BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.2 of 2019

       Date of Instt. 01.01.2019

       Date of Decision:22.12.2020

1.       Naveen Kumar aged 20 years, son of Late Shri Mangat Rai Paul

2.       Anita Paul aged 50 years, wife of Late Shri Mangat Rai Paul

3.       Ram Piari wife of Mohan Lal

          All residents of House No.B-9/472, Santokh Pura Industrial, Balt      No.1913, Jalandhar, Punjab 144001.

..........Complainants

Versus

1.       HDFC Ergo General Insurance Co. Ltd., Registered Office: 1^st           Floor, HDFC House, 165-166, Backbay Reclamation, H. T.         Parikh Mark, Church Gate, Mumbai.

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

3.       HDFC Bank Limited, Retail Way Service Centre, Plot No.911,         1^st Floor, Near Narendra Cinema, G. T. Road, Jalandhar.

                                                ….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before:        Sh. Kuljit Singh             (President)

Smt. Jyotsna                   (Member)

Present:       Sh. S. C. Sood, Adv. Counsel for the Complainant.

                   Sh. R. K. Sharma, Adv. Counsel for OPs No.1 & 2.

Sh. Vikas Kumar Gupta, Adv. Counsel for the OP No.3

Order

Kuljit Singh (President)

1.                The instant complaint has been filed by the complainant, wherein alleged that the complainants are successor in interest of Shri Mangat Rai Paul who unfortunately expired on 21.10.2018 while he was in service with Government of Punjab as Head Constable. Similarly complainant No.1 was nominee and son of the deceased, while complainants No.2 and 3 are also legal heirs of deceased being wife and mother. That Late Shri Mangat Rai Paul when he was alive had taken personal loan from HDFC Bank Limited i.e. OP No.3 and against the said loan itself the deceased Mangat Rai Paul had been insured by the OPs under Master Policy No.2999201366179901 of which HDFC Bank Limited was the Master Policy Holder. Against the said insurance the detailed Cover Note had also been issued by the OPs and copy of the Bank Passbook, Policy Cover Note and Insurance Plan Certificate are annexed with the file. That the deceased had been insured by the OPs after being fully satisfied and premium to that effect as consideration had also been charged by the OPs. That during the subsistence of said policy Late Shri Mangat Rai Paul suffered from ailment and was subsequently under medical treatment. The deceased suffered critical illness which eventually lead to his unfortunate death on 21.10.2018. The deceased expired on account of heart attack and the policy itself covered critical illness for the sum assured of Rs.1,00,000/- The deceased even remained hospitalized and was medically treated at Shriman Super Speciality Hospital at Pathankot Road, Jalandhar. Even for the treatment itself an expenditure of Rs.91,000/- had been incurred. The deceased even remained on Ventilator Support. That in addition to coverage for critical illness the OPs have covered “Credit Shield Insurance” for sum insured of Rs.5,00,000/- for which premium of Rs.1400/- was paid. The deceased had been regularly paying his installments towards loan in a disciplined manner and without any default and on date of death of deceased an amount of Rs.3,73,775/- is outstanding. That thus on account of unfortunate death of the deceased as per insurance policy itself the complainants are entitled to an amount of Rs.1,00,000/- on account of critical illness and further for waive of Rs.3,73,775/- on account of Credit Shield Insurance. That it may further be mentioned that the complainants had been provided only with the Cover Note and no actual detail of the insurance policy had been further provided. It may be mentioned and stated herein that this in itself is violation of IRDA guidelines. That to this effect the complainant No.1 had lodged claim with the OP No.1, but unfortunately the OP No.1 on 30.11.2018 repudiated the claim of the complainants. That the OP No.2 have further wrongly deducted installment of loan after the death of the insured as the insured was entitled to Credit Shield Insurance and the said amount is also liable to be remitted to the complainants. That the OP No.1 had repudiated the claim in a non-speaking and capricious manner without stating any reason whatsoever which itself amounts to unfair trade practice and calls for interference from this Forum. That the OPs are guilty of unfair trade practice and deficiency in service and the complainants are entitled to total claim of Rs.1,00,000/- and further waiver of the arrears of amount outstanding against the loan and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to remit an amount of Rs.1,00,000/- on account of critical illness and to provide waiver of outstanding loan amount of Rs.3,73,775/- to remit installment of Rs.12,881.22/- and to pay damages for mental tension, agony and harassment to the tune of Rs.50,000/- with interest @12% per annum which comes to Rs.50,000/- and further directed to pay Rs.10,000/- as litigation expenses.

2.                Notice of the complaint was given to the OPs and accordingly, OPs No.1 & 2 appeared through its counsel and filed joint written reply, whereby contested the complaint by taking preliminary objections that the complainant has alleged that policy terms and conditions were not provided by the answering OP. It is pertinent to mention here that the policy was issued to the insured and therefore, the insured was the right person to raise the objection. It is pertinent to mention here that the policy cover in itself mentions that the policy working attached herewith includes all the standard coverage offered by the company to its customers. Your entitlement for coverage/benefits shall be restricted to the coverage/benefits as mentioned in this policy schedule issued to you. Please read the policy wording in conjunction with the policy schedule. For clarification please call out toll free number. Thus, the contention of the complainant that no terms and conditions were provided comes to an end. Had the insured would had not been provided with the policy wording, then the insured would had called or informed the answering respondent about the non-receiving of the policy wordings, but nothing was received from the side of the insured about the non-receiving of the terms and conditions till the filing of the present complaint. It is pertinent to mention here that the same issue is decided by the Hon’ble National Commission in RP No.455 of 2018 titled Venkat Reddy Vs. HDFC Bank & Anr. It is further alleged that the complaint pertains to claim under Sarv Suraksha Policy having policy No.2950 2018 6564 4700 000 which is valid from 05.08.2017 to 04.08.2021. However, it is to be noted that the liability of the company, if any, is subject to terms and conditions of the policy. It is further submitted that the present insurance policy is not a life insurance policy where claim becomes payable only in case of death. However, it is peril based policy and claim becomes payable only on happening of any of the insured perils. As per the policy schedule, following coverages were provided to the insured by the respondents:

                   It is further submitted that the deceased insured was admitted in Shriman Superspeciality Hospital on 18.10.2018 with the complaints of Acute Anterior Wall Myocardial Infarction, Coronary Artery Disease, Left ventricular Dysfunction, Respiratory Failure and Cardiac Arrest and unfortunately died on 21.10.2018 due to Cardiorespiratory arrest. That after the death of the insured, the complainant lodged a claim seeking benefits under Critical Illness section of the policy. It is submitted that claim was lodged by the complainant No.1 with the answering OPs No.1 & 2 under critical illness only and not under the credit shield. It is further submitted that the claim of the complainants was repudiated after due application of mind and as per terms and conditions of the insurance policy vide letter of repudiation dated 19.11.2018 and intimation was sent accordingly. It was specifically stated in letter of repudiation that claim for critical illness does not meet the requirement for the eligibility as per policy terms and conditions and since the claim is not admissible and loss not payable, the same was repudiated. Certificate dated 21.10.2018 issued by Shriman Superspeciality Hospital is Ex.O2. It is further submitted that the complaint is without any cause of action and is liable to be dismissed. It is further submitted that there is neither any deficiency in service nor any negligence nor any unfair trade practice on the part of the answering OPs No.1 & 2. On merits, it is admitted that the complainant availed personal loan from OP, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.

3.                OP No.3 appeared through its counsel and filed separate written reply, whereby contested the complaint by taking preliminary objections that the above said complaint is not maintainable against answering OP No.3 and is liable to be dismissed with heavy costs qua answering OP No.3. It is further alleged that no cause of action has ever accrued to complainant against answering OP No.3 to file present complaint. Hence, the present complaint is liable to be dismissed against answering OP. It is further alleged that the complainant has un-necessarily dragged the answering OP No.3 in inter-se dispute between complainant and OP No.1 & 2. Hence the present complaint is liable to be dismissed qua OP No.3. It is further submitted that the father of the complainant No.1 and husband of the complainant No.2 and son of complainant No.3 i.e. Sh. Mangat Rai has obtained a personal loan from the answering OP No.3, copy of loan application form is attached as Annexure OP-3/A, Loan agreement is Annexure OP-3/B. As per records of the bank a sum of Rs.500000/- was the loan account and said loan has been disbursed under loan account bearing No.49928105. It is submitted that presently said loan account is running highly irregular which is evident from the statement of account attached with the written reply i.e. Annexure OP-3/C, it is submitted as on 11.02.2019 a sum of Rs.40995/- is overdue in said loan and sum of Rs.3,72,471/- is due towards principal and total collectable is Rs.4,02,236.87/- is collectable in said loan account. It is further submitted that complainants are not making the payments of the loan amount despite repeated request and reminders. It is submitted that answering OP is the beneficiary under the Sarv Suraksha Policy obtained by Late Sh. Mangat Ram and is the holder of master policy. On merits, it is admitted that the complainant availed personal loan from OP, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.

4.                Rejoinder to the written statement of OPs No.1 and 2 filed, whereby reasserted the entire facts as narrated in the complaint and denied those of the written statement.

5.                In order to prove their respective versions, both the parties produced on the file their respective evidence alongwith documents.

6.                We have heard the learned counsel for the respective parties and have also gone through the case file very carefully.

7.                In this case, Shri Mangat Rai had taken personal loan from HDFC Bank Limited i.e. OP No.3. Complainant No.1 was nominee and son of the deceased and complainants No.2 ad 3 are legal heirs of deceased being wife and mother. During the subsistence of said police late Mangat Rai Paul suffered from ailment and was subsequently under medical treatment. The deceased suffered critical illness which eventually lead to his unfortunate death on 21.10.2018. The deceased expired on account of heart attack and the policy itself covered critical illness for the sum assured of Rs.1,00,000/-, Insurance Plan Certificate is Ex.C-7, in which Policy Issuance Date is 05.08.2017 and policy period is commenced from 05.08.2017 to 04.08.2021 and in the Coverage Details all details like Accidental Hospitalization, Credit Shield Insurance, Critical illness etc. have been clearly mentioned. In his evidence the complainant brought on the file document Ex.C-8 i.e. Report of Shrimann Superspeciality Hospital, wherein it is stated that the patient’s condition is critical and is on ventilator support. Patient is under hospitalization till recovery. Relevant medical record is also attached. In addition to coverage for critical illness the OPs have covered Credit Shield Insurance for sum insured of Rs.5,00,000/- for which premium of Rs.1400/- was paid. The deceased had been regularly paying his installments towards loan in a disciplined manner and without any default and on date of death of deceased an amount of Rs.3,73,775/- is outstanding and lastly prayed that the complainants are entitled to an amount of Rs.1,00,000/- on account of critical illness and for waive of Rs.3,73,775/- on account of Credit Shield Insurance.

8.                In their reply, OPs No.1 and 2 brought on the file copy of claim form submitted by the complainant No.1 as Ex.O-1, Certificate dated 21.10.2018 issued by Shrimann Superspeciality Hospital is Ex.O-2 and Copy of Repudiation Letter is Ex.O-3, Copy of Insurance policy alongwith its terms and conditions is Ex.O-4. Further, OPs submitted that the claim was lodged by the complainant No.1 with the anserwing OPs No.1 and 2 under critical illness only and not under the credit shield, copy of the claim form is Ex.O-1 and then claim repudiated vide letter dated 19.11.2018, copy of the same is Ex.O-3 with remarks that the claim for critical illness does not meet the requirement for its eligibility as per the policy terms and conditions. Since the claim is not admissible and losses not payable, we are constrained to close the claim as “No Claim” in our records. But in document Ex.O-4 in Coverage Details column, complainant covered under Accidental Death, Permanent Total Disability/Permanent Partial Disability, Accidental Hospitalization, Credit Shield Insurance and Critical Illness.

9.                In his reply, OP No.3 admitted on merits that the OP No.3 is the holder of the Master Policy under which Sh. Mangat Rai Paul was insured and OP No.3 is the beneficiary under the policy and in case any compensation is granted qua the credit shield insurance policy then the same is to be paid to the answering OP for the discharge of liabilities of Sh. Mangat Rai Paul in the loan account No.49928105 since the loan amount is covered under the Credit Shield Insurance Policy.

10.              After considering the overall facts and circumstances, we came to conclusion that the complainant is entitled for the relief as he is covered Credit Shield Insurance as well as Critical Illness as per Policy Ex.C-7 and the complaint of the complainant is partly accepted and OPs are jointly and severally directed to pay an amount of Rs.1,00,000/- on account of Critical Illness and waive of outstanding amount of Rs.3,73,775/- to remit instalment of Rs.12,881.22 and also OPs are directed to pay compensation as well as litigation expenses to the complainant, to the tune of Rs.7000/- for causing mental tension and harassment to the complainant. The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.

11.               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                                       Jyotsna                           Kuljit Singh

22.12.2020                              Member                          President