Haryana

Ambala

CC/68/2022

Parul Kumari - Complainant(s)

Versus

HDFC ERGO General Inss Co Ltd - Opp.Party(s)

Satish Kumar

08 Apr 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

Complaint case no.	:	68 of 2022
Date of Institution	:	24.02.2022
Date of decision	:	05.04.2024

Parul Kumari, Daughter of Sh. Kamal Raj, aged about 30 years Resident of House No.3155, Near Gas Godown, Ward No.31, Monmohan Nagar, Ambala City.

…..Complainant

                                                                                    Versus

1. HDFC ERGO General Insurance Company Limited, Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H.T/ Parekh Marg, Churchgate, Mumbai-400020. Through authorized Signatory.
2. HDFC ERGO General Insurance Company Limited, Branch office: 2nd Floor, SCO No.237, Sector-12, Karnal, Haryana, 132001. Through authorized Signatory.
3. HDFC ERGO General Insurance Company Limited, Local office: 5202-05/1, Surya Tower, 1st Floor, Nicholson Road, Ambala Cantt.- 133001., Through authorized Signatory

….…. Opposite Parties

Before:         Smt. Neena Sandhu, President.

                     Smt. Ruby Sharma, Member,

         Shri Vinod Kumar Sharma, Member.           

 

Present:       Shri Gopal, Advocate, counsel for the complainant.

                     Shri Mohinder Bindal, Advocate, counsel for the OPs.

Order:        Smt. Neena Sandhu, President.

                   Complainant has filed this complaint under Section 35 of the Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

1. To pay the sum assured amount of Rs.1,00,000/- along with interest @ 18% per annum.
2. To pay Rs.1,00,000/- as compensation for causing mental agony and harassment to the complainant.
3. To pay Rs.11000/- as litigation expenses
4. Grant any other relief, which this Hon’ble Commission may deem fit.

 

2.             Brief facts of this case are that  the complainant and Aruna (Wife), Shivani  Parocha (Daughter) and Parul Kumari (Daughter) are the descendants of late Sh. Kamal Raj S/o late Som Nath and there is no other legal heir of late Sh. Kamal Raj, except mentioned above. The complainant's father (Late Sh. Kamal Raj) during his life time obtained HDFC ERGO Sarv Suraksha Plan Policy bearing No.2999201363863002 for a term of 5 years from the OPs as under:-

Coverage Details

coverage	Premium Rs.	Sum Insured Rs.
Loss Of Job (3EMI)		00
Accident Death		00
Permanent Total Disability/ Permanent Partial Disability		00
Accident Hospitalization		00
Critical Illness		00
Credit Shield Insurance		00
Garage Cash		00
Householders Coverage		00

The policy commenced from 23.05.2018. The complainant's father paid 5 yearly premiums of Rs.6761/- each. Subsequently, on 08.02.2020 father of the complainant (Sh. Kamal Raj, the policy holder) died while undergoing treatment at Fortis Hospital, Mohali. The complainant being the nominee under the insurance policy submitted claim form along with the relevant document to the OPs on 05.03.2021. The OPs repudiated the claim of the complainant vide letter dated 10.12.2021 on the ground that critical illness is not covered in the said policy, which is illegal.  Hence, the present complaint.

3.           Upon notice, OPs appeared and filed  written version wherein they raised preliminary objections to the effect that this complaint is premature; the complaint is without cause of action; the complainant has no locus standi to file the present complaint etc. On merits, it has been stated that the claim of the complainant has not been rejected but closed due to non-receipt of documents from the complainant. The liability of company, if any, is subject to terms and conditions of the policy. The copy of insurance policy along with its coverage details, terms and conditions were duly supplied to the complainant which has never been disputed till the claim of the complainant was closed. The complainant even after various repeated requests and reminders letters dated 02.12.2021, 17.12.2021 and 01.01.2022 failed to submit the following requisite documents:-

a. Duly filled in Claim form.

b. Histopathology report supporting diagnosis.

c. Treating doctor's certificate for exact duration of the ailment in DD/MM/YYYY format along with past consultation papers and treatment records

4.           The OPs act as a custodian of the funds of public and therefore in order to protect the policy holders, it has to be at all times vigilant in ensuring that only admissible claims under the policy are paid. The OPs opt for the best trade practices and always acts in the interest of its policy holders, but at the same time it seeks to protect itself from the mischief of the policy holder. The claim paid by any Insurance Company goes out of the common pool of funds belonging to all policyholders of the Company and the Insurance Company has to check the validity of a claim as per the terms and conditions of the policy before honouring it. The Insurance Company cannot do injustice to genuine policyholders by allowing ingenious and invalid claims. Nevertheless the OPs are ready to consider the claim of the complainant, provided the requisite documents which the company have been time and again asked from the complainant are submitted. If the complainant provides the documents so desired, then the OPs are ready to consider the claim of the complainant as per terms and conditions of the policy. Rest of the averments of the complainant were denied by OP and prayed for dismissal of the present complaint with special compensatory costs.
5.           Learned counsel for the complainant tendered affidavit of the complainant, as Annexure CW1/A alongwith documents as Annexure C-1 and C-12 and closed the evidence on behalf of the complainant. Learned counsel for the OPs tendered affidavit of Manoj Kumar Prajapati, Assistant Manager, duly constituted attorney & authorized signatory, HDFC Ergo General Insurance Co. Ltd., Noida as Annexure OP-1/A alongwith documents as Annexure OP-1 to OP-5 and closed the evidence on behalf of OPs.
6.           We have heard the learned counsel for the parties and have also carefully gone through the case file.
7.           The learned counsel for the complainant submitted that by repudiating the claim filed by the complainant being nominee on the ground that critical illness is not covered under the policy in question, the OPs are deficient in providing service, negligent and adopted unfair trade practice. 
8.           On the contrary, learned counsel for the OPs submitted that the claim has not been repudiated on the ground that the critical illness is not covered under the policy in question. From the email dated 10.12.2021, C-12, it is quite clear that the claim No.RR-Cl19-10810972, which pertains to some other policy was rejected on the ground that the critical illness was not covered under the said policy. However, the claim no.RR-Cl20-12324891, which pertains to policy in question was closed vide letter dated 16.01.2022 for non-submission of requisite documents.
9.           The plea of the OPs is that the claim of the  complainant has not been repudiated, but, it has been closed on account of the reason that despite asking the complainant vide letters dated 02.12.2021, 17.12.2021 and 01.01.2022, Annexure OP-1 to OP-3 to provide necessary documents like Duly filled in Claim form; Histopathology report supporting diagnosis; Treating doctor's certificate for exact duration of the ailment in DD/MM/YYYY format along with past consultation papers and treatment records, the same were not provided and left with no alternative her claim was closed. We have perused these letters and found that the documents sought for by the OPs including the claim form, vide the said letters, are significant documents for the settlement of the claim. It may be stated here that in para no.12 of the preliminary objections of the written version filed by the OPs, it is stated that the OPs are ready to consider the claim of the complainant, as per terms and conditions for the policy, provided the requisite documents which the company have been time and again asked from the complainant are provided. Under these circumstances, in the interest of justice, we hereby dispose of this complaint with the directions to the complainant to provide the requisite documents to the OPs within 30 days from the date of receipt of certified copy of this order. At the same time, we also direct the OPs to settle the claim of the complainant within a period of 45 days on receipt of the requisite documents from the complainant. However, the complainant is left with the liberty to file a fresh complaint, if any cause of action arose to her, qua the claim in question. Certified copies of the order be sent to the parties concerned as per rules.  File be annexed and consigned to the record room.     

Announced:- 08.04.2024.

 

(Vinod Kumar Sharma)	(Ruby Sharma)	(Neena Sandhu)
Member	Member	President