Haryana

Karnal

CC/206/2021

Ram Parkash - Complainant(s)

Versus

HDFC ERGO General Insurance Company Limited - Opp.Party(s)

Rajiv Gupta

23 Apr 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                        Complaint No.206 of 2021

                                                        Date of instt.07.04.2021

                                                        Date of Decision:23.04.2024

 

Ram Parkash son of Shri Rameshwar Dass Goel, resident of house no.3286, ward no.6 (now ward no.4), shop no.105, behind Anaj Mandi, tehsil Nissing, Karnal (Haryana).

                                                                        …….Complainant.

                                              Versus

 

1. HDFC Ergo General Insurance Company Limited, through its Branch Head, Branch SCO no.(2^nd floor), sector-12, Karnal, Haryana India-132001.
2. HDFC Ergo General Insurance Company Limited, through its CEO/President/Authorized Officer, 6^th floor, Leela Business Park, Andheri-Kurla Road, Andheri-East, Mumbai-400059.
3. HDFC Bank Limited, through its Authorized Officer, Branch Nissing, Karnal-Kaithal Main Road, tehsil Nissing, District Karnal.
4. HDFC Bank Limited, through its Chairman/Authorizer Officer, registered office: Ramon House, H.T. Parekh Marg, 169, Backbay Reclamation, Churchgate, Mumbai-400020.
5. Ivy Hospital, Super Specialty Healthcare, through its M.D., Sector 71, S.A.S. Nagar Mohali, Punjab-16007.

 

                                                                …..Opposite Parties.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.      

      Sh. Vineet Kaushik…….Member

      Dr.  Suman Singh…..Member

 

 Argued by: Shri Rajiv Gupta, counsel for the complainant.

                    Shri Sanjeev Vohra counsel for the OPs no.1& 2.

                    OPs no.3 to 5 exarte.

 

                     (Dr. Suman Singh, Member)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant is filing the present complaint as he is beneficiary to the extent of 100% to all claims arising out of the two insurance policies bearing no.2918201889716300000 dated 31.08.2017 and 2918201907514300000 dated 15.09.2017 issued by the OPs no.1 to 4 in the name of the insured person, Hitesh Goel (now deceased). Both the policies carry the caption/title of ‘Home Suraksha Plus” being a comprehensive insurance policy providing extensive cover to the insured as enumerated in sections 1 to IV of the policy schedule and both these policies were issued by the OPs no.1 to 4 as the insured was having privity as a borrower of loan disbursed by OP no.3 and 4 and in all 4 loan accounts were running with OP no.3 and 4. At the time of disbursing loan facility the OPs no.3 and 4 insisted to insured Hitesh Goel to subscribe to a comprehensive insurance cover which has unique feature and will serve as  assurance to the insured for his lifetime in case of any future untoward mis-happening which may cause loss or damage/disablement to life or property/business as are provided in Sections no.1 to IV of the policy in question. These two policies were subscribed at the persuasion of OPs no.3 and 4 by the insured Hitesh Goel by paying a policy premium amount of Rs.26281/- and Rs.39423/-respectively and thereafter the insurance policies were issued by the OPs no.1 and 2 to the insured.

2.             It is further alleged that OPs no.3 and 4 stood as financer of both the said policies as the said two premiums of insurance policies were deductable from the 4 loan accounts. Under the first insurance policy dated 31.08.2017 of Home Suraksha Plus issued by OPs no.1 and 2 with customer ID 1012790104950002, the loan account no.626467952 and 627686615 running with OPs no.3 and 4 were used for the comprehensive coverage as detailed in Sections I to IV of the Schedule for the coverage/benefit of the insured Hitesh Goel. Under the second insurance policy dated 15.09.2017 of Home Suraksha Plus issued by OPs no.1 and 2 with customer ID;1012790104950003, the loan account no.626467990 and 627686347 running with OPs no.3 and 4 were used for the comprehensive coverage as detailed in sections 1 to IV of the policy schedule for the coverage/benefit of the insured Hitesh Goel. It is further alleged that the sum insured of Rs.10,26,281/- applicable under section III in Coverage detail head of Major Medical Illness and Procedures as is contained in policy dated 31.08.2017 and covers under its scope the sum insured of Rs.15,39,422/- applicable under Section III in Coverage detail head of Major Medical illness and procedures as is contained in policy dated 15.09.2017 respectively. Under both the two said policies the contingent event/happening which covers the scope of present complaint is illness as covered under point 7 and 9 which are specifically attracted as Stroke and Myocardial Infarction. On 11.11.2020, Hitesh Goel all of a sudden reported unease, breathlessness, verigo and pain in epigastrium and bouts of vomiting. Insured Hitesh Goel was medically checked in the OPD at a hospital in Karnal but he could not be diagnosed and ultimately on 13.11.2020, he was referred to higher centre i.e. hospital of OP no.5. Hitesh Goel was tested for covid-19 as per protocol of health department and was found covid-19 positive and was suffering from other complications coupled with severe acute respiratory, infection, pneumonia with effusion, respiratory failture, acute pancreatitis, T2DM and sepsis with mods and shortly after admission in just 5 hours, the patient Hitesh Goel suffered heart attack/cardiac arrest on 14.11.2020 and died on 16.11.2020.

3.             It is further alleged that due to the entitlement of the 100% beneficiary of right as nominee, after the irreversible loss of his son Hitesh Goel, lodged a claim on the basis of insurance policies bearing no.2918201889716300000 dated 31.08.2017 and 2918201907514300000 dated 15.09.2017 issued by the OPs no.1 to 4. But on 31.12.2020, vide communications the OPs no.1 to 4 have closed both the claims as No Claim. In the first repudiation letter, the claim is rejected as the insured suffered from Acute pancreatitis and the second repudiation letter, the causes for rejection are cardio-respiratory arrest secondary to septic shock and other complications like Covid-19 etc. Two different causes are enumerated regarding death of insured Hitesh Goel. Complainant approached the OPs no.1 to 4 and requested to release the benefits of the policy and to  also bear the future EMI in the said four loan accounts running with the OPs no.3 and 4 to be paid by OPs no.1 and 2 from the date of death of insured (Hitesh) but OPs did not bother to the request of complainant. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence this complaint.

4.             On notice OPs no.1 and 2 appeared and filed its written version raising preliminary objections with regard to maintainability; cause of action and concealment of true and material facts. On merits, it is pleaded that the insured opted three policies under Home Suraksha Plus Policy having policy nos. 2918201889716300 and 2918201907514300. The Home Suraksha Plus Policy provides coverage’s against ailment as suffered by the insured due to specified under list of critical illness as mentioned in the policy terms and condition. The complainant lodged the claim against following policies:-

1. Policy no.2918201889716300-Claim no.RR-C120-12220122:- That the insured/deceased had taken the Home Suraksha Plus Policy bearing no. 2918201889716300, valid from 31.08.2017 to 30.08.2022 from the OP. Claim was repudiated on the ground of ailment not covered.
2. Policy no. 2918201907514300-claim no.RR-C120-12222581:- That the insured/deceased had taken the Home Suraksha Plus bearing no. 2918201907514300, valid from 15.09.2017 to 14.09.2022 from the OP. Claim was repudiated on the ground of ailment not covered.

It is further pleaded that as per the death summary issued by Narinder Mohan Hospital and Heart Centre, the cause of death of the insured was cardiopulmonary arrest with covid-19 positive. Acute Respiratory Distress Syndrome with bilateral pneumonia with shock with type-II respiratory failure. As per terms and conditions of the policy, the cause of death of the insured is not covered under the section of Major Medical Illness of the policy as it does not fall under any of the category of illness/procedures as opted by the insured/deceased under the policy. As per the policy, only certain illnesses have been categorized as Major Medical Illnesses. It is further pleaded that insured opted only nine major medical illness/procedures against the available 18 major medical illness/procedures and the same is clearly mentioned in the policy. The insured had opted for the coverage of following illnesses:

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

If any claim arising out of the aforesaid ailment, OPs shall pay  subject to the terms and conditions of the policy. In the present case the cause of death i.e. Cardiopulmonay arrest with Covid-19 positive, Acute Respiratory Distress Syndrome with bilateral pneumonia with Shock with Type-II respiratory failure was not included in the policy coverage. It is pertinent to mention here that 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 result in death of heart tissue. Hence the claim was repudiated on the ground of non-coverage of the case of death under the policy terms and conditions and intimation of the same was given to the applicant, vide letter dated 02.10.2020. It is further pleaded that the cashless hospitalization request was also denied by the OPs on the ground that claim is not found payable. There is no deficiency in service and unfair trade practice on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

5.            OP no.3 to 5 did not appear despite service and opted to be proceeded against exparte, vide order dated 06.06.2022 of the Commission.

6.             Parties then led their respective evidence.

7.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copies of insurance policies Ex.C1 and Ex.C2, copy of repudiation letters Ex.C3 and Ex.C4, copy of death certificate Ex.C5, copy of death summary Ex.C6 and closed the evidence on 18.01.2023 by suffering separate statement.

8.             On the other hand, learned counsel for the OPs no.1 and 2 has tendered into evidence affidavit of Manoj Kumar Prajapati Ex.OP1/A, copy of claim form Ex.OP1, copy of admission letter of Virk Hospital, Karnal Ex.OP2, copy of death summary Ex.OP3, copy of letters dated 31.12.2020 Ex.OP4 and Ex.OP5, copy of insurance policies Ex.OP6 and Ex.OP7 and closed the evidence on 12.12.2023 by suffering separate statement.

9.             We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

10.           Learned counsel for complainant, while reiterating the contents of complaint, has vehemently argued that Hitesh Goel (since deceased) had taken four loans and for securing the loans, insured Hitesh Goel has taken two policies i.e. ‘Home Suraksha Plus” being a comprehensive insurance policy. At the time of obtaining the said insurance policy, the representative of OPs assured the insured that all types of ailments are covered in the said policies. In the Month of November 2020, Hitesh Goel suffered from Covid-19 Virus and was admitted in Ivy Hospital, Super Specialty Healthcare, Mohali and during hospitalization Hitesh Goel developed major critical illness and died on 16.11.2020.  Intimation was given to the OPs and all the formalities were completed but OPs did not pay the benefits provided under insurance policies and repudiated the claim of the complainant on the false and frivolous ground. He further argued that the alleged terms and conditions of the policy on the basis of which the claim of the complainant was repudiated were never explained nor supplied by the OPs any time and lastly prayed for allowing the complaint.

11.           Per contra, learned counsel for the OPs no.1 and 2, while reiterating the contents of written version, has vehemently argued that insured opted two policies under Home Suraksha Plus Policy. The insured opted only nine major medical illness/procedures against the available 18 major medical illness/procedures and the same is clearly mentioned in the policy. Insured died due to Covid-19, which is not covered under policy. He further argued that complainant was duly informed about the features or terms and conditions of the policy and policy was also dispatched to the complainant. The claim of complainant has rightly been repudiated, as per policy terms and condition and prayed for dismissal of complaint.

12.           Admittedly, Hitesh Goel (since deceased) had availed three  loans from the OPs no. 3 to 4. It is also admitted that the said loans were insured by the OPs no.3 and 4 from OPs no.1 and 2. It is also admitted that during the subsistence of the insurance policy, the insured  expired. It is also admitted that complainant is nominee in the abovesaid policies.

13.           The claim of the complainant has been repudiated by the OP no.1, vide repudiation letters Ex.C3 dated and Ex.C4 dated 31.12.2020. The repudiation letter Ex.C3 is reproduced as under:-

“We regret to inform you that the claim for Critical Illness does not meet the requirement for its eligibility as per the policy terms and conditions. Since the claims is not admissible and losses not payable, we are constrained to close the claim as “No claim in our record.

We would like to draw your attention, your claim has been declined due to below mentioned reason which is the basis for disallowing the claim, an extract of which is mentioned below for your ready reference.

As per the case summary received insured was treated for Acute Pancreatitis. The said ailment is not covered under Major medical illness section of policy. Please refer to diseases covered under section 3. Major Medical Illness and Procedure -1. Cancer of specified variety 2. Kidney Failure required regular dialysis 3. Multiple sclerosis with persistent sympotoms. 4. Major Organ/Bone Marrow transplant. 5. Open heath replacement or repair of heart valve. 6. Open chest coronary artery bypass graft 7. Stroke resulting in permanent symptoms 8. Permanent Paralysis of limbs. 9. First heart attack of specified severity. Since the losses claimed under Critical illness are  not covered, the claim is not admissible as per the policy terms and conditions.”

 

The second repudiation letter Ex.C4 is reproduced as under:-

“We regret to inform you that the claim for Critical Illness does not meet the requirement for its eligibility as per the policy terms and conditions. Since the claims is not admissible and losses not payable, we are constrained to close the claim as “No claim in our record.

We would like to draw your attention, your claim has been declined due to below mentioned reason which is the basis for disallowing the claim, an extract of which is mentioned below for your ready reference.

As per the submitted documents, insured died on 16.11.2020 due to Cardiorespiratory Arrest secondary to Septic Shock, Covid-19, Severe Acture Respiratory Distress Syndrome, Acute Pancreatitis, Pneumonia with Effusion, Respiratory Failure, Diabetes, Sepsis with Multiple Organ. Dysfuntion Syndrome. As per the said ailment are not covered under Critical Illness enlisted in Section 3 major medical illness and procedures of policy terms and conditions, hence this claim is being repudiated in the light of above. The illness covered under Critical illness and procedures are Cancer (II) End Stage Renal Failuer (III) Multiple Sclerosis (IV)Major Organ Transplant (V)Hearth Valve Replacement (VI) Coronary Artery (VII) Bypass Graft (VIII) Stroke (IX) (X)Paralysis Myocardial Infarction.”

 

14.           The claim of the complainant has been repudiated by the OPs on the abovesaid grounds.  As per death summary Ex.C6 dated 16.11.2020, deceased was diagnosed with:-

                “Diagnosis: Covid-19 SARI

                                Acute Pancreatitis

                                Pneumonia with Effusion

                                Respiratory Failure

                                T2DM

                                Sepsis with Mods

                Cause of death: Cardio respiratory Arrest/Secondary to septic shock       

 15.          The OPs have alleged that insured opted only nine major medical illness/procedures out of 18 major medical illness/procedures and the same is clearly mentioned in the policy, which are reproduced as under:-

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

 16.          As per the complainant, OPs have neither explained nor supplied the terms and conditions of the alleged policy. The onus to prove regarding supply of the terms and conditions of the  policy was relied upon the OPs but OPs have miserably failed to prove the same by leading any cogent and convincing evidence. OPs have not placed on file any correspondence with regard to supplying the terms and conditions of the alleged policies. If the OPs had sent the same to the insured they should have placed on file the receipt/acknowledgement  in this regard. It has been proved on the record that OPs have neither explained nor supplied the alleged terms and conditions of the policy. In this regard, we are relying upon the case law titled as  New India Assurance Co. Ltd Versus Anil Manglunia 2016 (1) CPR 150 (NC),wherein Hon’ble National Commission held that OP failed to provide policy clause to the complainant and rejected genuine claim of the complainant. Hence, they do not find any merit in the revision petition and the same is hereby dismissed. Hence, the plea taken by the OPs has no force

17.           In the repudiation letter Ex.C4 dated 31.12.2020, the OPs have alleged that the insured died due to Cardiorespiratory Arrest secondary to Septic Shock, Covid-19, Severe Acture Respiratory Distress Syndrome, Acute Pancreatitis, Pneumonia with Effusion, Respiratory Failure, Diabetes, Sepsis with Multiple Organ. Dysfuntion Syndrome.

18.            COVID 19 had spread in India in the beginning of 2020. In April 2021, severe acute respiratory syndrome Coronavirus has caused over 150 million cases of coronavirus disease 2019 (COVID-19) and over 3 million deaths occurred worldwide. The COVID-19 pandemic had been characterized by local surges of infection accompanied by tremendous demand for hospital and intensive care unit (ICU) resources. In parallel with these uniquely challenging conditions, knowledge around the treatment of this novel disease has accelerated rapidly. An estimated one-fifth to one-third of hospitalized patients with COVID-19 experience critical illness, with clinical decomposition at a median of 9 days from symptom onset and 3 days from hospital admission. Acute hypoxemic respiratory failure is the most common form of organ failure, contributing to over 90% of COVID-19-related deaths in ICU patients. Roughly in one-quarter of patients with COVID-19 critical illness requires , two-thirds require invasive mechanical ventilation (MV), two-thirds require vasopressor support, and one in six require renal replacement therapy. The corona virus is such a disease which can cause failure of all the organs of the body in one or two days, then how, the OPs can say that this is not a critical illness.  It is more dangerous disease than the diseases mentioned in the column of critical illness in the terms and conditions of the insurance policy. Possibility of printing of Performa of terms and conditions of the policy much prior to coming of Covid-19, cannot be ruled out.  It had caused a huge tragedy in the world whereas the diseases which are mentioned by the OPs in the terms and conditions of the policy, are less critical than the Covid 19 virus. Hence, this plea taken by the OPs is having no force.

19.           It is not a case, if the insured had opted for all other major illnesses, he would have had to pay additional premium. Apart from this, it is not believable that the insured would have chosen only some part of the major illnesses and left out the remaining illnesses, as alleged by the OP.

20.           Further,  Hon’ble Punjab and Haryana High Court in case titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, has held as under:-

“It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy.”

 

 21.          Keeping in view the ratio of the law laid down in the abovesaid judgments, facts and circumstances of the complaint, the act of the OPs no.1 and 2 amounts to deficiency in service and unfair trade practice. 

22.           The loan amounts of Rs.10,26,281/- and Rs.15,39,422/- were insured by the OPs no.1 and 2, vide insurance policies Ex.C1 and Ex.C2 respectively. Hence, the insurance company i.e. OPs no.1 and 2 are liable to pay the remaining loan amount to the Bank i.e. OPs no.3 and 4 after the death of the insured. It is made clear if any loan amount was already due prior the death of insured, the complainant is liable to pay the same and if the Bank i.e. OPs no.3 and 4 have charged the remaining loan amount after the death of life assured for that complainant is entitled to refund the same alongwith interest.

23.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the insurance company i.e. OPs no.1 and 2 to pay the remaining loan amount to the bank i.e. OPs no. 3 and 4. It is made clear if any loan amount was already due prior to the death of insured, the complainant is liable to pay the same and if the Bank i.e. OPs no.3 and 4 have charged the remaining loans amount due after the death of life assured for that OPs no.3 and 4  (Bank) are liable to refund the same alongwith interest as charged on the loans amount. We further direct the OPs no.1 and 2 to pay Rs.25,000/- to the complainant on account of mental agony and harassment suffered by him and Rs.11,000/- for litigation expenses. We further direct the OPs no.3 and 4, on receipt of loan amount, to issue the No Objection Certificate (NOC) and return the documents which were taken at the time of availing the loan. The complaint qua OP no.5 stands dismissed. This order shall be complied with within 45 days from the receipt of copy of this order. The parties concerned be communicated the order accordingly, and the file be consigned to the record room, after due compliance

Announced

Dated:23.04.2024

                                                        President,

                                                   District Consumer Disputes

                                                   Redressal Commission, Karnal.

 

                (Vineet Kaushik)        (Dr. Suman Singh)   

                      Member                   Member