Haryana

Karnal

CC/155/2021

Vinita Gupta - Complainant(s)

Versus

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

Manjeet Kamboj

07 Aug 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                          Complaint No. 155 of 2021

                                                          Date of instt.16.03.2021

                                                          Date of Decision 07.08.2023

 

1. Vinita Gupta widow of Pankaj Gupta daughter of Pankaj Kumar.

 

2. Divya Gupta daughter of Pankaj Gupta both resident of 672, Sector-1, Part-2, HUDA, Shahabad (M), at present resident of 549, Holi Mohalla, Kalandari Gate, Karnal.

 

                                                 …….Complainants.

                                              Versus

 

1. HDFC Ergo General Insurance Co. Ltd., 2^nd floor, SCO no.237, Sector-12, Urban Estate, Karnal through its Divisional Manager.

 

2. HDFC Bank Ltd. Loan Service Centre, SCO 2-3, 1wst floor Sector-8, Urban Estate, Karnal.

 

                                                                      …..Opposite Parties.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.       

      Sh. Vineet Kaushik…….Member

      Dr. Rekha Chaudhary…..Member

 

 Argued by: Shri Manjeet Kamboj, counsel for complainants.

                    Shri Sanjeev Vohra, counsel for the OP no.1.

                    Shri Amit Munjal, counsel for the OP no.2.

 

                    (Jaswant Singh President)

ORDER:   

                

                The complainants have filed the present complaint Under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainants are successors of Shri Pankaj Gupta who unfortunately expired on 20.11.2020 due to critical illness while he was in service as teacher in Government Middle School Shahabad. Complainants no.1 is nominee who is wife of deceased and complainant no.2 is legal heir of deceased being daughter. Pankaj Gupta (since deceased) had taken personal loan of Rs.5,00,000/-from the OP no.2 and same was disbursed vide loan no.4996363 on 11.08.2017. Complainants also purchased one i-10 Grand Sport and same also got financed from OP no.2 and amount of Rs.5,56,715/- against loan no.54362215 was disbursed on 29.01.2018 by the OP no.2. At the time of disbursement of personal loan, OP no.2 through OP no.1 got insured Pankaj Gupta under Sarav Suraksha Policy having Master Policy no.299201366179901 for the period from 16.08.2017 to 15.08.2021 under various head i.e. accidental death, permanent total disability, accidental hospitalization, credit shield and critical illness and premium of Rs.4738/- was duly paid.

2.             It is further averred that  similarly, OP no.2 at the time of disbursement of car loan also got insured Pankaj Gupta through OP no.1, vide master policy no.299920136386301 for the period from 30.01.2018 to 29.01.2023 and premium of Rs.6761/- was duly paid. It was assured by the OP that in case of any mishappening regarding life of insured due to illness/accidental etc., OP no.1 will make payment of entire balance loan amount to OP no.2 in both the aforesaid loan and further will pay insured amount to nominee against each policy. Unfortunately, on 09.11.2020, Pankaj Gupta admitted in Sidharth Hospital, Shahabad in critical condition and diagnoses CAD (coronary Artery Disease) Obesity/Primary Pulmonay Arterial Hypertension with decreased O2 Safuration. Doctor of Sidharth Hospital had given treatment to the patient and on seeing his condition very critical referred the patient to higher centre and complainants took patient to Healing Touch Super Specialty Hospital, Ambala City where he remained admitted upto 20.11.2020 and during treatment patient suffered heart attack/Cardiac arrest and died due to aforesaid critical illness on 20.11.2020. After the abovesaid mis-happening OPs were informed and claim form was submitted and all relevant documents as required by OP no.1 were duly submitted to OP no.1 at Karnal but neither the OP no.2 nor the OP no.1 ever supplied detailed terms and conditions of the policy to complainants as well as Pankaj Gupta at the time of insurance. The complainants approached the OP no.1 several times and requested to give claim benefit and make balance outstanding amount against personal loan as well as car loan. But OP kept on postponing the matter on the ground that their claim is under process but very surprisingly through letter dated 16.01.2021 wrongly repudiated the claim of the complainants on the ground that deceased Pankaj Gupta is not covered under critical illness.

3.             It is further averred that Dr. Deepak Sharma of Sidharth Hospital, Shahabad Markanda where patient was initially admitted in critical condition and specifically issued certificate that patient was admitted with diagnosis CAD (Coronary Artery Disease) Obesity/Primary Pulmonay Arterial Hypertension with decreased O2 Safuration and the said disease duly fall under critical illness duly mentioned in critical illness list. Moreover, during treatment, the patient had suffered heart attack/cardiac arrest. OP no.1 just to save itself from the liability to pay the benefits under the said policy has wrongly repudiated the claim of the complainants. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence this complaint.

4.             On notice, OP no.1 appeared and filed its written version raising preliminary objections with regard to maintainability and concealment of true and material facts. On merits, it is pleaded that present complaint is seeking claim under both the policies as opted by the insured. However, at the time of lodging the claim under the one policy i.e.2950201880249000, which is prima facie proved from the claim form as filed by the complainants, which mentions only one policy details. At the time of claim intimation, only claimed under benefit of Critical illness, however, through the present complaint it is alleged that claim under Credit Shield was also claimed, which is wrong and denied. It is further pleaded that policy in question is Sarv Suraksha Policy which provides coverage’s against ailment as suffered by the insured due to specified under list of Critical Illness as mentioned in policy terms and condition. The claimants lodged the claim against following opted policy is as mentioned under:-

1. Policy no. 2950201880249000, claim no.RR-C120-12177154:- that the insured had taken the Sarve Suraksha Plus bearing no. 2950201880249000, valid from 16.08.2017 to 15.08.2021 from the OP. Claim was repudiated on the ground of ailment not covered.
2. Policy no.299920136386301 (Master Policy): That the insured/deceased had taken the Sarv Suraksha Plus bearing no. 299920136386301, valid from 30.01.2018 to 29.01.2023 from the OP. Claim was repudiated on the ground of Ailment not covered.

As per death summary issued by Healing Touch Hospital, the cause of death of insured was Septic Shock, Multiple Organ Dysfunction Syndrome, Lower Respiratory Tract infection, Type II Respiratory Failure, Coronary Artery Disease. As per terms and conditions of the policy, the cause of death of the insured is not covered under the section of Critical 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 Critical Illnesses. The diagnosed ailments are not covered under the Critical Illnesses mentioned in the policy as only First Heart Attack of specific severity is only covered. As per the terms and conditions of the policy, only the following diseases are covered under Critical Illnesses section of the policy:

1. First Heart Attack of specified severity.
2. Open Chest CABG
3. Stroke resulting in Permanent symptoms
4. Cancer of specified severity
5. Kidney Failure Requiring Regular Dialysis
6. Major Organ/Bone Marrow Transplant
7. Multiple Sclerosis with persistent symptoms
8. Surgery of Aorta
9. Primary Pulmonary Arterial Hypertension
10. Permanent Paralysis of Limbs

It is further pleaded that any claim arising out of the aforesaid ailment shall be payable subject to terms and conditions of the policy. Since in the present case the ailment suffered was not included in the policy coverage, hence the claim under Critical Illness was repudiated, vide letter dated 16.01.2021. It is further pleaded that through the present complaint, complainants are seeking the Outstanding Loan Amount under the Credit Shield Insurance Benefit of the policy. As per terms and conditions of the policy, under Credit Shield Insurance, OP is liable to pay the balance outstanding loan amount up to the maximum sum insured in the event of Accidental Death or Permanent Total Disability. Since the cause of death in the present case is not accidental in nature, the claim of the complainants does not cover under the terms and conditions of the policy, therefore any claim under Credit Shield Insurance is not admissible. There is no deficiency in service and unfair trade practice on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

5.             OP no.2 filed its separate written version raising preliminary objections with regard to maintainability; cause of action; locus standi; jurisdiction and concealment of true and material facts. On merits, it is pleaded that an amount of Rs.5,00,000/- was financed to Shri Pankah Gupta by HDFC Banik Branch Shahabad as personal loan. Borrower has to repay the said loan in 52 installments of Rs.12993/- starting from 07.09.2017 till 07.12.2021. For getting personal loan, borrower executed a loan agreement no.49996363 after understanding the terms and conditions of the same. Again on application, an amount of Rs.556715/- was financed to Shri Pankaj Gupta by HDFC Bank Branch Kurukshetra for purchasing of vehicle Hyundai i10 Grand Spot AT. Borrower has to repay the same in 89 installments of Rs.8868/- staring from 05.03.2018 till 05.07.2025. For getting vehicle on finance borrower executed a loan agreement no.54362215 after understanding the terms and conditions of the same. In personal loan, OP no.2 booked loss amounting to Rs.1,18,571/- and in car loan loss of Rs.2,51,959/- is booked by the OP after settlement due to death of borrower. OP reserve his right to recover his money from legal heirs of the borrowers as per law in case insurance company denies indemnifying to bank. There is no deficiency in service and unfair trade practice on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

6.             Parties then led their respective evidence.

7.             Learned counsel for the complainants has tendered into evidence affidavit of Vinita Gupta Ex.CW1/A, copy of insurance policy period from 16.08.2017 to  15.08.2021 Ex.C1, copy of insurance policy period from 30.01.2018 to 29.01.2023 Ex.C2, copy of death certificate Ex.C3, copy of repudiation letter Ex.C4, copy of Nabh Accredited Sidharth Hospital Ex.C5, copy of aadhar card of complainants Ex.C6 and Ex.C7, copy of aadhar card of Pankaj Gupta Ex.C8, copy of ration card Ex.C9, copy of bank statement dated 22.01.2021 Ex.C10, copy of statement dated 25.01.2021 Ex.C11 and closed the evidence on 23.12.2021 by suffering separate statement.

8.             On the other hand, learned counsel for the OP no.1 has tendered into evidence affidavit of Manoj Kumar Prajapati, Manager Ex.OP1/A, copy of claim form O1, copy of insurance policies Ex.O2 and Ex.O3, copy of death summary of Healing Touch Hospital Ex.O4, copy of repudiation letter dated 16.01.2021 Ex.O5 and closed the evidence on 02.08.2022 by suffering separate statement.

9.             Learned counsel for the OP no.2 has tendered into evidence affidavit of Gagandeep Singh Ex.OP2/A, copy of agreement for auto loan Ex.OP1, copy of terms and conditions of personal loan Ex.OP2, copies of statement of account of loan account no.54362215 for the period from 20.01.2018 to 31.08.2021 Ex.OP3, copy of statement of account of loan account no.49996363 for the period from 04.08.2017 to 31.08.2021 Ex.OP4 and closed the evidence on 02.08.2022 by suffering separate statement.

10.           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.

11.           Learned counsel for complainants, while reiterating the contents of complaint, has vehemently argued that on 11.08.2017, Pankaj Gupta (since deceased) had taken one personal loan of Rs.5,00,000/- from the OP no.2. insured has purchased one i-10 Grand Sport and same also got financed from OP no.2 and amount of Rs.5,56,715/- was disbursed on 29.01.2018 by the OP no.2. At the time of disbursement of personal loan, OP no.2 through OP no.1 got insured Pankaj Gupta under Sarav Suraksha Policy for the period from 16.08.2017 to 15.08.2021. He further argued that at the time of disbursement of car loan also Pankaj Gupta got insured through OP no.1, for the period from 30.01.2018 to 29.01.2023. On 09.11.2020, Pankaj Gupta admitted in Sidharth Hospital, Shahabad in critical condition and due to critical condition he was referred to Healing Touch Super Specialty Hospital, Ambala City where he remained admitted upto 20.11.2020 and during treatment patient suffered heart attack/Cardiac arrest and died on 20.11.2020. Intimation was given to the OPs and all the formalities were completed but OPs did not pay the benefits regarding both the insurance policies and lastly prayed for allowing the complaint.

12.           Per contra, learned counsel for the OP no.1, while reiterating the contents of written version, has vehemently argued that insured had taken two loans, one personal and one for car from the OP no.2. Both the loans were insured by the OP no.1 but same was not payable as per terms and conditions of polices and prayed for dismissal of the complaint qua OP no.1.

13.           Learned counsel for the OP no.2, while reiterating the contents of written version, has vehemently argued that an amount of Rs.5,00,000/- was financed to Pankaj Gupta deceased as personal loan. Loan agreement executed between the parties. An amount of Rs.5,56,715/- was financed to Pankaj Gutpa for purchasing of vehicle. In personal loan, OP no.2 booked loss amounting to Rs.1,18,571/- and in car loan loss of Rs.2,51,959/- is booked by the OP after settlement due to death of borrower. OP has right to recover the loan amount from legal heirs of the borrowers as per  terms and conditions of the loan agreement and prayed for dismissal of complaint qua OP no.2.

14.           Admittedly, Pankaj Gupta (since deceased) had availed two loan facilities from the OP no.2. It is also admitted that both the loans were got insured by the OP no.2 from OP no.1. It is also admitted that during the subsistence of the insurance policies, the insured was expired.

15.           The claim of the complainants has been repudiated vide letter Ex.C4 dated 16.01.2021 which is reproduced as under:-

“We refer the captioned claim intimated on 09.12.2020 and have carefully reviewed the documents submitted by you to validate the eligibility of claim basis policy terms and conditions.

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 claim is not admissible and losses not payable, we are constrained to close the claim as ‘No Claim’ in our records.”

16.           The husband of the complainant No.1 had obtained two loans i.e. on personal loan and another car loan. Alongwith the said loans, the husband of the complainant No.1 had also taken two insurance policies whereby in case of any mis-happening, the insurance company will pay the outstanding loan amount and also pay the sum assured to the nominee. The husband of the complainant No.1 has expired on 20.11.2020 due to critical illness and the complainants applied for claim as per the insurance policies, but the OP No.1 has closed the claim on the ground that the illness due to which the husband of complainant No.1 has died does not cover under critical illness.

17.           As per the OP no.1, according to death summary issued by Healing Touch Hospital, the cause of death of insured was Septic Shock, Multiple Organ Dysfunction Syndrome, Lower Respiratory Tract infection, Type II Respiratory Failure, Coronary Artery Disease and as per terms and conditions of the policy, the cause of death of the insured is not covered under the section of Critical 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 terms and conditions of the policy, only the following diseases are covered under Critical Illnesses section of the policy:

1. First Heart Attack of specified severity.
2. Open Chest CABG
3. Stroke resulting in Permanent symptoms
4. Cancer of specified severity
5. Kidney Failure Requiring Regular Dialysis
6. Major Organ/Bone Marrow Transplant
7. Multiple Sclerosis with persistent symptoms
8. Surgery of Aorta
9. Primary Pulmonary Arterial Hypertension
10. Permanent Paralysis of Limbs

18.           The complainants alleged that the insured was covered under the policies. The onus to prove their case was relied upon the complainants. In order to prove their case, the complainants have placed on record certificate dated 24.01.2021 Ex.C5 issued by Sidharth Hospital, Heart Care, Maternity and Ultra Sound Centre, Ladwa Road, Shahabad (M). The contents of the same are reproduced as under:-

                                TO WHOM IT MAY CONCERN

“Late Pankaj Gupta 55 years/male son of Vijender Kishor Gupta, resident of H.No.672, Sector-1, Part-2, HUDA, Shahabad (M), Kurukshetra was admitted at our hospital on 09.11.2020 at 11:10 am diagnosis (CAD Cornary Artery Disease) obesity/Primary Pulmonary Arterial Hypertension deceased O2 sofuration ( critical condition) under CR No.2229 in ICCU Patient was referred to higher medical center for urgent RX and management on 09.11.2020 at 06:40 PM oxygen support patient was suffering shortness of breath since last X1 month.”

19.           According to the said certificate the husband of complainant No.1 was suffering diagnosis for “Primary Pulmonary Arterial Hypertension” and was suffering from shortness of breath since last one month. OP No.1 in its pleading as well as evidence has mentioned the names of diseases which covered under critical illness and the disease “”Primary Pulmonary Arterial Hypertension” is mentioned at Sr.No.IX in the list of OP No.1. OPs have not rebutted the said certificate issued by Sidharth Hospital, Heart Care, Maternity and Ultra Sound Centre, Ladwa Road, Shahabad (M) by leading any cogent and convincing evidence. Thus, the plea taken by the OP No.1 that the claim lodged by the complainants is not admissible as the disease due to which the insured died does not cover under critical illness, is having no force.

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”.

                Keeping in view the ratio of the law laid down in the abovesaid authority and the facts and circumstances of the present complaint, we are of the considered view that the act of the OPs amounts to deficiency in service and unfair trade practice while repudiating the claim of the complainants.

22.           In view of the above discussion, we allow the present complaint and direct the OP No.1 to pay all the benefits covered under both the insurance policies purchased by the insured Pankaj Gupta (since deceased) to the complainants and also pay the outstanding loan amount to OP No.2, if any. We further direct the OP No.1 to pay Rs.25,000/- to the complainant on account of mental agony and harassment suffered by the complainants and Rs.11,000/- for the litigation expenses. On receipt of the remaining loan amount from the OP no.1, if any, OP No.2 is also directed to issue NOC with regard to loan cases and also return all the documents in this regard to the complainants. This order shall be complied within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:07.08.2023                                                                     

 

                                                                  President,

                                                       District Consumer Disputes

                                                       Redressal Commission, Karnal.

 

(Vineet Kaushik)             (Dr. Rekha Chaudhary)

                     Member                          Member