BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.401 of 2016

Date of Instt. 19.09.2016

Date of Decision: 03.10.2017

1. Jaswinder Kaur Widow of Jagdish Singh.

2. Gurpreet Singh S/o Late Jagdish Singh.

3. Manjinder Singh S/o Late Jagdish Singh, All residents of H.No.2017, V.P.O. Gumtali, Tehsil Phillaur, Distt. Jalandhar, Punjab.

..........Complainants

Versus

1. HDFC Ergo General Insurance Co. Ltd. 6^th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (E), Mumbai 400059

2. HDFC Ergo General Insurance Co. Ltd. 3^th Floor, Eminent Mall, 261, Lajpat Nagar, Near Guru Nanak Mission Chowk, Jalandhar.

3. HDFC Bank Ltd. Shopers Paradise Building, Mandi Road, Nurmahal, Jalandhar.

….… Opposite parties

Complaint Under the Consumer Protection Act.

Before: Sh. Karnail Singh (President)

Sh. Parminder Sharma (Member)

Present: Sh. Rajesh Verma, Adv Counsel for the complainant.

Sh. RK Sharma, Adv Counsel for the OP No.1 and 2.

OP No.3 exparte.

Order

Karnail Singh (President)

1. This complaint filed by the complainants, wherein alleged that the complainants are the legal heirs of Late Jagdish Singh, who died on 07.01.2016. The said Late Jagdish Singh purchased a vehicle Cheverlot Car Enjoy for personal use bearing registration number PB-08-CM-8368. The said vehicle was got financed from OP No.3 and Late Jagdish Singh paid the EMI of the vehicle regularly till his death. Copy of the registration certificate is placed on the file. The above said vehicle was insured with OP No.2, vide policy No.2950200600514300000 for the period from 23.10.2013 to 22.10.2018. The said vehicle was insured under policy/plan SARV SURAKSHA PLUS and it was covered under the following heads:-

2. That Late Jagdish Singh deposited the total premium of Rs.6438/- under the above mentioned policy heads/coverages and accordingly policy documents were issued by the OP No.1 and 2 to Late Jagdish Singh on 23.10.2013. The said policy was issued by the OP No.2 under the control and management of the OP No.1. Copy of the policy documents are attached. That on 15.11.2014, Late Jagdish Singh suffered heart problem and was admitted at Chawla Heart Care Centre, Jalandhar for treatment and he was operated there and was discharged on 26.11.2014 in stable condition. Late Jagdish Singh spent an amount of Rs.1,90,875/- for his medical treatment. Copies of the medical bills are attached. That on 24.12.2015, Late Jagdish Singh was again admitted in the Chawla Heart Care Centre, Jalandhar for heart problem in the ICU Ward but due to the seriousness of the heart problem, he could not get recovered and died on 07.01.2016.

3. That the claim with regard to the policy Sarv Suraksha Plan was lodged by the wife of Late Jagdish Singh with the OP No.2 as the death of the Late Jagdish Singh was accidental death due to the severe heart problem and the cause of death is covered under the policy purchased by him. The sum insured under accidental death is Rs.5,00,000/-. That due to the accidental death of Jagdish Singh, the present policy was also covered under the Credit Shield Insurance, which means that the remaining outstanding EMI of the vehicle were exempted from payment with the OP No.3 as after death, the remaining EMI were 34 of Rs.12,920/- each amounting to Rs.4,39,280/-, which the OP No.1 and 2 are liable to pay to the Legal Heirs or to the OP No.3 i.e. Bank to adjust the outstanding EMI of the vehicle. The complainants completed the requisite formalities and submitted the necessary documents to the OP No.1 and 2, but the claim under the policy was repudiated arbitrarily without applying mind upon illogical and baseless grounds. The OP No.2 has wrongly mentioned that Late Jagdish Singh was having history of Myocardial infarction since 2007, which is based upon flimsy grounds as Late Jagdish Singh was never admitted in any Hospital nor taken any medicine of any heart problem in the year 2007. The complainants told the doctor about the earlier Blood Pressure problem and the doctor has wrongly written a heart problem, which was mentioned without any earlier medical investigation. It is not out of place to mention here that the complainant has explained/clarified each and every objection of the OP No.1 and 2 but inspite of that the OP has not settled/paid the claim to the complainants of the above said vehicle and harassed the complainant mentally, physically and financially without any reason, which is deficiency in service on the part of the OP No.1 and 2. The complainant insured his vehicle with the OP No.1 and 2 having its office situated at Jalandhar as the premium under the policy was deposited with the OP No.1 and 2 at its office situated at Jalandhar, hence, this Forum has got the jurisdiction to try and decide the present complaint and accordingly this complaint was filed with the prayer that the complaint of the complainant may be accepted and OP No.1 and 2 be directed to pay a sum of Rs.4,39,280/- on account of policy covered under Credit Shield Insurance, the remaining amount standing in the loan account of deceased as per the bank account statement and further OP No.1 and 2 be directed to pay hospital bills and medicine expenses incurred during hospitalization of deceased to the tune of Rs.1,90,875/- and further be directed to pay compensation of Rs.20,000/- for mental and financial harassment and also be directed to pay litigation cost of Rs.25,000/-.

4. Notice of the complaint was given to the OPs but despite service, OP No.3 did not come present and ultimately OP No.3 was proceeded against exparte.

5. OP No.1 and 2 appeared through their counsel and filed reply, whereby contested the complaint by taking preliminary objections that the insurance is a contract between the insurer and the insured and the liability, if any, is decided only on the fulfillment of terms and conditions of the contract. In the present case, since the ailments are not covered under Critical Illness cover, the claim has rightly been denied. Further, since the loss to the life of the insured is also not within the purview of accidental death, the claim under Credit Shield and Accidental Death is not maintainable. It is further averred that the claim was lodged by the legal heir, Jaswinder Kaur, widow of the deceased insured claiming benefit under Critical Illness stating that the deceased suffered Heart Attack while going to hospital Chawla Heart Care Centre. Thereafter, the claim was lodged and all the necessary documents viz discharge card, treatment sheet, medical bills and other related documents were asked for processing of the claim. The copy of the claim form is annexed herewith. It is further alleged that as per treatment record of the insured, the insured Jagdish Singh earlier was admitted in the Chawla Heart Care Centre on 15.11.2014 and underwent for OPCAB (Off Pump Coronary Artery Bypass Grafting-OPCAB surgery is open heart surgery performed without the patient on cardiopulmonary bypass and with the heart still beating and was discharged from the Hospital on 26.11.2014. The discharge summary dated 26.11.2014 of the hospital clearly mentioned about the patient having History of Myocardial Infarction in 2007 not taking medicines regularly. Thereafter, also complainant Jagdish Singh received treatment from Chawla Heart Care Centre in the month of December, 2015 and died on 07.01.2016 due to Heart Attack. It is further alleged that the death of the insured Jagdish Singh was not accidental death, as such the claim under Accidental Death and Credit Shield Insurance is not maintainable. As per the coverage under Credit Shield, the liability of the insurance company for paying the balance outstanding loan amount is only in the event of Accidental Death of insured or Permanent Total Disablement of the Insured, which is not so in the present case as the insured died due to Heart Attack and further alleged that there is neither any deficiency in service nor any negligence nor any unfair trade practice on the part of the answering OPs and as such the claim of the complainant is rightly repudiated. On merits, the purchase of the policy by the deceased Jagdish Singh and death of the Jagdish Singh in the Chawla Hospital and further submitting of claim by the complainant is not disputed by the OPs rather these factum have been admitted and the other averments as made in the complaint are categorically denied and lastly prayed that the complaint of the complainant is without merit and the same may be dismissed.

6. In order to prove the case of the complainant, one of the complainants Jaswinder Kaur tendered his duly sworn affidavit Ex.C1 alongwith some documents Mark C2 to Mark C23 and then closed the evidence.

7. In order to rebut the evidence of the complainant, the counsel for the OP No.1 and 2 tendered into evidence affidavits of the Pankaj Kumar Ex.OA and Ex.OB alongwith some documents Ex.O1 to Ex.O4 and closed the evidence.

8. We have heard the learned counsel for the respective parties and also scanned the case file very minutely.

9. From the over all circumstances, it reveals that the factum in regard to purchase of the policy/plan Sarv Suraksha Plus by deceased Jagdish Singh, who is the husband of the complainant No.1 and father of the complainant No.2 and 3 and after the death of Jagdish Singh, the complainant submitted an insurance claim with the OP No.1 and 2 but the same was repudiated by the OPs, vide repudiation letter Mark C22 and the said repudiation letter is challenged by the complainant, on the ground that the said repudiation letter is not based on any solid grounds rather the claim of the complainant is rejected illegally. No doubt, the insurance claim of the complainant is not denied by the OP. Moreover, when OP rejected the claim, vide repudiation letter dated 21.07.2016 Mark C22, then it is clearly established that the complainant filed an insurance claim and now question remains whether the claim of the complainant is rightly repudiated by the OP or not, for that purpose, the material document is Mark C4, issued by the OP No.1 and 2, sent to deceased Jagdish Singh and in this letter the benefits cover under the policy is very well mentioned, which are about 8 in numbers and similarly these coverage are also elaborated in the insurance policy Mark C5. The claim of the complainant is repudiated by the OP on the ground that there is a delay of intimation of claim about 597 days and as the delay is not explained by the complainant, therefore the complainants are not entitled for the claim.

10. The next ground taken by the OP in the repudiation letter is that any Critical Illness for which care, treatment or advise 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. The grounds for repudiation of the claim is considered and co-related with the other documents i.e. letters sent by the complainant and insurance policy and find that the claim of the complainant is covered under the heading of Credit Shield Insurance not under the Critical Illness as elaborated by the OP in the written statement, the OP alleged that as per the term and condition 3/3.1 according to that provision, the intimation in regard to death is to be made immediately but in this complaint, the complainant made any intimation after the expiry of 597 days, but we find that the terms and conditions are not proved to be supplied to the complainant at the time of giving insurance, if so then, neither the complainants nor the deceased Jagdish Singh is bound by the said term and condition as alleged by the OPs. So, accordingly we find that if the complainants or insured Jagdish Singh were not aware about the submitting of intimation in regard to death or any un-towards accident, to the OP immediately, then the complainant cannot be suffered for that fault of the OP.

11. Apart from above, if we go through the insurance policy Mark C5, then we can say without any hesitation that there is no specific condition is given in the said insurance policy that the claim is to be submitted within any specific period. So, accordingly we do not find any delay and moreover, the version of the OP is not acceptable that the case of the complainant is covered under the Critical Illness because as per coverage detail, which is eight type coverage category and case of the complainant is covered under six category Credit Shield Insurance and as per this coverage, the OPs are bound to pay the remaining EMI, but to the extent of the insured amount i.e. Rs.5,00,000/-, but in this complaint, the complainant asked for payment of remaining EMI Rs.4,39,280/-, the outstanding loan amount against insured deceased Jagdish Singh. In order to give strength to above observation, we like to refer Section 5 of the term and condition under the heading 'Credit Shield Insurance Policy', whereby OPs are bound to pay the balance outstanding loan amount in the manner agreed in the name of the insured person in the books of the finance, subject to the maximum sum insured specify in the schedule, in the event of accidental death or permanent total disability of the insured person during the policy period, claims payment will be deposited directly in the loan account number maintained by the finance/bank/mortgage company to the extent of outstanding loan amount.

12. If, we see the case of the complainant in the light of above detailed discussion, then we find that the claim of the complainant is arbitrarily and illegally repudiated by the OP No.1 and 2 and as such, we reach to the conclusion that the complainants are entitled for the relief and accordingly the complaint of the complainants is partly accepted and OP No.1 and 2 are directed to pay the remaining loan amount of Rs.4,39,280/- in the loan account of deceased Jagdish Singh and further OP No.1 and 2 are directed to pay compensation for physical, mental and financial harassment to the complainant to the tune of Rs.20,000/- and OP No.1 and 2 are also directed to pay litigation expenses of Rs.10,000/-. The entire compliance be made within one month from the date of receipt of the copy of order. Complaint could not be decided within stipulated time frame due to rush of work.

13. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated Parminder Sharma Karnail Singh

03.10.2017 Member President