loan, the officials of OPs insisted upon Deepak Gambhir that incase he wants to avail loan facility from them then he will have to mandatorily avail insurance from them and further represented that this insurance will be linked and connected with the loan and in case of any sort of mishap or death of the insured, the entire outstanding loan amount up to the sum insured will be waived off and surplus amount, if any, will be paid to the nominee of the insured. The complainant further stated that on the allurements and assurances of the Ops, Deepak Gambhir availed HDFC ERGO GIC Policy No.2950 2024 3535 7900 00 having validity from 01.10.2018 to 30.09.2021. Unfortunately, Deepak Gambhir expired on 18.11.2019 due to Dengue during validity of the insurance policy. After his death, the complainant being nominee, lodged the claim of Rs.5,00,000/- with the OPs for settlement of the entire loan amount of Rs.4,31,000/- outstanding against the vehicle and to pay the surplus claim amount to him vide claim No.RR-PA19-10783866. But the OPs rejected the claim of the complainant on the excuse that the policy being an accidental policy does not cover the death due to Dengue. Even the OPs started pressurizing the complainant to pay the outstanding amount along with interest and threatened to lift the vehicle and to sell it off in the market. According to the complainant the acts and conducts of the OPs of illegal rejection of the claim and hurling threats amounts to deficiency in service and unfair trade practice on the part of the OPs due to which the complainant suffered physical and mental pain, agony, harassment etc. for which he is entitled to compensation. In the end, the complainant has prayed for directing the Ops to allow his claim of Rs.5,00,000/- and to adjust the entire outstanding loan liability along with interest and to pay surplus amount to him as well as to pay compensation of Rs.2,00,000/- and litigation expenses of Rs.21,000/-.
2. Upon notice, OP1 and OP2 appeared and filed joint written statement and assailed by complaint by taking preliminary objections on the ground of maintainability; lack of jurisdiction; lack of cause of action concealment and suppression of material facts; the complaint being barred under Section 11 of the Consumer Protection Act; try to misleading the Forum by the complainant etc. OP1 and OP2 stated that Deepak Gambhir was insured for the period of 01.10.2018 to 30.09.2021 under policy no. 295020243535790000 under the Sarv Suraksha Policy by them for benefits as detailed in Coverage Details of the policy subject to conditions and exclusions of the Policy wordings. The benefits under the policy are governed by the terms and conditions of the policy and the liability of the OPs is limited to the insured perils occurring within the policy period subject to conditions and exceptions as mentioned in the terms and condition of the Policy. OP1 and OP2 further stated that a claim was lodged by the complainant on account of death of insured and upon registration of the claim vide Claim No. RR- PA19-10783866, demand letters dated 11.12.2019 & 26.12.2019 were sent to the complainant wherein claim and treatment related documents were sought. Upon receipt of the documents from the complainant it was noted that Deepak Gambhir suffered from fever initially which was not relieved by local medicine and was further taken to Kalra Hospital, Ludhiana where he was examined and investigated and found to have low platelet count and was further referred to CMC Ludhiana. The insured was diagnosed with severe dengue, dengue shock refractory by the hospital and ultimately died on 18.11.2019 due to said dengue.
OP1 and OP2 further stated that their authorized officer applied their mind and carefully reviewed the documents submitted in favour of the claim and on the basis of Policy Terms and conditions found the claim for 'Accidental Death' does not meet the requirement for its eligibility as per Policy Terms and conditions and found the claim to be not admissible and losses not payable and thus closed the claim being 'No-Claim' under clause 2.1.1 of the Policy and intimated the Complainant vide its letter dated 19.01.2020, which is reproduced as under:
"As per received documents insured died due to Dengue Fever which is medical condition, not due to accident. As per Policy accidental death cover, hence this claim is deny. (Please refer as per Policy clause 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)."
For a claim to be admissible under Accidental Death category, there should be an Accidental Bodily Injury which has caused the death of the insured within 12 months of the Accidental Bodily Injury. Relevant condition is reproduced herein under:
"SECTION 2. PERSONAL ACCIDENT
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."
According to OP1 and OP2 the claim under accidental death is not admissible as it is admitted fact that there was no accidental bodily injury. Op1 and OP2 further stated that as per the death summary issued by Christian Medical College, the insured was diagnosed with severe dengue, dengue shock refractory, Acute Kidney Injury and Severe Metabolic and lactic acidosis. Further as per the terms and conditions of the policy, for any claim to be admissible under Critical illness, the insured person first has to be diagnosed with a Critical illness as mentioned in the policy and further has to survive for a period of 30 days from the date of such Diagnosis. The diagnosed ailments are not covered under the Critical illnesses mentioned in the policy. Further the IRDAI has listed out certain categories of illnesses as Critical Illnesses under Guidelines on Standardization in Health Insurance. The definitions used to define these Critical Illnesses have been duly provided by the Guidelines on Standardization in Health Insurance issued by IRDAI, as per which the same illnesses have been incorporated as Critical Illness by the OPs as well. The liability of the Ops would arise only if the insured is diagnosed with any of the illnesses mentioned in the terms and conditions of the policy. As per the policy terms and conditions, diseases covered under Critical illnesses section of the policy are reproduced as under:
OP1 and OP2 further stated that any claim arising out of the aforesaid ailment shall be payable subject to terms and conditions of the policy. Moreover, in the present case the ailments i.e. severe dengue, dengue shock refractory, Acute Kidney Injury and Severe Metabolic and lactic acidosis were not included in the policy coverage; hence, the claim under Critical Illness is not admissible. It is further submitted that in the present case, the insured was admitted on 17.11.2019 and unfortunately died on 18.11.2019. That as per the terms and conditions the insured has to survive for a period of 30 days after diagnosis. Further, in the present case both the conditions for a claim to be admissible under Critical Illness i.e. diagnosis of Critical Illness and subsequent surviving for a period of 30 days were not fulfilled and so any claim under Critical Illness is not admissible. As per the terms and conditions of the policy, under Credit Shield Insurance, OP1 and OP2 are liable to pay the balance outstanding loan amount up to the maximum sum insured in the event of Accidental Death or Permanent Total Disability. OP1 and OP2 further stated that as per death summary of CMC Hospital, the insured was diagnosed with severe dengue, dengue shock refractory, Acute Kidney Injury and Severe Metabolic and lactic acidosis and unfortunately died because of the same. Further as per the terms and conditions of the policy, the term Accident is defined as under:-
“Accident or Accidental” means a sudden, unforeseen and involuntary event caused by external, visible and violent means.
The claim under Credit Shield is not admissible as the cause of death is not accidental in nature.
On merits, OP1 and OP2 reiterated the crux of averments made in the preliminary objections and facts of the case. OP1 and OP2 have denied that there is any deficiency of service and have also prayed for dismissal of the complaint.
3. OP3 and OP4 filed separate written statement and assailed the complainant by taking preliminary objections on the ground of maintainability; lack of jurisdiction; lack of cause of action; suppression of material facts etc. OP3 and OP4 stated that Deepak Gambhir took Auto Loan from them and Rs.6,04,598/- was financed to be payable in 36 EMIs of Rs.19,370/- from 05.11.2018 to 05.10.2021. On 20.11.2020, the loan No.61376206 was closed by depositing Rs.2,15,000/- due to which OP3 and OP4 claimed to have suffered a loss on closure of loan account of Rs.2,50,022.70. Even they issued the NOC towards closure of the loan and there is no dispute with regard to terms and conditions of loan agreement. OP3 and OP4 further stated that they have been unnecessarily dragged in the litigation. They only assisted the insured to get insurance policy from OP1 and OP2.
On merits, OP3 and OP4 reiterated the crux of averments made in the preliminary objections and facts of the case. OP3 and OP4 have denied that there is any deficiency of service and have also prayed for dismissal of the complaint.
4. In evidence, the complainant tendered his affidavit as Ex. CA and reiterated the averments of the complaint. The complainant also placed on record documents Ex. C1 is the copy of his Aadhar card, Ex. C2 is the copy of RC No.PB09-Z-0707, Ex. C3 is the copy of insurance policy issued by Liberty General Insurance Limited w.e.f. 23.09.2018 to 22.09.2019, Ex. C4 is the copy of insurance policy issued by National Insurance Company Limited w.e.f. 04.01.2020 to 03.01.2021, Ex. C5 is the copy of screenshot of text message, Ex. C6 is the copy of repudiation letter dated 19.01.2020, Ex. C7 is the copy of Email; Ex. C8 is the copy of death certificate of Deepak Gambhir, Ex. C9 is the copy of death summary dated 18.11.2019 of CMC Hospital and closed the evidence.
5. On the other hand, the counsel for OP1 and OP2 tendered affidavit Ex. RA of Ms. Shweta Pokhriyal, Manager Legal – Claims, HDFC ERGO General Insurance Co. Ltd. along with documents Ex. R1/1 is the copy of welcome letter and insurance policy, Ex. R2/1 is the copy of claim reminder letter dated 11.12.2019, Ex. R3/1 is the copy of claim reminder letter dated 26.12.2019, Ex. R4/1 is the copy of prescription slip of Kalra Hospital, Ex. R5/1 is the copy of death summary dated 18.11.2019 of CMC Hospital, Ex. R6/1 is the copy of statement of Ritu wife of Deepak Gambhir, Ex. R7/1 is the copy of repudiation letter dated 19.01.2020 and closed the evidence.
The counsel for OP3 and OP4 tendered affidavit Ex. RW1/A of Sh. Harpreet Nath, Legal Manager, HDFC Bank Ltd., near Miller Ganj, Ludhiana along with documents Ex. RW-1A is the copy of power of attorney, Ex. RW-1B is the copy of agreement for Autoloan, Ex. RW-1C is the copy of statement of account dated 11.06.2021 and closed the evidence.
6. We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written statements along with affidavits and documents produced on record by both the parties.
7. One Deepak Gambhir (now deceased) son of the complainant purchased a car bearing registration No.PB09-Z-0707 in September 2018 and also got it financed from the OP bank. The vehicle was also got insured from Liberty General Insurance Limited vide certificate of insurance cum policy schedule Ex. C3. The OP insurance company also issued a policy Sarv Suraksha Plus having validity from 01.10.2018 to 30.09.2021 to Deepak Gambhir and the complainant, being father, was appointed as nominee. The details of coverage contained in the document Ex. R1 are given hereunder:-
Coverage Details | ||
Coverage | Premium (₹) | Sum Insured (₹) |
| 324 | 100,000 |
| 372 | 500,000 |
| 496 | 500,000 |
| 248 | 100,000 |
| 868 | 100,000 |
| 620 | 500,000 |
| 558 | 3,500 |
| 409 | 150,000 |
8. On 17.11.2019, Deepak Gambhir fell ill and was initially treated at Kalra Hospital as an OPD patient vide Ex. R4. However, on the same day, he was brought to the casualty ward of Christian Medical College and Hospital, Ludhiana with chief complaints of fever for last 3 days, palpitations, giddiness etc. On 18.11.2019 at 06.10 AM he suffered cardiac arrest. CPR was initiated. However, the patient could not return to spontaneous circulation and he could not be revived. He was declared dead on 06.55 AM as per death summary Ex. C9 = Ex. R5 dated 18.11.2019. He was finally diagnosed as under:-
9. According to the complainant, a sum of Rs.4,31,000/- was outstanding against the vehicle and he being father and nominee, lodged a claim with the OPs. The claim was registered and during the course of settlement of the claim, the OPs sent two identically worded claim reminder letters dated 11.12.2019 Ex. R2/1 and 26.12.2019 Ex. R3/1 calling upon the complainant to provide documentary proof as detailed in the letters. Finally after reviewing the documents submitted by the complainant, vide letter dated 19.01.2020 Ex. R7/1, the claim was repudiated. The operative part of Ex. R7/1 is reproduced as under:-
“We refer the captioned claim intimated on 30/11/2019 and have carefully reviewed the documents submitted by you to validate the eligibility of claim basis policy terms and conditions.
We regret to inform you that the claim for Accidental Death does not meet the requirement for its eligibility as per the Policy terms and conditions. Since the claim is not admissible and losses not payable, we are constrained to close the claim as “no Claim” in our records.
We would like to draw your attention, Your claim has been declined due to below mentioned reason which is the basis for disallowing the claim, an extract of which is mentioned below for your ready reference:
As per received documents Insured died due to Dengue Fever which is medical condition, not due to accident. As per policy accidental death cover, hence this claim is deny. (Please refer as per policy clause 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).”
10. Now the point of determination arises whether the repudiation of the claim is justified or not.
11. The OP insurance company has annexed the certificate of insurance Sarv Suraksha policy wording along with welcome letter Ex. R1/1. The repudiation of the claim of the complainant is based upon Section 2 mentioned in insurance policy Ex. R1/1 is reproduced as under:-
“SECTION 2. PERSONAL ACCIDENT
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."
In order to appreciate the definition of Accidental Death, it is important to reproduce the specific definition applicable to Section 2 (4) and (5) as under:-
“4. ‘Accident or Accidental’ means a sudden, unforeseen and involuntary event caused by external, visible and violent means.
5. ‘ Bodily Injury’ means physical bodily harm or injury, but does not include any mental sickness, disease or illness.”
The insurance policy Ex. R1/1 Section 1 Critical Illness provides the Critical Illness Coverage for the following diseases/medical conditions:-
It is further a condition that “If the Insured Person named in the schedule is diagnosed as suffering from Critical Illness which first occurs or manifests itself during the Policy Period, and the Insured survives for a minimum of 30 days from the date of diagnosis, the Company shall pay the Critical Illness Benefit as shown in the schedule.”
Further Section 5 of the insurance policy provides as under:-
SECTION 5. CREDIT SHIELD INSURANCE POLICY
Coverage
Credit Shield
In the event of Accidental Death or Permanent Total Disability of the Insured Person during the Policy Period, the Company will make payment under this policy as detailed below:
The Company will pay the balance outstanding loan amount to the legal heirs of the Insured or the Named Insured subject to the maximum Sum Insured specified in the Schedule.
The outstanding Loan amount would not include any arrears of the borrower due to any reasons whatsoever. The claim to be settled only in respect of the death of the first named borrower and not in respect of the others, which may happened if loan is taken jointly.”
12. Perusal of these benefits shows that for entitlement of benefits under these sections, the complainant was required to prove that insured Deepak Gambhir died due to accidental death. As per death summary dated 18.11.2019 Ex. C9 = Ex. R5/1, deceased insured Deepak Gambhir was diagnosed as a severe Dengue patient. The patient was admitted in the hospital on 17.11.2019 and he died on 18.11.2019. As per the definition of “Accident Death” Section 2 (4) and (5), “Critical Illness” Section-1 and “Credit Shield” Section-5, the case of the complainant does not fall under the purview of the policy terms and conditions.
13. In this regard, reference can be made to Civil Appeal No.2614 of 2019 decided on 26.03.2019 by the Hon’ble Supreme Court of India in the Branch Manager, National Insurance Co. Ltd. Vs Smt. Mousumi Bhattacharjee & others whereby the Hon’ble Apex Court has made following observations in para No.20 of the judgment:-
“20. In a policy of insurance which covers death due to accident, the peril insured against is an accident: an untoward happening or occurrence which is unforeseen and unexpected in the normal course of human events. The death of the insured in the present case was caused by encephalitis malaria. The claim under the policy is founded on the hypothesis that there is an element of uncertainty about whether or when a person would be the victim of a mosquito bite which is a carrier of a vector- borne disease. The submission is that being bitten by a mosquito is an unforeseen eventuality and should be regarded as an accident. We do not agree with this submission. The insured was based in Mozambique. According to the World Health Organization’s World Malaria Report 2018, Mozambique, with a population of 29.6 million people, accounts for 5% of cases of malaria globally. It is also on record that one out of three people in Mozambique is afflicted with malaria. In light of these statistics, the illness of encephalitis malaria through a mosquito bite cannot be considered as an accident. It was neither unexpected nor unforeseen. It was not a peril insured against in the policy of accident insurance. 21 We are hence of the view that the interpretation placed on the terms of the insurance policy was manifestly incorrect and that the impugned order of the National Commission is unsustainable.”
Reference can be further made to Chitra Mukherjee Vs Union of India and others 2023 ACJ 2465 whereby the Hon’ble Calcutta High Court has made the following observations:-
“Constitution of India, 1950 Article 226 Death – Mosquito bite – Compensation claim – Scope – Deceased was serving in Army – He was found to be Dengue NSI Ag positive and succumbed to his illness – Whether death caused from mosquito bite would count as an ‘accident’? – (N0) – Mosquito bites are not unforeseen events – No disease caused by an Mosquito bite is an accident – Insurance Policy and precedents on the subject did not permit interpreting any disease caused by a mosquito bit as an accident – It was neither fortuitous nor unexpected and is entirely country/city-specified – Impugned refusal on the part of the Insurance Company to admit liability in the particular policy cannot be arbitrary or unreasonable – petition dismissed.”
As such, there is no ambiguity qua the terms and conditions of Ex. R1/1 discussed in detail above and further in the absence of specific coverage, no liability can be fastened upon the OPs. As such, the complainant has failed to establish his case for accepting the claim.
14. As a result of above discussion, the complaint is hereby dismissed being devoid of any merits. However, there shall be no order as to costs. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.
15. Due to huge pendency of cases, the complaint could not be decided within statutory period.
(Monika Bhagat) (Sanjeev Batra) Member President
Announced in Open Commission.
Dated:02.05.2024.
Gobind Ram.
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