Tamil Nadu

StateCommission

CC/9/2015

K.Sivasamy, F/o. S.Nandakumar (Deceased) - Complainant(s)

Versus

HDFC ERGO General Insurance Co.Ltd, Rep by Authorised Signatory, and anr - Opp.Party(s)

Mr.P.Balamurali

07 Feb 2023

ORDER

Date of filing:15.12.2014

IN THE STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI

                         BEFORE      Hon’ble Thiru Justice R. SUBBIAH                      PRESIDENT

                                              Thiru R VENKATESAPERUMAL                          MEMBER

 

CC.NO. 9/2015

 DATED THIS THE 7^th DAY OF FEBRUARY 2023

K.Sivasamy

F/o. S.Nandakumar (Deceased)

No.1/91,Kullichettipalayam

Kovilpalayam- PO, Pollachi Taluk

Coimbatore                                                                 ....Complainant

 

                                                  Vs 

 

1.       HDFC ERGO General Insurance Company Ltd.,

Rep. by Authorised Signatory

6^th Floor, Leela Business Park

Andheri Kurla Road, Andheri (East)

Mumbai 400 059

 

2.       HDFC Bank

Rep. by its Authorised Officer

Second Floor, ITC Centre

No.760, Anna Salai, Chennai – 600 002                ....Opposite parties

 

Counsel for complainant                               :   M/s. P. Balamurali

Counsel for 1^st Opposite party                       :   M/s. M.B.Gopalan Associates

Counsel for 2^nd opposite party                      :   M/s. Pass Associates

 

         This complaint coming before us for hearing finally today and on hearing the arguments of counsel appearing on bothsides and upon perusing the material records this Commission made the following order:

ORDER

Justice R. SUBBIAH,  PRESIDENT  (Open Court)

1.       This complaint has been filed under Sec.17 of the Consumer Protection Act, 1986, as against the opposite parties for the following reliefs:

          1.       To direct the 1^st opposite party to pay Rs.17,86,051/- towards the principal amount as claimed by the 2^nd opposite party

          2.       To pay compensation of Rs.5,00,000/- for pain and suffering

          3.       To pay compensation of R.3,00,000/- for mental agony

          4.       To pay cost of Rs.2,00,000/-

 

2.       The case of the complainant in brief is as follows:

          The complainant’s son late S.Nandakumar was working in a reputed car company viz. Hyundai at Chennai, and he availed housing loan for a sum of Rs.15,00,000/- from the 2^nd opposite party /bank, for purchasing of a house at Flat No.A2, Ground Floor, Plot No.6, VV Giri Street, Devi Nagar, Annanoor, Thirumullaivoyal, Ambattur, Chennai.   In respect of the loan availed by him, he took policy viz. Home Suraksha Plus, bearing Policy No.2918200006318800 from the 1^st opposite party.  The said policy covers the period from 5.5.2010 to 4.5.2015.  The monthly premium was fixed at Rs.18,849/- by the 1^st opposite party.  The complainant’s son had paid the monthly premium for the month of May 2010 and for the month of June 2010 for Rs.21,542/- through cheque of HDFC Bank, Poonamallee Branch.  The Home Suraksha Plus policy was communicated to the complainant’s son by the 1^st opposite party on 5.5.2010, which reads as follows:

“Home Sureksha Plus is just the right plan which protects you and your home against major incidences.  It is a comprehensive quadruple benefit insurance plan which covers risk arising due to critical illness, personal accident, Loss of job and accidental loss/ damage to your home and/ or contents”

    While so, all of a sudden, the complainant’s son died on 2.10.2011 due to acute myocardial infarction. The doctor who examined the complainant, had also issued certificate that the death of his son was due to myocardial infarction.  Subsequently, the complainant had submitted the claim form under the policy to the 1^st opposite party on 6.7.2012, by registered post, which contains claim form with doctor certificate, and covering letter, stating his native address for communication, and the same was received by the 1^st opposite party, but there was no reply.  In such a situation, the complainant had received a letter dt.4.9.2013 from the 2^nd opposite party, stating that in the loan Account No.359289456 of Nandakumar .S (Deceased), the total outstanding as on 31.8.2013 was Rs.17,86,051/-.  The complainant sent a reply to the 2^nd opposite party through his counsel on 9.2.2014 by praying time to settle the amount, due to the loss of his son.  For the said letter, a reply was received from the 2^nd opposite party on 17.4.2014 stating the request of the complainant would be considered on humanitarian grounds if the complainant would approach them on or before 30.4.2014. Therefore, the complainant sent a notice to the 1^st opposite party, through his counsel on 10.2.2014.  The 1^st opposite party had replied for the notice on 28.2.2014 stating that the claim for “Critical Illness Benefit” was registered as C291811000151, and the same was pending for certain documents.  Subsequently, the complainant had sent all the relevant documents to the 1^st opposite party on 3.4.2014, and request to settle the claim.  While so, the complainant received another letter dt.14.4.2014 from the 1^st opposite party stating that they need some more documents to scrutinise the claim.  The complainant replied for the said letter on 23.6.2014, stating that all the available document were already sent.  Inspite of receipt of the said documents, and repeated reminders, the 1^st opposite party has not come forward to settle the claim of the complainant.  The 2^nd opposite party had threatened the complainant that they are going to sell the property in public auction if the amount demanded by them alongwith interest not settled.  Thus alleging negligence on the part of the 1^st opposite party, the complainant had filed the complaint praying for the direction as stated supra. 

 

4.       The case of the complainant was resisted by the 1^st opposite party as follows:

          The complaint is not maintainable either in law, or on facts and is liable to be dismissed.  On vague allegations and completely ignoring the terms of the contract of insurance, the complainant has filed this complaint.  The policy provides cover viz. a) Fire & Allied Perils cover for the building and contents vide Sec.1 besides Burglary, House breaking and theft cover under Sec.II;  b) Major Medical illness cover under Sec.III;  c) Personal Accident cover under Sec.IV;  d) Loss of Job cover under Sec.V.  

          Each of the above covers is subject to limits specified in the policy.  For major medical illness, the sum insured is Rs.7,00,000/- only and the same is payable only in the event of the policy holder suffering specified major illness as defined in the policy and submitting necessary documents, information and particulars to substantiate a valid claim.  A claim was reported on 7.2.2012 for critical illness benefit under major medical illness.  The opposite party was not aware either of the death of the policyholder or of anyother alternate address at that stage.  In view of the lack of response for the request letters, the claim was closed on 30.4.2012 which was duly intimated.  The above documents are essential both under the terms of the policy and otherwise to determine whether a) there has been major illness suffered b) the same falls within coverage  c) any of the exclusion apply. 

          Without submission of the documents, no claim can be maintained or pursued under the policy.  In the absence of submission of the documents neither the claim can be established, nor can the opposite party be blamed of any deficiency in service.  The opposite party had sent a letter dt.14.4.2014 to the complainant, requiring the submission of the documents.  However, the complainant has failed to comply with the requirement after which a closure of the claim was advised on 14.5.2014 to the complainant himself.  Merely on the basis of a medical certificate issued for the purpose of death certificate, it cannot be conclusively stated that the deceased suffered heart attack/ myocardial infarction or a major illness as covered by the policy.  The complainant has failed to provide information or documents to substantiate an admissible claim under the policy.  There is no evidence of any formal medical examination at any hospital or medical establishment to determine the cause.  There are no records to substantiate the cause of myocardial infarction at such young age all of a sudden.   The intimation of death was not given immediately as required by condition No.6 of the policy.   Therefore, there is no deficiency in service on their part.   Thus prayed for dismissal of the complaint. 

 

5.       The version of the 2^nd opposite party in brief is as follows:

          The complainant had wrongly impleaded the HDFC Bank, instead of HDFC Ltd., from whom the deceased availed home loan.  Absolutely there is no privity of contract between the 2^nd opposite party and the complainant.  There is no cause of action against the 2^nd opposite party.  The HDFC Bank/2^nd opposite party is no way connected with the complaint.  The HDFC Bank / 2^nd opposite party and the HDFC Ltd., are totally a different and separate legal entity.  Thus prayed for dismissal of the complaint against them. 

 

6.       In support of the contentions, proof affidavits are filed by both parties alongwith documents, which are marked as Ex.A1 to A13 on the side of the complainant and Ex.B1 to B7 on the side of the opposite parties.  

 

7.       We have carefully heard the submissions and gone through the materials placed on record. 

 

8.       The main case of the complainant is that his son who availed loan from the 2^nd opposite party, died suddenly due to heart attack.   The complainant’s son has taken an insurance policy with the 1^st opposite party, against the loan availed from the 2^nd opposite party. Therefore the complainant made a claim with the 1^st opposite party.  Since the claim of the complainant has not been settled by the 1^st opposite party inspite of repeated reminders, this complaint has been filed. 

 

9.       Per contra, the 1^st opposite party would contend that the complainant had not provided the material documents for honouring the claim.  Moreover there is no evidence of any formal medical examination at any hospital to determine the cause for death of the complainant’s son.  Merely on the basis of a Medical Certificate issued for the purpose of Death Certificate, it cannot be conclusively stated that the deceased suffered myocardial infarction or a major illness as covered by the policy condition. 

 

10.     Point for consideration is

          1.       Whether the complainant is entitled for the claim?

          2.       Whether there is deficiency in service on the part of the opposite parties?

 

11.     POINT NO.1 & 2:

          The learned counsel for the complainant would submit that the insured died on 2.10.2011 due to sudden heart failure.  Therefore, there is no occasion for them to take treatment.  In this regard, the complainant produced a Medical Certificate for the Cause of Death under Ex.A3, issued by the Government Doctor.  As per the Medical certificate, the cause of death had been given as “Acute Myocardial Infarction; Heart Failure”. 

          In view of the above certificate, it could be confirmed that the insured died due to heart failure.  Moreover, the complainant would submit that there was no occasion for taking the insured to hospital for treatment, since he succumbed to death before taking for treatment.   

          In this connection, a perusal of the Ex.A1, policy schedule coverage details under Sec.III,  Major Medical Illness & Procedures it had been stated as 

          c) Occurrence for the first time of the following medical events more specifically described below

          1.Stroke     2.  Paralysis     3. Myocardial infarction

            This policy condition itself covers the illness that it occurs for the first time.  When the complainant’s son suffered from the heart attack, and passed away before even attempting to take treatment, there is no point in asking for the documents viz. Medical Investigation reports, Discharge summary etc.   In view of the above clause, we are of the considered opinion that the complainant is entitled for the claim as per the policy condition. 

 

12.     As far as the claim is concerned, the complainant had claimed for a sum of Rs.17,86,051/- towards the loan amount alongwith interest.

          In this connection, a perusal of Ex.B1, the terms and conditions of the policy, under the heading coverage details, Sec.III, the sum insured for Major Medical Illness is given as Rs.7,00,000/- only.  Therefore, the complainant is entitled for Rs.7,00,000/- only towards the policy amount.  Point No.1 is answered accordingly.

 

13.     Point No.2:

          The complainant, having lost his son at the young age, would have suffered the  stress of handling the financial burden in addition to the loss of his son.  In such a situation, the 1^st opposite party, having not honoured the claim, inspite of repeated reminders, would have given mental agony for the complainant, for which he has to be suitably compensated.  Therefore, we feel that awarding a sum of Rs.25000/- towards compensation would meet the ends of justice.   Point No.2 is answered accordingly.

 

14.     Since there is no role for the 2^nd opposite party in this complaint, and also because no claim has been made against the 2^nd opposite party, the complaint against the 2^nd opposite party is dismissed.

 

15.     In the result, the complaint is allowed in part, and the 1^st opposite party is hereby directed to pay a sum of Rs.7,00,000/- towards the policy amount alongwith interest @ 9% p.a., from the date of complaint till realisation, alongwith compensation of Rs.25000/- and cost of Rs.5000/-Time for compliance two months from the date of receipt of copy of the order, failing which the above amount shall carry further interest @6% p.a., from the date of default, till realisation.

          The complaint against the 2^nd opposite party is dismissed.

 

 

 

 

            R  VENKATESAPERUMAL                                            R SUBBIAH     

                       MEMBER                                                          PRESIDENT

 

 

 

Exhibits filed on the side of complainant

A1    05.05.2010  Home Suraksha Plus Policy from 1^st OP

A2    04.05.2010  Monthly premium to 1^st OP through cheques

A3    06.07.2012  Complainant’s claim form with all documents

A4    09.07.2012  Copy of acknowledgement

A5    04.09.2013  Letter from 2^nd OP to complainant

A6    09.02.2014  Reply to 2^nd OP from counsel for complainant

A7    17.04.2014  Reply from 2^nd OP

A8    10.02.2014  Legal notice to 1^st OP

A9    28.02.2014  Reply from 1^st OP

A10  03.04.2014  All the documents sent to 1^st OP

A11  14.04.2014  1^st OP letter to complainant

A12  23.06.2014  Advocate’s rejoinder to 1^st OP

A13  10.07.2014  Acknowledgement card

 

 

Exhibits filed on the side of  Opposite party:   

B1                         Insurance Policy with terms and conditions

B2      20.02.2012   Reminder letter from 1^st OP to complainant

B3      06.032012                       -do-                               

B4      20.03.2012                      -do-

B5      30.04.2012                      -do-

B6      14.04.2014                      -do-

B7      14.05.2014   Letter from 1^st OP to complainant closing the claim

 

 

 

 

 

  R  VENKATESAPERUMAL                                                    R SUBBIAH     

           MEMBER                                                                    PRESIDENT