Chandigarh

DF-II

CC/221/2016

Supinder Kaur and Surinder Kaur - Complainant(s)

Versus

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

Devinder Kumar Adv.

27 Jan 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	221 of 2016
Date  of  Institution	:	30.03.2016
Date   of   Decision	:	27.01.2017

 

 

 

 

Supinder Kaur @ Surinder Kaur wife of Late Sh.Mohinder Singh Dhanoa, R/o H.No.2054/T-11, Sector 41, Chandigarh. 

             …..Complainant

Versus

1]  HDFC Ergo General Insurance Company Limited, SCO No.124-125, First Floor, Sector 8-C, Chandigarh, through its Branch Manager.

2]  HDFC Ergo General Insurance Company Limited, Regd. & Corporate Office: 1^st Floor, 165-166, Backbay Reclamation, H.T. Parekh Marg, Churchgate, Mumbai 400 020, through its Managing Director.

….. Opposite Parties 

 

BEFORE:  SH.RAJAN DEWAN                 PRESIDENT

         MRS.PRITI MALHOTRA             MEMBER

                                SH.RAVINDER SINGH             MEMBER 

        

 

For complainant(s)      : Sh.Devinder Kumar, Advocate 

 

For Opposite Party(s)   : Sh.Gaurav Bhardwaj, Adv. for OPs.

 

 

PER PRITI MALHOTRA, MEMBER

 

 

          As per the case, the complainant’s husband Sh.Mohinder Singh Dhanoa (now deceased) had taken one Sarv Surakha Policy NO.41594922 from OPs effective from 3.4.2014 to 2.4.2017 (Ann.C-1) where under critical illness was also covered for Rs.1.00 lakh.  It is submitted that on 31.8.2015, the husband of the complainant was admitted in GMCH, Sector 32, Chandigarh as he was suffering from breathing problem and was not able to breathe properly and died on 2.9.2015 due to Coronary Artery Diseases after three days of his admission in the Hospital. Averred that the OPs were informed and thereafter claim was filed along with all requisite documents (Ann.C-2).  However, the OPs repudiated the claim vide letter dated 25.11.2015 on the ground that Critical illness is not covered under the policy (An.C-3). The complainant again represented the OPs and sent death report of the deceased insured issued by GMCH, Sector 32, Chandigarh (Ann.C-4 to C-6), but the OPs without considering the documents, rejected the claim vide letter dated 28.1.2016 (Ann.C-7). Alleging the said repudiation as illegal, arbitrary and claiming deficiency in service, this complaint has been filed.

 

2]       The OPs have filed written statement and while admitting the factual matrix of the case, stated that the insured unfortunately suffered from Cardio Respiratory Arrest, which resulted in his death, thus, the ailment causing the death does not fall under any of the ailment, which are categorized as Critical Illness under the policy. Therefore, the claim of the complainant is not payable as per terms & conditions of the policy and it has rightly been repudiated.  Pleading no deficiency in service and denying rest of the allegations, it is prayed that the complaint be dismissed.

 

3]       Rejoinder has also been filed by the complainant thereby reiterating the assertions as made in the complaint and controverting that of the OPs in the reply.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and have also perused the entire record as well as written arguments. 

 

6]       The record on file is sufficient to prove that the complainant is fully entitled for the claim as claimed from the OPs under the policy availed by her husband (now deceased) for the reasons recorded hereunder. 

         It is well proved on record that the husband of the complainant subscribed for ‘Sarv Surakha’ Policy NO.41594922 for the period from 3.4.2014 to 2.4.2017 and during the validity of the said policy period, on 31.8.2015, he was admitted to G.M.C.H., Sector 32, Chandigarh, as was suffering from breathing problem and unfortunately he expired on 2.9.2015 due to Coronary Artery Disease.  The complainant rightly claimed that the claim lodged under the policy was wrongly declined by the OPs, as her husband suffered from critical illness of Coronary Artery Disease, which is duly covered under Section 1 of the ‘Critical Illness’, as mentioned by the OPs in their letter dated 25.11.2015 (Ann.C-3) wherein they repudiated the claim of the complainant wrongly stating it to be out of the preview of the terms & conditions of the policy as they failed to notice the term ‘CAD’ written on the Death Report (Ann.C-5).  When the complainant vide her letter (Ann.C-4) brought the said fact to the notice of the OPs, it resulted in issuance of another letter dated 28.1.2016 by the OPs, which shows that the OP Insurance Company targeted only to repudiate the  genuine claim by all means. Said letter surprisingly reveals that the OPs created a new list under Section 1 of the Critical Illness claiming it to be the part of the policy terms & conditions whereby they omitted the claim on account of ‘Coronary Artery Disease’, which earlier was duly covered in their earlier letter dated 25.11.2015 (Ann.C-3) at Serial No.2. 

         In our considered opinion such deceitful act of the Opposite Parties certainly would have caused great mental harassment to a widow lady, who has to indulge in litigation to get her rightful claim. The OPs also failed on their part to place on record the actual terms & conditions of the policy to negate the genuine claim of the complainant. However, it is evident from Ann.C-1 that the complainant is fully entitled for Rs.1.00 lakh under the head - Critical illness. Therefore, the repudiation done by the OPs is held to be illegal and amounts to deficiency in service as well as unfair trade practice. 

 

7]       In the light of above observations, we are of the opinion that the OPs not only remained deficient in their services but also indulged into unfair trade practice. Therefore, the present complaint of the Complainant is allowed qua OPs jointly & severally. The Opposite parties are jointly & severally directed as under:-

 

[a]      To pay Rs.1.00 lakh against the claim being the amount covered under the policy;

 

[b]      To pay Rs.25,000/- to the complainant as consolidated amount of compensation for causing mental agony and harassment for the deficiency in service of the OPs.

 

[c]     To pay Rs.10,000/- towards litigation expenses to the complainant. 

 

         The above said order shall be complied within 45 days of its receipt by the Opposite Parties jointly & severally; thereafter, they shall be liable to pay an interest @18% per annum on amount as mentioned in sub-para [a] & [b] above from the date of filing this complaint till it is paid, apart from paying litigation expenses.

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

27^th January, 2017                          Sd/-                                           

(RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER