DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BARNALA, PUNJAB.
Complaint Case No : 55/2015
Date of Institution : 31.03.2015
Date of Decision : 21.08.2015
Charanjit Kaur, aged about 31 years, widow of Jaspal Dass resident of Patti Lalu, Dhilwan (Nabha) 1481018 Tehsil Tapa, District Barnala, Punjab.
…Complainant
Versus
HDFC ERGO General Insurance Co. Ltd., Registered and Corporate Office : 1st Floor, 165-166 Backbay Reclamation, H.T. Parekh Marg, Churchgate, Mumbai 400 020 through its Managing Director;
HDFC Bank Ltd., Branch Office B-XII/263-264, College Road, Barnala, through its Branch Manager.
…Opposite Parties
Complaint Under Section 12 of Consumer Protection Act, 1986.
Present: Sh. Harpreet Singh counsel for complainant.
Sh. Anuj Mohan Gupta counsel for opposite party No. 1.
Sh. Gagandeep Garg counsel for opposite party No. 2.
Quorum.-
1. Shri S.K. Goel : President.
2. Sh. Karnail Singh : Member
3. Ms. Vandna Sidhu : Member
ORDER
(By SHRI KARNAIL SINGH, MEMBER):
The complainant Charanjit Kaur has filed the complaint under Consumer Protection Act, 1986 (hereinafter called as Act) against HDFC ERGO General Insurance Company the opposite party No. 1 and HDFC Bank Limited Branch Office, Barnala, through its Branch Manager on the ground that Jaspal Dass, husband of the complainant availed Gold Loan from the opposite party No. 2 and deposited 14.600 grams of gold (2 ear rings weighing 9.900 grams and 2 rings weighing 4.700 grams) with the opposite party No. 2.
2. It is alleged that late Sh. Jaspal Dass, husband of the complainant was suffering from critical illness at the time of availing the loan in question and this fact was brought to the notice of the Branch Manager of opposite party No. 2, therefore the opposite party No. 2 insured the life of late Sh. Jaspal Singh, by purchasing Sarv Suraksha Insurance Policy bearing No. 2950 2007 6547 3900000, which included critical illness from the opposite party No. 1. It is further alleged that to insure the life of Sh. Jaspal Singh, the opposite party No. 1 charged Rs. 157/- under head critical illness. The said insurance policy provided coverage and benefit, which are as under:-
(i) accidental death (ii) permanent total disability/permanent partial disability (iii) Credit Shield Insurance (iv) Accidental Hospitalization and (v) Critical illness and this is clear from letter dated 28.5.2014 of opposite party No. 1 sent to the husband of complainant.
3. It is further alleged that due to the critical illness the husband of the complainant died on 4.8.2014 at Max Hospital, Bathinda. Late Sh. Jaspal Singh had appointed the complainant as his nominee in respect of the said loan and insurance, therefore being the nominee of the deceased Jaspal Dass, the complainant is legally entitled to receive Rs. 1,00,000/- the insurance amount in respect of the said insurance policy, which was in the name of her husband, who has since expired.
4. It is further alleged that complainant approached the opposite parties for the payment of insurance amount on account of death of her husband, but the opposite parties have been putting off the matter on one pretext or the other. Complainant sent a letter dated 29.12.2014 to the opposite party No. 1 to pay the insurance amount upon which she received letter dated 16.1.2015, whereby the complainant was asked to submit certain documents. In pursuance of letter dated 16.1.2015, complainant vide her letter dated 12.2.2015 submitted the documents to the opposite party No. 1. It is further alleged that the opposite party No. 1 repudiated the claim of the complainant vide its letter dated 19.2.2015 on the ground that the deceased husband of the complainant was never told at the time of insurance that he was to survive for a period of 30 days from the time he was diagnosed for such illness. As such, the complainant suffered a great mental agony, shock and harassment. Hence, it was alleged that it is a deficiency in service and unfair trade practice on the part of opposite parties, therefore the present complaint is filed seeking the following reliefs.
To pay the insured amount of Rs. 1,00,000/- alongwith interest @ 18% per annum from the death of Jaspal Dass till its realization.
To pay Rs. 50,000/- as compensation.
To pay Rs. 10,000/- as litigation expenses.
5. Upon notice, the opposite party No. 1 appeared and filed written version taking preliminary objections on the ground that the complaint is false, frivolous, vague and vexatious. It is further in the preliminary objections that the insured Mr. Jaspal Dass suffered cardiac arrest on 4.8.2014 with no prior symptoms, whereas policy inception date is 28.5.2014. As per policy terms any critical illness suffered within 90 days from policy inception date is EXLUDED from the policy benefit. Further, the complainant herself admitted that at the time of availing the loan, her husband was suffering from critical illness. Therefore, as per policy terms & conditions the claim is not payable on account of previous illness. The liability of the opposite party No. 1 is determined and as per the terms and conditions of the policy, which is to be strictly adhered to while processing any claim. The policy terms and conditions alongwith policy schedule was duly supplied to the insured. The complainant has concealed material facts.
6. On merits, it is admitted that the husband of the complainant namely Jaspal Dass was insured under “Sarv Suraksha Policy” bearing No. 2950-2007-6547-3900-000 for the period 28.5.2014 to 27.11.2014 having premium of Rs. 461/-. The said insurance policy was subject to its terms and conditions. However, it is denied for want of knowledge that the deceased was already suffering from critical illness at the time of taking the policy. It is wrong that the complainant is entitled to get the amount of Rs. 100,000/- from the opposite party. It is further denied that the insured was not told about the conditions at the time of taking policy. However, it is admitted that the claim of the complainant was repudiated vide letter dated 19.2.2015 as per terms and conditions of the policy, as complainant was not admissible. All other allegations of the complainant are denied and prayed for the dismissal of complaint.
7. Upon notice, the opposite party No. 2 also appeared and filed written version taking preliminary objections on the ground that complainant has got no locus-standi or cause of action to file the present complaint against the opposite party No. 2 and deceased Jaspal Dass was insured with HDFC ERGO General Insurance Company, the opposite party No. 1. The O.P Bank cannot carry on “Insurance Business” as per the provisions of Banking Regulations Act, 1949. Further, the opposite party No. 2 was only a facilitator/corporate agent merely introducing the parties.
8. On merits, all the allegations of the complainant are denied. It is submitted that the opposite party No. 2 debited the amount from the account of Jaspal Dass as requested by him and the said amount has been transferred to the account of opposite party No. 1. Further, the role of opposite party No. 2 was only a facilitator/corporate agent merely introducing the parties and insurance company and complaint is liable to be dismissed against the opposite party No. 2. Further, the opposite party No. 2 denied any deficiency in service on its part and prayed for the dismissal of complaint.
9. In order to prove her case, the complainant tendered into evidence her own affidavit Ex.C-1, affidavit of Binder Singh Ex.C-2, photocopy of gold loan application Ex.C-3, photocopy of letter dated 28.5.2014 Ex.C-4, photocopy of policy Ex.C-5, photocopy of certificate for the purpose of deduction under Section 80-D of Income Tax Act, 1961 Ex.C-6, copy of application dated 29.1.2014 Ex.C-7, copy of letter of opposite party No. 1 dated 16.1.2015 Ex.C-8, copy of letter dated 12.2.2015 Ex.C-9, copy of letter dated 19.2.2015 Ex.C-10, photocopy of death certificate of Jaspal Dass Ex.C-11 and closed the evidence.
10. To rebut the case of the complainant the opposite party No. 1 tendered into evidence affidavit of Pankaj Kumar Ex.O.P1/1, photocopy of letter dated 28.5.2014 Ex.O.P1/2, photocopy of policy schedule of Sarv Suraksha policy Ex.O.P1/3, photocopy of death certificate of Jaspal Dass Ex.O.P1/4, photocopy of letter dated 29.12.2014 Ex.O.P1/5, photocopy of letter dated 15.1.2015 Ex.O.P1/6, photocopy of claim form Ex.O.P1/7, photocopy of death summary of Jaspal Dass Ex.O.P1/8, photocopy of letter dated 12.2.2015 Ex.O.P1/9, photocopy of certificate issued by Max Hospital Bathinda Ex.O.P1/10, photocopy of investigation report of Max Hospital Bathinda Ex.O.P1/11, photocopy of death summary Ex.O.P1/12 and photocopy of letter dated 19.2.2015 Ex.O.P1/13 and closed the evidence.
11. To rebut the case of the complainant the opposite party No. 2 also tendered in evidence affidavit of Mukesh Kumar Branch Manager Ex.O.P2/1 and copy of gold loan application from Ex.O.P2/2 and closed the evidence.
12. We have heard the Ld. Counsels for the parties and gone through the documents tendered by the parties.
13. It is the case of the complainant that her husband availed a Gold Loan from the opposite party No. 2 and for this deposited 14.600 Grams of gold with the opposite party No. 2. It is further submitted that her husband was suffering from critical illness at the time of availing the loan and this fact was brought to the notice of Branch Manager of opposite party No. 2, therefore the Bank insured the life of said Jaspal Dass by purchasing Sarv Suraksha Insurance Policy bearing No. 2950200765473900000 from the opposite party No. 1. Due to the said critical illness her husband died on 4.8.2014 at Max Hospital, Bathinda. The complainant being the nominee of deceased Jaspal Dass approached the opposite parties for the payment of insured amount of Rs. 1,00,000/-. But the opposite parties vide letter dated 19.2.2015 repudiated the claim as the same was not admissible as per terms and conditions of the policy.
14. The case of the opposite party No. 1 is that deceased Jaspal Dass suffered cardiac arrest on 4.8.2014 with no prior symptoms, whereas for critical illness to be admissible under policy, the insured person has to survive a period of 30 days from the time he was diagnosed for such critical illness. The complainant in Para No. 3 of the complaint herself admitted that at the time of availing the loan, her husband was suffering from critical illness. Therefore, as per policy terms and conditions the claim is not payable on account of previous illness. In support of their case the opposite party No. 1 tendered in evidence affidavit of Pankaj Kumar Ex.O.P1/1, wherein he stated that the policy terms and conditions alongwith policy schedule was duly supplied to the insured, which was never disputed by him. The complainant has concealed the material fact regarding policy terms and conditions by not filing the same. Further, the contract of the insurance between the complainant and respondent is governed by its policy terms and conditions. Hence, the claim of the complainant is repudiated.
15. Now it is to be determined whether the complainant is entitled to the compensation as per terms and conditions of the policy/instructions.
16. It is relevant to refer Section 1 pertaining to Critical Illness, which reads as:-
“If the insured person named in the schedule is diagnosed as suffering from a 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”.
17. Apart of the ibid clause it is also relevant to refer clause for specific exclusions applicable to this case, which reads as:- No payment will be made by the Company for any claim directly or indirectly caused by, based on, arising out of or howsoever attributable to any of the following:-
Any Critical Illness for which care, treatment, or advice was recommended by or received from a Physician, or which first manifested itself or was contracted before the start of the Policy Period or for which a claim has or could have been made under any earlier policy.
Any Critical Illness diagnosed within the first 90 days of the date of commencement of the Policy is excluded. The exclusion shall not apply to an Insured for whom coverage has been renewed by the Named Insured , without a break, for subsequent years.
18. Coming to the present case, the patient in question has not survived for 30 days after getting treatment. Moreover, specific exclusion clause as referred above is fully applicable to the present case.
19. We are of the opinion that the complainant has failed to prove by leading any evidence that the present case is fully covered under the provisions of the policy.
20. In view of the above discussion, the present complaint merits dismissal and the same is accordingly dismissed. However, there is no order as to costs. Copy of the order be supplied to the parties free of costs. The file be consigned to the records.
ANNOUNCED IN THE OPEN FORUM:
21st Day of August, 2015.
(S.K. Goel)
President.
(Karnail Singh)
Member.
(Vandana Sidhu)
Member.
