Complaint No: 194 of 2022.
Date of Institution: 15.09.2022.
Date of order: 19.10.2023.
Menka Gautam Gaur w/o Rakesh Gaur, resident of Rattan Colony Gandran Lahri, Gurdaspur at present Army School Tibri Cant, Gurdaspur. Pin Code – 143534.
….......Complainant.
VERSUS
1. HDFC Ergo General Insurance Company Ltd. 6th Floor, Leela Business Park, Andheri Kurla Road, Andheri (East) Mumbai – 400059.
2. HDFC Ergo General Insurance Company Ltd. Registered and Corporate office First Floor HDFC house, 165/166 Backbay Reclamation, H.T. Parekh Marg, Church gate, Mumbai – 400020, through its Authorized Signatory.
3. Retail Loan Service Centre, HDFC Bank Ltd. Third floor 21-14570, G.T. Road Dholewal Chowk, Adjoining Guljar Motors Ludhiana, through its Branch Manager. 141003.
4. Satguru Partap Singh Hospital, Sherpur Chowk, G.T. Road, Ludhiana -141003, through its Managing Director.
5. Kotak Mahindra General Insurance Company Ltd. Kotak Car Secure, Claims Department 7th Floor, Zone-2, Kotak Infiniti, Building No. 21, Infinity Park, Off Western Express Highway General AK Vaidya Mark, Malad (E) Mumbai - 400 097, through its Managing Director.
.....Opposite parties.
Complaint u/s 35 of The Consumer Protection Act.
Present: For the complainant: Sh.Pardeep Singh, Advocate.
For the opposite parties No.1 and 2: Sh.Rajpal Singh and
Sh.Rajinder Singh, Advocates.
Opposite parties No.3 & 4 exparte.
Complaint against opposite party No.5 has already been
withdrawn.
Quorum: Sh.Lalit Mohan Dogra, President, Sh.Bhagwan Singh Matharu, Member.
ORDER
Lalit Mohan Dogra, President.
Menka Gautam Gaur, Complainant (here-in-after referred to as complainant) has filed this complaint under section 35 of The Consumer Protection Act, (here-in-after referred to as 'Act') against HDFC Ergo General Insurance Co. Ltd. etc. (here-in-after referred to as 'opposite parties).
2. Briefly stated, the case of the complainant is that the better half of complainant took Auto Loan of Rs.5,57,998/- from opposite party No.3 which was disbursed on 30.9.2021. It is further pleaded that the installment start date was 05.11.2021 and installment end date was 05.10.2028 which was to be paid at fixed rate of interest @ Rs.8600/- per month for 84 months to the opposite parties. It is further pleaded that the husband of complainant paid two installments at the rate of Rs.8600/- per month to the opposite parties which was duly received by the vide Cheque No.S122885140/1-1 and S122885140/1-2. It is further pleaded that the auto loan was insured with HDFC Ergo as preferred insurance partner under the Sarv Suraksha Plus Group policy reference No. 2855204324123700000 for which the opposite parties received an amount of Rs.3153/- towards Premium for Sarv Suraksha Plus (Group) and certificate was issued to husband of complainant which was valid for the period 04.10.2021 to 03.10.2026. It is further pleaded that Sarv Suraksha is comprehensive insurance policy specially designed for customers availing a loan with an objective to provide financial security to the loan borrower and his family in case of an unfortunate event. It is further pleaded that this policy provides insurance cover maximum up to the loan amount. It is further pleaded that the major coverage under the policy are:-
i. Accidental death
ii. Permanent total or partial disablement
iii. Accident hospitalization
iv. Householder cover
v. Critical illness
vi. Loss of job
vii. Credit shield
viii. Garage cash.
It is further pleaded that the tenure of the policy is 5 years or the loan tenure whichever is less. It is further submitted that the policy covers the critical illnesses which means an illness, sickness or a disease or a corrective measure like cancer, kidney failure, coronary artery (Bypass) surgery Heart Attack (Myocardial Infraction), Heat Valve surgery major organ transplantation, multiple sclerosis, primary pulmonary, Arterial Hypertension, Aorta Graft Surgery Paralysis, Coma, total Blindness and stroke all as defined in scope of cover and benefits section of this policy as per IRDA Rules and Regulations. It is further pleaded that on 10.12.2021 at midnight the husband of complainant suffered first time heart attack with severity and he was rushed to Satguru Partap Singh Hospital, Sherpur Chowk Ludhiana, where he died due to Cardiac Arrest as per the death confirmation report issued by opposite party No. 4. It is further pleaded that after the death of the husband of complainant she intimated the opposite parties through online for the waiving off auto loan as the opposite parties had done the insurance of Sarv Suraksha Plus (Group) which provides financial security to the loan borrower and his family in case of an unfortunate event as the policy provides maximum cover upto the loan amount and waive off the remaining amount of Rs.5,47,880/- outstanding claim of auto loan by the issuing NOC of the loan amount to the complainant as her husband died of critical illness i.e. first heart attack of severity as per the medical record of the opposite parties. It is further pleaded that the opposite parties repudiated the genuine claim of the complainant vide claim No. RR- C121-12773999 by assigning the reason that first heart does not falls under critical illness which is illegal, arbitrary, null and void and against the provisions and guidelines of IRDA be set aside by accepting the claim petition as heart attack falls within the definition of critical illness as held by the Hon'ble High Courts and Supreme Court of India has held that heart attack death is undersigned, unwanted mishap and therefore amounts to an accident for the family.
In Union of India vs. Sunil Kumar Ghosh, this court dealt with the expression accident and held thus: -
"13. An accident is an occurrence or an event which is unforeseen and startles one when it takes place but does not startle one when it does not take place. It is the happening of the unexpected, not the happening of the expected, which is called an accident. In other words an event or occurrence the happening of which is ordinarily expected in the normal course by almost everyone undertaking a rail journey cannot be called an accident. But is happening of something which is not inherent in the normal course of events, and which is not ordinarily expected to happen or occur, is called a mishap or an accident."
P Ramanatha Aiyar's Law Lexicon defines the expression accident as
"an event that takes place without one's foresight or expectation and event that proceeds from an unknown cause or is an unusual effect of a known cause and therefore not expected, chance, causality, contingency".
The expression 'accident' in the context of an accident insurance policy has been explained in McGillivray on Insurance Law.
"In the context of an accidental insurance policy the word is usually contained in phrased such as "injury by accident", "accidental injury", “injury caused by or resulting from an accident" or "injury caused by accident means" and in each of these phrases it has the connotation of an unexpected occurrence outside the normal course of events."
Collnvaux's Law of Insurance explains the expression 'bodily injury' thus:-
"It is usual for the policy to require an accident to manifest itself as "bodily injury" to the assured. The most obvious form of bodily injury is external trauma causing physical injury, but the phrase is not limited to injury to the exterior of the body the term "body injury". When used in a personal accident policy is not limited to lesions, abrasions or broken bones. Nor is it essential that there should be an external mark of injury on the assured's body..."
In Swaranjit Kaur Vs. ICICI Lombard General Insurance Co. Ltd the assured while travelling on his scooter, suffered a heart attack and fell from his scooter. The claim for accident benefit cover was repudiated on the ground that the insured had died a natural death because of heart attack. The State Commission set aside the order of the district from allowing the claim. The NCDRC while upholding the State Commission's judgment; noted that the onus to prove that the insured had died as a result of an accident and not a heart attack was on the claimant. It held thus:
"On perusal of the copy of repudiation letter, it is clear that the respondents repudiated the insurance claim on the ground that cause of death of insured was heart attack. On perusal of the report of the investigator, we find that the stand of the petitioners in the statement made before the investigator on 17.8.2006 was that
While driving the scooter insured suffered a heart attack, consequently, he felt down from the scooter and died. From this; it is clear that the accident took place
after the insured had suffered heart attack. Otherwise also, in order to succeed in the insurance claim, the onus of proving that the insured had died as a result of accident was on the petitioners. Undisputedly, incident was not reported to the police nor post mortem to establish cause of death was done. No evidence has been produced by the petitioners to prove the cause of death of the insured. There is nothing in the statement of the petitioners as recorded by the investigator that the insured had suffered any bodily injuries due to fall from the scooter. Thus, under the circumstances the conclusion of the State Commission that cause of death of the insured was heart attack and not an accident cannot be faulted. It is further submitted that as per the Sarv Suraksha Plus (Group) the complainant is entitled for Accidental Hospitalization expenses of Rs.1,00,000/-.
i. Last rites of Rs.10,000/-
ii. Loss of income/ EMI Protector Rs.10,000/-
iii. Major Medical illness Rs.1,00,000/-
iv. Accident death Rs.10,00,000/- (Ten Lacs) P.A Cover for owner driver of Rs.15,00,000/-.
v. Transportation of mortal remains Rs.10,000/- from the opposite parties as they have received premium of Rs.7998/- along with GST which is implicit from the certificate No. 2855204324123700000 issued on 5.10.2021 to the husband of the complainant.
It is further pleaded that the complainant approached numerous times to the opposite parties for the immediate waiving off the remaining loan amount of Rs.5,47,880/- and issue NOC as the auto loan sanctioned by the opposite parties was insured under the Sarv Suraksha Plus policy (Group) for which the opposite parties had received Rs.3153/- as premium but the opposite parties hoodwinked the complainant and till date the genuine claim has not been released and outstanding loan amount not waived off which is unfair practice and deficiency in services by the opposite parties. It is further pleaded that due to this illegal act and conduct of the opposite parties the complainant has suffered great loss and also suffered mental agony, Physical harassment and inconvenience. It is further pleaded that there is a clear cut deficiency in service on the part of the opposite parties.
On this backdrop of facts, the complainant has alleged deficiency and negligence in service and unfair trade practice on the part of the opposite parties and prayed that necessary directions may kindly be issued to the opposite parties to waive off the remaining outstanding auto loan in the name of husband of complainant amounting to Rs.5,47,880/- as the Auto loan was insured with Sarv Suraksha Plus Policy (Group) for which the opposite parties received the premium which insurer the financial security to the loan borrower and his family in case of an unfortunate event and issue NOC to the complainant. The opposite parties be also directed to release the last rites cover of Rs.10,000/- loss of income/EMI protector Rs.10,000/- Major Medical illness Rs.1,00,000/-, accident death Rs.10,00,000/- (Ten Lacs) P.A Cover for owner driver of Rs.15,00,000/- and Transportation of mortal remains Rs.10,000/- from the opposite parties as they have received premium of Rs.7998/- alongwith GST which is implicit from the certificate No.2855204324123700000 issued on 05.10.2021 to the husband of the complainant to the complainant alongwith interest of 18% per annum from the date of death till the realization of the amount in the interest of justice. The complainant be also granted compensation to the complainant of Rs.1,00,000/- for causing mental agony and harassment by withholding the genuine claim. Or any other order deems fit may also be passed in favour of the complainant, in the interest of justice.
3. Upon notice, the opposite parties No.1 and 2 appeared through counsels and contested the complaint and filing their written reply by taking the preliminary objections that as admitted by the complainant that she has already filed complaints before Permanent Lok Adalat bearing No. 11/2022, 12/2022, 22/2022 and 23/2022 and the same is still pending, therefore the complainant cannot evoke the jurisdiction of two Commissions simultaneously, therefore the present complaint is liable to be dismissed. It is further pleaded that the complainant has concealed the material facts from this Hon’ble Commission. It is further pleaded that the present complaint has been filed without any cause of action qua the replying opposite parties and the present complaint has not been filed by a competent person. It is further pleaded that insured/ policy holder Rakesh Gaur has died and the complaint if any can only be filed by all the legal heirs of the decreased, therefore, the present complaint is liable to be dismissed and the complainant has not come to this Hon’ble Commission with clean hands, therefore, the complainant is not entitled for any relief as claimed. It is pleaded that Rakesh Gaur was insured for the period of 04.10.2021 to 03.10.2026 under policy No. 2855 2043 2412 3700 000 for Sarv Suraksha Plus (Group) by the Answering OP’s for benefits as detailed in Coverage Details of the policy subject to conditions and exclusions of the Policy wordings. It is further pleaded that the benefits under the policy are governed by the terms and conditions of the Policy and the liability of the Opposite Parties is limited to the insured perils occurring within the policy period subject to conditions and exceptions as mentioned in the terms and condition of the Policy. The terms and conditions have been duly assessed and approved by the IRDAI. It is further pleaded that the present insurance policy is not a life insurance policy where claim becomes payable only in case of death. It is further pleaded that it is event based policy and claim becomes payable only on happening of the insured events. It is further pleaded that it is wrong that on 10.12.2021 at midnight the husband of the complainant suffered first time heart attack with severity or he was rushed to Satguru Partap Singh Hospital, Sherpur Chowk, Ludhiana, where he died due to cardiac arrest as per death confirmation report issued by the opposite party No. 4. It is further pleaded that the complainant has claimed outstanding loan amount of Rs.5,47,880/- as loan was insured with Sarv Suraksha Plus Policy, further reliefs of last rites cover of Rs.10,000/-, loss of income/EMI protector Rs.10,000/- Major Medical illness of Rs.1,00,000/-, accidental death of Rs.10,00,000/- and P.A cover for owner driver of Rs.15,00,000/- and transportation or mortal Rs.10,000/- besides further compensation of Rs.1,00,000/-, which are not maintainable as the deceased did not die in any accident, rather admittedly the deceased Rakesh Gaur died due to cardiac arrest as such he died naturally, therefore, the alleged claim is legally not maintainable as per policy terms and conditions and liable to be dismissed. It is further pleaded that the complainant intimated the claim to the replying opposite parties on 27.12.2021 and upon carefully reviewing the documents submitted by the complainant to validate the eligibility of claim on the basis of policy terms and conditions, the replying opposite parties repudiated the claim as claim for Major Medical illness does not meet the requirement for its eligibility as per the Policy terms and conditions (which is not disputed as duly supplied to the complainant at the time of issuance of policy), the intimation of repudiation was duly given to the applicant vide letter dated 30.12.2021. It is further pleaded that the complainant is disputing the definition of the word "Accident" as defined under the terms and conditions of the policy, however, it is to be noted that the complainant/insured never disputed the same while purchasing the policy. It is further pleaded that as per detailed facts and submissions made in this reply, the claims of the complainant have been rightly repudiated as per terms and conditions of the policy.
On merits, the opposite parties No.1 and 2 have reiterated their stand as taken in legal objections and denied all the averments of the complaint and there is no deficiency in services on the part of the opposite parties. In the end, the opposite parties prayed for dismissal of complaint with costs.
4. Opposite parties No.3 and 4 did not appear despite the service of notice and was proceeded against exparte vide order date 24.11.2022.
5. Upon notice, the opposite party No.5 appeared through counsels and contested the complaint and filing their written reply by taking the preliminary objections that as admitted by the complainant that she has already filed complaint before Permanent Lok Adalat and the same is still pending, therefore, the complainant cannot evoke the jurisdiction of two Commissions simultaneously, therefore, the present complaint is liable to be dismissed on the ground of subjudice principle as the complaint is not maintainable when the complaint on similar cause of action is pending before the Permanent Lok Adalat. It is further pleaded that the complainant has concealed the material facts from this Hon'ble Commission. It is submitted that in the Permanent Lok Adalat, arguments were heard and the replying opposite party convinced the Chairman, Permanent Lok Adalat that the cardiac arrest do not fall under accident, therefore, the file was kept for order and it was in the knowledge of the complainant that it is not going to get any relief from the Permanent Lok Adalat, therefore, by misusing the process of law the present complaint has been filed which is liable to be dismissed. It is further pleaded that the complainant has made the replying opposite party as party in the present complaint, but from the perusal of complaint, no cause of action has been shown to be arisen against the replying opposite party, therefore, it has been made party unnecessarily and the present complaint is liable to be dismissed qua the replying opposite party. It is further pleaded that the complaint is bad for mis-joinder and non-joinder of necessary parties. It is further pleaded that replying opposite party has been made party in the present complaint without any reason and cause and even no particular relief has been sough against the replying opposite party thus the opposite party shall be deleted from the array of parties to the case and the present complaint is liable to be dismissed qua the replying opposite party. It is further pleaded that present complaint is vague and the complainant has not clarified the reason for impleading the replying opposite party as opposite party No. 5 in the present complaint and the present complaint has not been filed by a competent person. It is further pleaded that insured/policy holder Rakesh Gaur has died and the complaint if any can only be filed by all the legal heirs of the deceased and the complainant has not disclosed with regard to the other legal heirs of the deceased in the present complaint, therefore, the present complaint is liable to be dismissed on this short ground. It is further pleaded that the complainant has not come to the commission with clean hands and has concealed material facts from this Hon'ble Commission, therefore, the complainant is not entitled for any relief as claimed. It is further pleaded that the complainant is estopped by her own act and conduct from filing the present complaint. It is further pleaded that the complainant has got no locus standi to file the present complaint and there is no deficiency in service on the part of replying opposite party, therefore, the present complaint qua the replying opposite party is liable to be dismissed. It is pleaded that without prejudice to above defense’s it is submitted that the death of insured has been taken place due to cardiac arrest while policy terms and conditions and provisions of Indian Motor tariff clearly states that the claim under personal accident cover is only admissible when the accident has been occurred while driving the insured vehicle or while seated as co-driver is the insured vehicle. It is further pleaded that in the present case, no accident has been taken place, there has been no evidence produced to confirm the involvement of vehicle. It is further pleaded that alleged death has occurred due to heart attack which is natural death thus claim is not payable under the personal accident section and there is no intimation of claim, thus complaint is pre-matured.
On merits, the opposite party No.5 have reiterated their stand as taken in legal objections and denied all the averments of the complaint and there is no deficiency in services on the part of the opposite party. In the end, the opposite party prayed for dismissal of complaint with costs.
6. Learned counsel for the complainant has tendered into evidence affidavit of Menka Gautam Gaur, (Complainant) as Ex.CW-1/A alongwith other documents as Ex.C-1 to Ex.C-15.
7. Learned counsels for the opposite parties No.1 and 2 has tendered into evidence affidavit of Ms. Shweta Pokhriyal, (Senior Manager – Legal Claims, HDFC ERGO General Insurance Company Ltd, U.P) as Ex.OP-1,2/1 alongwith other documents as Ex.OP-1,2/2 to Ex.OP-1,2/6.
8. Learned counsels for the opposite party No.5 has tendered into evidence affidavit of Sh. Milind Myakal, (Senior Vice President – Legal Claims, Kotak General Insurance Company Ltd, Chandigarh) as Ex.OP-5/1 alongwith other document as Ex.OP-5/2.
9. Counsel for the complainant has argued that the husband of the complainant had obtained auto loan of Rs.5,57,998/- form opposite party No.3 on 30.09.2021 and the installment was to start from 05.11.2021 and was to end on 05.10.2028. It is further argued that husband of the complainant had paid only two installments of Rs.8600/- per month. It is further argued that the auto loan obtained by the husband of the complainant was insured with HDFC Ergo under Sarv Suraksha Plus Group Policy and the opposite parties received premium amount of Rs.3153/- for Sarv Suraksha Plus Group Policy which was valid from 04.10.2021 to 03.10.2026 and as such loan was secured. As per column of the policy major coverage under the policy was as under:-
i. Accidental death
ii. Permanent total or partial disablement
iii. Accident hospitalization
iv. Householder cover
v. Critical illness
vi. Loss of job
vii. Credit shield
viii. Garage cash.
And as per the column No.5 critical illness means illness, sickness or a disease or a corrective measure like cancer, kidney failure, coronary artery (Bypass) surgery Heart Attack (Myocardial Infraction), Heat Valve surgery major organ transplantation, multiple sclerosis, primary pulmonary, Arterial Hypertension, Aorta Graft Surgery Paralysis, Coma, total Blindness and stroke. It is further argued that on 10.12.2021 at midnight husband of the complainant suffered first heart attack with severity and was rushed to Satguru Partap Singh Hospital, Sherpur Chowk Ludhiana, where he died due to cardiac arrest. It is further argued that complainant had approached the opposite parties for waiving off auto loan under Sarv Suraksha Plus Group Policy which provides financial security to the loan borrower and his family members but opposite parties repudiated the claim of the complainant by assigning reason that first heart attack does not fall under critical illness and accordingly the repudiation of the claim amounts to deficiency in service. It is further argued by the counsel for the complainant that the death of the husband of the complainant is also accidental one and has given reference of MacGillivray on Insurance Law which explains "In the context of an accidental insurance policy the word is usually contained in phrased such as "injury by accident", "accidental injury", "injury caused by or resulting from an accident" or "injury caused by accident means" and in each of these phrases it has the connotation of an unexpected occurrence outside the normal course of events". It is further argued that an accident postulates a mishap or an untoward happening something which is unexpected and unforeseen and as such the claim is payable by the opposite parties by considering the death of husband of the complainant as accidental one and accordingly has prayed that repudiation of the claim by the opposite parties amounts to deficiency in service.
10. On the other hand counsels for the opposite parties No.1 and 2 has argued that complainant had filed complaint before Permanent Lok Adalat inspite of same cause of action and as such present complaint is not maintainable. It is further argued that all the legal heirs have not been arrayed as a party to the complaint. As such complaint is liable to be dismissed. It is further argued by the counsel for the opposite parties No.1 and 2 that the death of husband of the complainant was not due to accident rather husband of the complainant died due to cardiac arrest and as such it was a natural death and claim legally is not maintainable as per the policy's terms and conditions and complaint is liable to be dismissed.
11. During the course of arguments counsel for the complainant Sh.Pardeep Singh Advocate withdraw the present against opposite party No.5 with liberty to file fresh complaint against opposite party no.5 by giving separate statement on 18.10.2018.
12. We have heard the Ld. counsels for the complainant and opposite parties No.1 and 2 and gone through the record.
13. To prove her case complainant has placed on record her duly sworn affidavit Ex.CW-1/A, copy of repudiation of letter Ex.C1, copy of welcome letter Ex.C2, copy of the policy Ex.C3, copy of the Sarv Suraksha Plus Group Policy issued by HDFC Ergo General Insurance Company Ex.C4, copy of statement of account Ex.C5, copy of letter regarding submissions of documents Ex.C6, copy of death certificate Ex.C7, copy of sale certificate Ex.C8, copy of claim form Ex.C9, copy of cancelled cheque Ex.C10, copy of death claim Ex.C11, copy of letter dated 11.02.2022 Ex.C12, copy of death certificate Ex.C13, copy of temporary registration certificate Ex.C14 and copy of hospital record Ex.C15, whereas opposite parties No.1 and 2 have placed on record affidavit of Shweta Pokhriyal Sr. Manager-Legal Claims Ex.OPW-1,2/1, copy of power of attorney Ex.OP-1,2/2, copy of policy Ex.OP-1,2/3, copy of terms and conditions Ex.OP-1,2/4, copy of hospital record Ex.OP-1,2/5 and copy of repudiation letter Ex.OP-1,2/6. Opposite party No.5 has placed on record affidavit of Milind Myakal Ex.OP-5/1 and copy of resolution Ex.OP-5/2.
14. It is admitted fact that the husband of the complainant had obtained auto loan from opposite party No.3 for purchasing a car which was to be repaid in monthly installments of Rs.8600/- per month for 84 months. It is further admitted fact that only two installments were paid by the husband of the complainant. It is further admitted fact that auto loan was insured with HDFC Ergo General Insurance Company Ltd. i.e. opposite parties No.1 and 2 against premium of Rs.3153/- under Sarv Suraksha Plus Group Policy. It is further admitted fact that under Sarv Suraksha Plus Group Policy is comprehensive insurance policy specially designed for customers availing loan with an objective to provide financial security to the loan borrower and his family in case of an unfortunate event. It is further admitted fact that policy provides insurance coverage maximum upto the loan amount. It is further admitted fact that accidental death and critical illness is major coverage under the policy. It is further admitted that husband of the complainant died on 10.12.2021 due to cardiac arrest at Ludhiana. It is further admitted fact that claim lodged by the complainant was repudiated by the opposite parties No.1 and 2 vide repudiation letter Ex.C1. It is further admitted fact that complainant is nominee as per the policy issued by opposite parties No.1 and 2. The only disputed question for adjudication before this Commission is whether the death of the husband of the complainant falls under critical illness or not. Since, it is admitted fact that husband of the complainant suffered first heart attack and was rushed to Satguru Partap Singh Hospital, Sherpur Chowk Ludhiana, where he died due to cardiac arrest. As far as the death under critical illness is concerned we are of the view that since the husband of the complainant admittedly suffered a heart attack with severity and it was first heart attack and as per the terms and conditions attached with the policy and ground mentioned in repudiation latter at serial number 9 first heart attack of specified severity is fully covered under the head critical illness but since in the death summary of the patient, the reason of the death was mentioned as cardiac arrest. As such opposite parties No.1 and 2 repudiated the claim by taking shelter of the word "Cardiac Arrest" and totally ignored this fact that husband of the complainant has suffered a first heart attack which resulted into the cardiac arrest. The arguments of counsels for the opposite parties No.1 and 2 that cardiac arrest was not included in the policy coverage and hence claim under major medical illness was repudiated is not sustainable. Opposite parties No.1 and 2 have further taken plea that the heart attack and cardiac arrest are totally different diseases and the policy document provides two separate coverage for the said ailments. However, it is admitted by the opposite parties No.1 and 2 that heart attack is a condition when the blood supply to part of the heart stops and thus causes a section of the heart muscle to begin to die and in case of cardiac arrest it is sudden and unexpected loss of heart function, breathing and consciousness meaning thereby that it is the heart attack which is responsible for the cardiac arrest and in the present case also it was the first heart attack which resulted into cardiac arrest in case of husband of the complainant and as such case of the complainant is fully covered under the term critical illness at column No.5 wherein myocardial infarction i.e. first heart attack specified severity has been covered under the head of major medical illness. We are of the view that although in column No.2 of the terms and conditions optional cover has been prescribed for cardiac arrest but we are of the view that cardiac arrest is also major illness and since it was the heart attack which resulted into cardiac arrest in the present case. As such clause for opting for major cover for cardiac arrest is totally unreasonable and seems to have been put in the policy terms and conditions to deny the claim whichever arises on account of heart attack resulting in cardiac arrest. We are of the view that massive heart attack probably resulted in cardiac arrest and the said condition of compelling for taking extra cover is totally unreasonable. Moreover, it is not the case of the opposite parties No.1 and 2 that they offered or suggested the insured to opt for extra cover to get the cover for cardiac arrest also. As such repudiation of the claim by the opposite parties No.1 and 2 is totally unjustified and since the death of the insured has taken place due to first heart attack resulting into cardiac arrest and as such claim of the complainant fully covered under the column No.5 of major medical illness. Accordingly, repudiation of the claim by the opposite parties No.1 and 2 vide letter Ex.C1 is totally unjustified and amounts to deficiency in service.
15. Accordingly, present complaint is partly allowed with the following directions:-
i) Opposite parties No.1 and 2 are directed to pay the balance loan amount to opposite party No.3 what so ever is payable by the deceased Mr. Rakesh Gaur.
ii) Opposite party No.3 is directed to issue NOC to the complainant after receiving the balance loan amount from opposite parties No.1 and 2.
iii) Opposite parties No.1 and 2 are further directed to pay all the other benefits payable under the policy Ex C4 to the complainant.
iv) Opposite parties No.1 and 2 are also directed to pay Rs.10,000/- to the complainant for mental tension, agony and Rs.5,000/- as cost of litigation.
v) The entire process/exercise will be completed within 30 days from the date of receipt of copy of this order. If the claim as stated above is not paid within the given time, the same shall carry interest @ 9% P.A. from the date of filing of the complaint till realization.
16. The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases.
17. Copy of the order be communicated to the parties free of charges. File be consigned.
(Lalit Mohan Dogra)
President.
Announced: (B.S.Matharu)
Oct. 19, 2023 Member.
*YP*
