Haryana

Ambala

CC/25/2021

Kamal Goel - Complainant(s)

Versus

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

Mrs Suman Goel

29 Aug 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

           

Complaint case no.	:	25 of 2021
Date of Institution	:	21.01.2021
Date of decision	:	29.08.2022

 

1. Kamal Goel aged about 35 years s/o Late Shri Shyam Sunder Goel
2. Rajan Goel aged about 37 years s/o Late Shri Shyam Sunder Goel;

Both R/o H.No.1125, Kartar Nagar, Model Town, Ambala City:

3. Smt. Jyoti Goel aged about 39 years w/o Shri Nitin Aggarwal, d/o Late Shri Shyam Sunder Goel, R/o H.No.5666, Sector-38-West, Chandigarh.

                                                                                       ……. Complainants.

                                      Versus

1. HDFC ERGO General Insurance Company Limited, Registered & Corporate Office 1^st  Floor, HDFC House, 165/166, Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai- 400 020, through its' Authorised Signatory.
2. HDFC ERGO General Insurance Company Limited, # SCO-124-125, Sector-08, Madhya Marg, Chandigarh, Pincode 160 008, through its Authorised Signatory.
3. Eakansh Wheel (NEXA), Ambala-Chandigarh Road, Ambala Chandigarh Road, Baldev Nagar, Near Passport Office, Ambala City (Haryana) Pincode-134 003, through its' Authorised Signatory.

                                                                              ….…. Opposite Parties.

Before:        Smt. Neena Sandhu, President.

                   Smt. Ruby Sharma, Member.

Shri Vinod Kumar Sharma, Member.         

                            

Present:       Mrs. Suman Goel, Advocate, counsel for the complainant.

                   Shri Mohinder Bindal, Advocate, counsel for the OPs No.1 & 2.

                   Shri U.S.Chauhan, Advocate, counsel for the OP No.3.

 

Order:        Smt. Neena Sandhu, President

1.                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:-

(i)To pay Rs.5,00,000/-, i.e the sum assured amount for the death of Shri Shyam Sunder Goel, who died on 24.05.2020 against Credit Shield insurance for which premium of Rs.912, was taken and insurance policy was issued on  26.10.2017 having Certificate No 2950 2019 6164 4400 000, Invoice No 201961644400000 Customer Id No. 102134397471, Master Policy No.2999201363863001 and in the said policy, Shri Kamal Goel, one of the LRs of  Late Shri Shyam Sunder Goel, was appointed as nominee.

(ii) To pay interest @ 18% per annum on the claim amount from the death of the insured i.e 24.05.2020 till the date of entire payment, to the complainants;

(iii) To pay Rs.1,00,000/- on account of compensation for causing deficiency in services and unfair trade practice and harassment, mental torture and agony to the complainants:

(iv) To pay Rs.22,000/-, as cost of litigation.

(v) Any other relief, which this Hon'ble Court deems fit and proper as per the facts and circumstances of the present complaint may also be granted in favour of the complainants. 

2.             Brief facts of the case are that Late Shri Shyam Sunder Goel was natural father of the complainants, who had purchased a New Car Maruti Nexa Ignis from OP No.3 against the loan taken by the complainant no.1 from HDFC Bank Limited, vide Loan Account No.51937221. At the time of purchase of the car by the father of the complainants, OP No.3 got the owner of the car- Late Shri Shyam Sunder Goel insured for a total sum of Rs.5,00,000/- under Credit Shield Insurance, on deducting premium to the tune of Rs.912/-. The said policy was valid for 05 years from 26.10.2017 to 25.10.2022, under Insurance Certificate No.2950 2019 6164 4400 000, Invoice No.201961644400000, Customer Id No.102134397471, Master Policy No 2999201363863001. Complainant no.1- Shri Kamal Goel was made nominee of this policy. At the time of purchase of the car, the father of the complainants, Shri Shaym Sunder Goel was perfectly alright and he had no any problem at that time but unfortunately after passage of time, he became seriously ill and was taken to Post-Graduate Institute of Medical Education & Research, Chandigarh in Emergency, where he died on 24.05.2020 due to sudden cardiac arrest. After the sudden demise of father of the complainants, complainant no.1-Kamal Goel being nominee of the aforesaid policy, lodged claim of Rs.5,00,000/- for the death of insured Shri Shyam Sunder Goel which occurred during the insurance period.  As per demands of the OPs, the complainants fulfilled all the requisite formalities and resultantly, complainant no.1- Kamal Goel was assured by the OPs that the sum insured amounting to Rs.5,00,000/- will be paid to him being nominee. Thereafter, the complainant no.1-Kamal Goel contacted the OPs number of times in the matter but they failed to pay the claim amount. However, in the second week of September, 2020, it was verbally told by the OPs to complainant no.1-Kamal Goel the claim file has been closed for "No Claim" without explaining the reason. The complainants then under constrained circumstances served legal notice dated 01.12.2020 upon the OPs in the matter but to no avail. Hence, the present complaint.
3. Upon notice, OPs No.1 and 2 appeared and filed written version and raised preliminary objections with regard to maintainability, cause of action, not come with clean hands and suppressed the true and material facts etc.  On merits, while admitting factual matrix of the case with regard to the fact of issuance of the insurance policy in question, it has been stated that  OPs No.1 and 2 raised certain queries to the complainants for clarification and further sought to provide the requite documents relating to illness and treatment of late Sh. Shyam Sunder Goel i.e. exact cause of myocardial infraction certified by treating doctors; exact duration of causative factor since when first time detected certified by treating doctors along with all past treatment records; ECG Report showing relevant findings & Cardiac enzymes report (Troponin test and Creatine Kinase (CK-MB) test) and exact duration of hypertension but they failed to provide the same. The Credit Shield Insurance coverage under the Sarv Suraksha insurance policy in question comes in picture only if the insured person died due to accidental injuries or suffers permanent total disablement during the policy period. Without admitting any liability, due to non submission of illness and treatment related papers by the complainants, it appeared that the insured late Sh. Shyam Sunder Goel had died due to heart failure and not due to any accidental injury and thus the claim of the complainants  does not fall with the purview of the policy in question. Moreover, the insurance company under this credit shield insurance coverage was liable to pay only the outstanding loan amount upto the extent of sum insured and that too, to the financer only but in the present case, the complainants have failed to prove their case even. Policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. Rest of the averments of the complainant were denied by the answering OPs No.1 and 2 and prayed for dismissal of the present complaint with costs.
4. Upon notice, OP No.3 appeared and filed written version and raised preliminary objections with regard to jurisdiction, locus standi, bad for non-joinder of necessary party, not come with clean hands and suppressed the true and material facts etc. It has been stated that the complainants did not fall within the definition of consumers.  Rest of the averments of the complainant were denied by the answering OP No.3 and prayed for dismissal of the present complaint with special costs.
5. Learned counsel for the complainants tendered affidavit of complainant No.1 as Annexure CA alongwith documents as Annexure C-1 to C-11 and closed the evidence on behalf of complainants. On the other hand, learned counsel for the OPs No.1 and 2 tendered affidavit of Shweta Pokhriyal, Authorized Signatory of HDFC ERGO General Insurance Co. Ltd., Registered  Office, Noida as Annexure OP-A alongwith documents Annexure OP-1 to OP-4 and closed the evidence on behalf of OPs No.1 and 2. However, learned counsel for OP No.3 has made a statement that written version filed on behalf of OP No.3 be read as evidence on behalf of OP No.3 and closed evidence on behalf of OP No.3.
6.           We have heard the learned counsel for the parties and carefully gone through the case file.
7.           Learned counsel for the complainants submitted that since the insured (deceased) had died during the subsistence of the policy in question, as such, OPs No.1 and 2 were under legal obligation to pay the claim amount of Rs.5 lacs, but they did not pay the claim amount to the complainants, on flimsy grounds, which act amounts to deficiency in providing service and adoption of unfair trade practice on their part. 
8.           On the contrary, the learned counsel for the OPs submitted that since the complainants failed to provide any documentary/medical evidence to prove that the death of the insured occurred because of any accident or it was accidental in nature, as such, their claim was rightly rejected by OPs No.1 and 2, strictly as per condition no.5-clause 4) of the insurance policy, for which they cannot be held liable for committing deficiency in service or guilty of adoption of unfair trade practice.
9.           It is not in dispute that father of the complainants Late Shri Shyam Sunder Goel, had purchased the policy in question from OPs No.1 and 2, valid from 26.10.2017 to 25.10.2022. It is also an admitted fact that for treatment the insured Shri Shyam Sunder Goel (now deceased) was taken to Post-Graduate Institute of Medical Education & Research, Chandigarh in Emergency, where he died on 24.05.2020 due to sudden cardiac arrest, whereafter, claim was filed by the complainants under the said insurance policy, which was ultimately closed by the OPs No.1 and 2. Thus, under these circumstances, the moot question which arises in this case is as to whether, the OPs No.1 and 2 were justified in not paying the claim amount to the complainants and closing their claim file under the category “No Claim” or not?
10.           Before proceeding further, it is significant to mention here that though the insured, under the said policy, was covered both for critical illness and accidental death, yet, since in the present case, the insured had died, as such, his case has to be adjudicated while keeping in mind the claim towards death of the insured and not reimbursement of expenses towards his critical illness.

                   A bare perusal of written version filed by OPs No.1 and 2 reveals that the main stand taken by them in their defence to justify their stand of not paying the claim amount to the complainants and putting their claim under the category “No Claim” is that since the death of the insured was not accidental/did not occur due to any accident and also at the same time, despite the fact that they wrote numerous letters to the complainants to prove the fact that the death of the insured was accidental, which they failed, as such, their claim was not payable under the policy in question and their file was closed as “No Claim”.

11.           In our considered opinion, for coming to any conclusion of this case, we have to refer the relevant condition no.5 of the policy, Annexure OP-4, which reads as under:-

“…..Section 5-Credit Shield Insurance Policy

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 in the manner agreed in the name of the Insured Person in the books of the Financer/Bank/Mortgage Company, subject to the maximum Sum Insured specified in the Schedule. Claim will be directly paid to the Financer/Bank/Mortgage Company, to the extent of Outstanding Loan amount.

 

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 happen in case loan is taken jointly.

 

12.           Furthermore, under the heading “SPECIFIC DEFINITIONS APPLICABLE TO SECTION 5”, the definition of Accident or Accidental has been given against clause 4) as under:-

          “…..SPECIFIC DEFINITIONS APPLICABLE TO SECTION 5

 

4)  “Accident" or "Accidental" means a sudden, unintended and fortuitous external and visible event.  ….”

13.           From the conjoint reading of Condition No.5 alongwith clause 4, of the policy extracted above, it is evident that in the event of Accidental Death of the insured i.e. a sudden, unintended and fortuitous external and visible event, the claim under the policy was payable by OPs No.1 and 2 i.e. the accident benefit was payable if the assured sustained any bodily injury resulting solely and directly from the accident caused by “a sudden, unintended and fortuitous external and visible event”. However, in the present case, perusal of “Medical Certificate of Cause of Death” dated 24.05.2020, Annexure C-3 issued by the PGIMER, Chandigarh clearly reveals that the cause of death of insured-Shyam Sunder Goyal was “Sudden Cardiac Arrest” and the antecedent cause has been mentioned therein as “Acute Coronary Syndrome, Coronary Artery Disease-I, Hypertension, Chronic Liver Disease Decompensated”. In this view of the matter, in our considered opinion, from the said certificate it can easily be culled out that the insured (deceased) did not die because of a sudden, unintended and fortuitous external and visible event, arising out of any accident, whereas, on the other hand, his death occurred due to sudden cardiac arrest.
14.           A similar question, under similar circumstances, as to whether, if a patient/insured dies due to heart attack will amount to his/her death as accident or accidental in nature under the insurance policy, fell for determination before the Hon’ble Supreme Court of India in Civil Appeal No. 3413 of 2019 (Arising out of SLP (C) No. 32335 of 2016) Smt. Alka Shukla Versus Life Insurance Corporation of India,  decided on April 24, 2019 , wherein, it was held that in order to sustain a claim under the accident/accidental benefit cover, it must be established that the assured has sustained a bodily injury which resulted solely and directly from the accident and that there must, in other words exist a proximate causal relationship between the accident and the bodily injury. Moreover, the accident must be caused by outward violent and visible means. The expression “outward violent and visible” signifies that the cause of the accident must be external. The Supreme Court gave findings in favour of the insurance company by holding as under:-
    • 10 .  The plain reading of the policy is to be accepted as our guide. Under the policy, in order for the complainant to prove her claim, she must show direct and positive  proof that the accident of the assured falling from his motorcycle caused bodily injury by external/outward, violent and visible means. The complainant will have to prove that the accident and the injuries sustained as a result were a direct or proximate cause of her husband’s death.

 

 

12. In the present case, there is no evidence to show that any bodily injuries were suffered due to the fall from the motorcycle or that they led to the assured suffering a heart attack. There is no evidence to show that the accident took place as a result of any outward, violent and visible means. The assured died as a result of a heart attack which was not attributable to the accident.

 

15.           Since, in the present case also,  admittedly the death of the insured occurred because of heart attack as explained above and the complainants have failed to prove that the said heart attack was having any direct proximate cause of any accident caused by “outward, violent and visible means” or because of a sudden, unintended and fortuitous external and visible event, arising out of any accident, therefore, in our considered opinion the OPs No.1 and 2 could not be held deficient or guilty of unfair trade practice, by not considering the claim in question and putting the same under the category of “No Claim”, keeping in mind the provisions of condition no.5  and clause 4) of the policy in question.
16.           In view of peculiar facts and circumstances of this case, it is held that because the complainants have failed to prove their case, therefore, no relief can be given to them. Resultantly, this complaint stands dismissed with no order as to cost. Certified copy of the order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced on: 29.08.2022.

 

 

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

              Member                         Member                       President