Delhi

North East

CC/134/2021

Archana Pandey - Complainant(s)

Versus

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

02 Sep 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

Complaint Case No.134/21

 

In the matter of:

	Mrs. Archana Pandey, W/o Late Sh. Sandeep Pandey, 1/4614-A, Gali No. 2, Ramnagar Extenstion, Shahdara, Delhi 110032	Complainant
	Versus
1.                   2.                     3.       4.                   5.	HDFC ERGO General Insurance Co. Ltd., 6th Floor, Leela Business Park, Andheri Kurla Road, Andheri(East) Mumbai 400059 Also at: 1st Floor, HDFC House,  165/166 Backbay Reclamation, H.T. Parekh Marg, Church Gate, Mumbai 40020   HDFC Bank Ltd. (Formerly Housing Development Finance Corporation Ltd.) Ground Floor, A-13/2, High Way Towers, Sector 62, Noida-201309 Also at: 1st Floor, HDFC House,  165/166 Backbay Reclamation, H.T. Parekh Marg, Church Gate, Mumbai 40020   HDFC Bank ltd. (HDFC Ltd.), India Habitat Centre- 6 A, 5th Floor, Lodhi Road, New Delhi 110003   HDFC Sales Pvt. Ltd., Ramon House, H.T. Parekh Marg, 169, Backbay Reclamation, Church Gate, Mumbai 40020 Also at: Plot No. C 9, 3rd Floor, Pearl Best Heights II Netaji Subhash Palace, New Delhi   HDFC Standard Life Insurance Co. Ltd., HDFC SL Delhi Mayur Vihar Branch, 1st Floor No. 1/A, Mayur Palace, Star City Mall, Mayur Vihar, Phase I Near Mayur Vihar Extn. Metro Station, New Delhi 110091	Opposite Parties

 

DATE OF INSTITUTION:         JUDGMENT RESERVED ON:                         DATE OF ORDER  :

24.09.2021 01.07.2024 02.09.2024

 

 

CORAM:

Surinder Kumar Sharma, President

Adarsh Nain, Member

ORDER

Adarsh Nain, Member

The Complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019.

Case of the Complainant

1. The case of the Complainant as revealed from the record is that her late husband had purchased two policies namely Sarv Suraksha Policy bearing no. 2999201366179903 and Home Suraksha Plus Policy bearing no. 2918 2019 2096 9900 000 from Opposite Party 1. i.e. HDFC ERGO General Insurance Co. Ltd.,Complainant stated that as her late husband availed  home loan for a sum of Rs. 42,00,000/- from the Opposite Party No. 2, in 2017, same was secured under Home Suraksha Plus  Policy no. 2918 2019 2096 9900 000  issued by Opposite Party No. 1. Complainant stated that due to high fever, vomiting and difficulty in breathing her late husband had to be hospitalized and was admitted in Yashoda Hospital, Ghaziabad, on 18.04.2021 but her late husband could not survive and died on 23.04.2021. Complainant stated that the death certificate of the deceased husband shows that the cause of the death was Cardio Pulmonary Arrest and in the death summary the relevant past medical/surgical history clearly states that there was no such pre-existing disease. Complainant stated that she being the nominee in the Home Suraksha Policy lodged the claim on 23.06.2021 and mother of the deceased being nominee in Sarv Suraksha Policy lodged the claim on 26.07.2021. Opposite Party No. 1 repudiated the claim vide its mail dated 30.07.2021. Complainant stated that Opposite Party No. 1 had issued the policy on mail that contained only two pages thereafter nothing was issued or supplied and on perusal of the same shows that the Critical Illness Section as mentioned by the Opposite Party No. 1 while repudiating the claim does not find any mention anywhere and specifically covers Credit Shield for a sum of  Rs. 7,00,000/-, Critical Illness for a sum of Rs. 1,00,000/- and it was for this reason that the insured got lured and induced to buy this policy that in case any mishap with his life the loan as sanctioned by the Opposite Party No. 2 would stand covered for a sum off Rs. 8 lakh. Hence, the Opposite Party No. 1 had wrongly repudiated the claim of the Complainant. Complainant stated that the second policy namely Home Suraksha Plus was lodged on 23.06.2021 but no response to the same till 25.08.2021 which means that the claim should stand accepted since the turnaround the time for settlement of a claim in terms of IRDA guidelines is 7 days. Complainant stated that with respect to Sarv Suraksha Policy she vide e-mail dated 03.09.2021 lodged its protest and requested Opposite Party No. 2 to review the same and pay the amount directly to the Home Loan Policy account. Complainant stated that the second policy namely Home Suraksha Plus was never responded and upon enquiry, it was told that no such claim had been registered by the Opposite Party No. 1. Complainant filed a fresh claim on 25.08.2021 though the demand of the complainant to treat the claim as lodged on 23.06.2021 as accepted as it was the Opposite Party No. 1 who had defaulted and violated the norms and the same need to be allowed on this score alone. Complainant stated that Opposite Party No. 1 vide its mail and letter dated 01.09.2021 communicated the repudiation of the claim on flimsy ground and another mail dated 06.09.2021 in which Opposite Party No. 1 had reiterated its repudiation while rejecting the request to review the cases. Complainant stated that Opposite Party No. 1 had taken COVID 19 to be the cause of death; it had completely ignored its commitment on its website that all the existing policies cover COVID 19. Hence, this shows the deficiency on the part of Opposite Parties. Complainant has prayed to direct the Opposite Party No.  1 to  refund of       Rs. 50,72,274/- as was made to pay under coercion and Legal Threat of Sarfaisi along with interest @ 18 % p.a. and direct the Opposite Party No. 1 to refund the amount  of Rs. 1,00,000/- plus interest @ 18 % p.a. charged as premium gComplainant also prayed for initiating the investigation qua the Opposite Parties in terms of Section 19 of the Act and imposing heavy penalty on the Opposite Parties for all the deficiency as well as appropriate compensation towards opportunity cost as defined under Section 39 (m) of the Act. Complainant also prayed for awarding the cost and expenses and Rs. 20,00,000/- as compensation.

Case of the Opposite Party No. 1

2. Opposite Party No. 1 has filed its written statement wherein they admitted the fact to have issued two insurance policies namely Sarv Suraksha Policy bearing no. 2999201366179903 and Home Suraksha Plus Policy bearing no. 2918 2019 2096 9900 000 to the Complainant’s late husband. It is also admitted that Complainant lodged two different claims against both the policies. On merits, it has been contended that medical documents i.e. death summary and medical certificate of case of death provided by the Complainant showed that the deceased insured was admitted in the hospital “with the complaint of high grade fever on and off in nature and with chills and rigors with difficulty in breathing associated with restlessness dizziness myalgia with nausea, vomiting since 8-9 days.” It is submitted that from the line of treatment, it is clear that insured was given treatment for COVID 19 following which he suffered complications leading to cardiopulmonary arrest which is the immediate cause of death while the antecedent cause of death has been ‘bilateral pneumonia, severe acute respiratory infection, respiratory failure, acute respiratory distress syndrome, sepsis.’ Opposite Party No. 1 contends that the claim of the insured under Sarv Suraksha Policy was repudiated on the ground that above mentioned ailments are not mentioned in the list of critical illness under Sarv Suraksha Policy while the liability of Opposite Party No. 1 is limited to the policy terms and conditions. As per the policy terms and conditions, only following disease are covered under critical illness section of the policy:

1. First Heart Attack of Specified Severity
2. Coronary Artery Disease Requiring Surgery
3. Stroke
4. Cancer
5. Kidney Failure (End stage renal disease)
6. Major Organ Transplantation
7. Multiple Sclerosis
8. Surgery of Aorta
9. Primary Pulmonary Arterial Hypertension
10. Paralysis

 

3. It is contended by Opposite Party No. 1 that the copy of the policy terms and conditions was duly provided to the insured as is clear from the welcome letter dated 03.04.2019 annexed by the Complainant herself. It is mentioned in the said letter that the details of coverage are mentioned only in the enclosed policy schedule of insurance. It is also submitted that Complainant or the deceased insured never asked for the copy of the policy terms and conditions. Regarding the second claim of the insured under Home Suraksha Plus Policy, it is submitted that the same was repudiated on the ground that the medical documents show that the insured was treated for COVID 19 and the same was not covered under nine nature medical illness/procedure opted for the coverage by the insured. Since, the insured had opted for the coverage of following illness:

1. Cancer
2. End Stage Renal Failure
3. Multiple Sclerosis
4. Major Organ Transplant
5. Heart Valve Replacement
6. Coronary Artery Bypass Graft
7. Stroke
8. Paralysis
9. Myocardial Infarction

 

4. Opposite Party No. 1 makes the submission that since the cause of death i.e. cardiopulmonary arrest with COVID 19, acute respiratory distress syndrome with bilateral pneumonia with Shock with Type II respiratory failure was not included in the policy coverage. Opposite Party No. 1 denied the allegations of the Complainant that as per IRDAI guidelines, all the treatment of COVID 19 are covered. It is contended that the guidelines passed by the IRDAI are against the hospitalization expenses incurred against the treatment of COVID 19 cases against Medical policies/Reimbursement claims and not against the benefit policies. While in the present case both the policies issued are survival benefit policy, and not a compensation policy which is issued covering the death, unlike life insurance policy. Opposite Party 1 also makes submission that medically, there is difference between the Cardiorespiratory Arrest and Acute Myocardial Infarction. Cardiorespiratory arrest means sudden loss of heart function and breathing. It is not a listed critical illness and is distinct from Acute Myocardial Infarction. Acute Myocardial Infarction occurs when blood flow to the heart is blocked and results in death of heart tissue.
5. In view of above facts and circumstances Opposite Party No. 1 prayed for the dismissal of the present complaint as there is no deficiency in service on the part of Opposite Party No. 1 while repudiating the claim of the Complainant.

Case of the Opposite Party No. 2 and 3

6. In their written statement, Opposite Party No. 2 and Opposite Party No. 3, while admitting to have issued housing loan of Rs. 42 lakhs to the Complainant’s late husband, contend that the insurance contract entered into between the Complainant’s deceased husband and Opposite Party No. 1 i.e. HDFC General Insurance Company Ltd. which is entirely different, separate

and independent contract from the loan agreement entered into between the Complainant’s husband and Opposite Party No. 2 and Opposite Party No. 3. Opposite Party No. 2 and Opposite Party No. 3 has no role to play in the case of breach of any terms of such contract or any alleged deficiency on the part of Opposite Party No. 1. It is further submitted that liability of the Complainant towards repayment of said loan is absolute and continuous till the time of full and final closure of loan. They have been wrongly impleaded in the matter and their name should be struck off from the array of parties. It is prayed that in case any amount is allowed to be paid by the insurance company to the Complainant, the same amount should firstly be allowed in favour of HDFC Ltd. i.e. Opposite Party No. 2 and Opposite Party No. 3 as they have first right over the amount towards recovery of loan amount and after recovery of loan amount the remaining shall be refunded to the Complainant.

7. None has appeared on behalf of the Opposite Party No. 4 to contest the case despite service of notice. Therefore Opposite Party No. 4 was proceeded against ex-parte vide order dated 22.04.2022.
8. None has appeared on behalf of the Opposite Party No. 5 to contest the case. Therefore Opposite Party No. 5 was proceeded against ex-parte vide order dated 01.05.2023.

 

Rejoinder to the written statement of Opposite Party No. 1, Opposite Party No. 2 and Opposite Party No. 3

9. The Complainant filed separate rejoinders to the written statements of Opposite Party No. 1, Opposite Party No. 2 and Opposite Party No. 3 wherein the Complainant has denied the pleas raised by the Opposite Party No. 1, Opposite Party No. 2 and Opposite Party No. 3 and has reiterated the assertion made in the complaint.

Evidence of the Complainant

10. The Complainant in support of her case filed her affidavit wherein she has supported the assertions made in the complaint.

Evidence of the Opposite Party No. 1

11. To support its case Opposite Party No. 1 has filed affidavit of Ms. Shweta Pokriyal, wherein, she has supported the case of the Opposite Party No. 1 as mentioned in the written statement.

Evidence of the Opposite Party No. 2 and Opposite Party No. 3

12. To support its case Opposite Party No. 2 and Opposite Party No. 3 has filed affidavit of Shri Neelabh Mishra, wherein, he has supported the case of the Opposite Party No. 2 and Opposite Party No. 3 as mentioned in the written statement.

 

Arguments & Conclusion

13. We have heard the Ld. Counsel for the Complainant and Opposite Party No. 2 and Opposite Party No. 3. We have also perused the file and written arguments filed by the Complainant and Opposite Party No. 1. The case of the Complainant is that her late husband had purchased two policies namely Sarv Suraksha Policy and Home Suraksha Plus Policy from Opposite Party 1. i.e. HDFC ERGO General Insurance Co. Ltd. It is alleged by the Complainant that upon death of her husband who was insured under both the policies, she filed two separate claims which were repudiated by Opposite Party No. 1 on flimsy grounds that COVID 19 was the cause of death and same is not covered under the policy. It is contended by the Complainant that the cause of the death was Cardio Pulmonary Arrest and in the death summary the relevant past medical/surgical history clearly states that there was no such pre-existing disease.  On the other hand, case of the Opposite Party No. 1 is that they have rightly repudiated the claims of the Complainant in accordance with terms and conditions of the policy as the line of treatment shows that the deceased insured was treated and died due to COVID 19 which is not covered under the subject policies.
14.  It is not disputed that the subject policies were issued by the Opposite Party No. 1 to the late husband of the Complainant and claims filed by the Complainant were repudiated by Opposite Party No. 1.
15.  The allegation of the Complainant is that her claims were wrongly repudiated by Opposite Party No. 1 on flimsy grounds that COVID 19 was the cause of death which is not covered under the policy. It is contended by the Complainant that in fact the cause of the death was Cardio Pulmonary Arrest and in the death summary the relevant past medical/surgical history clearly states that there was no such pre-existing disease. Opposite Party No. 1 has taken the defence that medical documents i.e. death summary and medical certificate of cause of death provided by the Complainant showed that the deceased insured was admitted in the hospital “with the complaint of high grade fever on and off in nature and with chills and rigors with difficulty in breathing associated with restlessness dizziness myalgia with nausea, vomiting since 8-9 days.” It is submitted by Opposite Party No. 1 that from the line of treatment, it is clear that insured was given treatment for COVID 19 following which he suffered complications leading to cardiopulmonary arrest which is the immediate cause of death while the antecedent cause of death has been ‘bilateral pneumonia, severe acute respiratory infection, respiratory failure, acute respiratory distress syndrome, sepsis.’
16. Opposite Party No. 1 contends that the claim of the deceased insured under Sarv Suraksha Policy was repudiated on the ground that above mentioned ailments are not mentioned in the list of critical illness under Sarv Suraksha Policy while the liability of Opposite Party No. 1 is limited to the policy terms and conditions. As per the policy terms and conditions, only following disease are covered under critical illness section of the policy:

1. First Heart Attack of Specified Severity
2. Coronary Artery Disease Requiring Surgery
3. Stroke
4. Cancer
5. Kidney Failure (End stage renal disease)
6. Major Organ Transplantation
7. Multiple Sclerosis
8. Surgery of Aorta
9. Primary Pulmonary Arterial Hypertension
10. Paralysis

 

17. Regarding the other claim of the insured under Home Suraksha Plus Policy, it is submitted that the same was repudiated on the ground that the medical documents show that the insured was treated for COVID 19 and the same was not covered under nine nature medical illness/procedure opted for the coverage by the insured. Since, the insured had opted for the coverage of following illness:

1. Cancer
2. End Stage Renal Failure
3. Multiple Sclerosis
4. Major Organ Transplant
5. Heart Valve Replacement
6. Coronary Artery Bypass Graft
7. Stroke
8. Paralysis
9. Myocardial Infarction

 

18. Opposite Party No. 1 also makes the submission that the cause of death i.e. cardiopulmonary arrest with COVID 19, acute respiratory distress syndrome with bilateral pneumonia with Shock with Type II respiratory failure was not included in the policy coverage. Their contention is that medically, there is difference between the Cardiorespiratory Arrest and Acute Myocardial Infarction. Cardiorespiratory arrest means sudden loss of heart function and breathing. It is not a listed critical illness and is distinct from Acute Myocardial Infarction. Acute Myocardial Infarction occurs when blood flow to the heart is blocked and results in death of heart tissue. The defence of Opposite Party on the point is accepted in view of the fact that Complainant has not been able to show anything to the contrary and also has not denied the contention specifically.
19. It is also the case of the Complainant that as per IRDAI guidelines, all the treatment of COVID 19 are covered. Opposite Party No. 1 has contended that the guidelines passed by the IRDAI are against the hospitalization expenses incurred against the treatment of COVID 19 cases against Medical policies/Reimbursement claims and not against the benefit policies. While in the present case both the policies issued are survival benefit policy, and not a compensation policy which is issued covering the death, unlike life insurance policy. Perusal of the IRDAI guidelines relied upon by the Complainant herself clearly confirms this fact, hence the case of Opposite Party No. 1 is accepted that COVID 19 is not covered under the subject policies which are benefit policies.
20. It is also the case of the Complainant that Opposite Party No. 1 had issued the policy on mail that contained only two pages thereafter nothing was issued or supplied while the contention of Opposite Party No. 1 is that the copy of the policy terms and conditions was duly provided to the insured as is clear from the welcome letter dated 03.04.2019 annexed by the Complainant herself. It is mentioned in the said letter that the details of coverage are mentioned only in the enclosed policy schedule of insurance. Opposite Party No. 1 also contends that Complainant or the deceased insured never asked for the copy of the policy terms and conditions. The Complainant has simply denied the said contention and has not produced any cogent evidence to show that upon receiving the policy documents, her late husband asked for the copy of the policy terms and conditions from Opposite Party No. 1 more particularly when the policy document admittedly received by the Complainant, clearly mentions that ‘the Policy wordings attached herewith’. Therefore, the contention of the Complainant cannot be accepted for want of any evidence and the defence of the Opposite Party No. 1 is accepted as the same has not been specifically rebutted and there is no evidence shown to the contrary.
21. It is clear from the evidence on record such as medical documents that the deceased insured was treated for COVID 19, following which he suffered complications leading to cardiopulmonary arrest which is the immediate cause of death while the antecedent cause of death has been ‘bilateral pneumonia, severe acute respiratory infection, respiratory failure, acute respiratory distress syndrome, sepsis.’. It is also clear from the perusal of both the policy documents that Complainant’s claims were not covered under the policy as IRDAI guidelines on COVID 19 are not covering cases under benefit policies. The Complainant has also been unable to show any evidence such as any correspondence with Opposite Party No. 1 asking for terms and conditions of the policies when it was written in the policy document itself that policy terms are enclosed. Since, both the claims were repudiated as not found covered under the policy, we do not see any deficiency on the part of any of the Opposite parties.
22.  In view of above facts and discussion, we are of the considered view that there has been no deficiency in services or unfair trade practice towards the complainant on the part of any of the Opposite Parties.
23. Thus, present complaint is dismissed with no order as to costs.
24. Order announced on 02.09.2024.

Copy of this order be given to the parties free of cost

File be consigned to Record Room.

(Adarsh Nain)		(Surinder Kumar Sharma)
(Member)		(President)