Complainant Jaspal Kaur has filed the present complaint against opposite parties (for short O.P.) U/S 12 of the Consumer Protection Act, 1986 with a prayer that opposite parties may kindly be ordered to make payment of insured amount qua her claim on account of death of her husband immediately in terms of the insurance policy in question alongwith interest @ 18% P.A. from the date of death till actual realization. Opposite parties be further directed to pay Rs.50,000/- on account of mental agony, physical harassment and deficiency in service on the part of the opposite parties alongwith Rs.5,000/- as litigation expenses, in the interest of justice.

2.     The case of the complainant in brief is that her husband Sh.Harjinder Singh obtained Insurance Policy from the opposite parties vide policy no.2950 2008 9071 6600 000 dated 30.10.2014 and its maturity was on 29.10.2017. Her husband was paying premiums from time to time and she is nominee. Her husband was serving as Home Guard and was posted  at P.S.Sekhwan Tehsil and Distt.Gurdaspur. He obtained Insurance policy through opposite party no.2 through his duly authorized agent code 201587086428 Tel No.91-22-28561818. Unfortunately her husband expired on 15.03.2016 as natural death on account of jaundice at Guru Nanak Hospital Amritsar. Before the death, her husband at the time of purchasing the policy was hale and hearty and was not suffering from any kind of disease. She is entitled to recover Rs.1,50,000/- from the opposite parties as per terms No.1 and 5 of the policy.  She sent due information regarding death of her husband to the opposite parties and submitted the claim as per terms and condition of the insurance policy but the opposite parties refused to entertain her claim and returned the same without any endorsement thereon on false and baseless oral observations. Thus, there is deficiency in service on the part of the opposite parties. Hence this complaint.

3.      On notice, opposite party no.1 appeared through their counsel and filed their written statement taking the preliminary objections that the complainant has no cause of action to file the present complaint;  this Hon’ble Forum has no jurisdiction to entertain and try the present claim; there is no deficiency in services on the part of the opposite parties;  the complainant has not come with clean hands before this Forum and has concealed the material facts, therefore, the complaint is liable to be dismissed and the present complaint has been filed on the ground of Sarv Suraksha Pro Policy bearing No.2950200890716600000 valid from 30.10.2014 to 29.10.2017 covering the risk of the complainant as mentioned in the policy for a sum of R.1,00,000/- for critical illness. The said policy was issued alongwith terms and conditions and the claim, if any, was always subject to term and condition of the policy. Further on 15.3.2016 the insured died and an intimation of death was received by the opposite party. A claim form alongwith documents were submitted by the complainant as legal heirs of the deceased, claiming benefits under critical illness cover. After going through the claim form and documents it was found that on 15.03.2016,  when the insured/deceased died then he was suffering from alcoholic liver disease only, which is clearly mentioned in the Medical Re-imbursement Certificate, where the period of treatment is mentioned from 12.03.2016 to 15.03.2016. Further the deceased was diagnosed with jaundice and alcoholic liver disease as mentioned in the Discharged Slip ad also it is mentioned in the Medical Re-imbursement certificate that the insured/complainant was suffering from Jaundice and alcoholic liver disease. Thus, both the ailment does not come under the purview of critical illness as defined under the policy conditions. The said ailment is also excluded under the policy, as the policy excludes any ailment encountered as a result of use or misuse of intoxicating substance whereas this condition has been reached as a result of alcohol abuse. The policy conditions specifically stated its exclusion that “No payment will be made by the company for any claim directly or indirectly caused by based on, arising out of or howsoever attributable to the use or misuse of intoxicating drugs and/or alcohol”. On merits, the same pleadings have been repeated and lastly the complaint has been prayed to be dismissed.

4.          On notice, opposite party no.2 appeared through their counsel and filed their written statement taking the preliminary objections that the opposite party no.2 Bank has been wrongly made party in this complaint. OP2 has no concern at all with HDFC ERGO General Insurance Co. Opposite party no.2 is totally different entity from HDFC ERGO General Insurance Co. Opposite party no.2 has nothing to do with the transaction in question. The only necessary party is HDFC ERGO General Insurance Co. and not HDFC Bank. Opposite party no.2 has o privity of contract with the husband of the complainant. Opposite party no.2 is Banking Company and not Insurance Company. The liability, if any, is only of HDFC ERGO General Insurance Co. in the contract of Insurance entered between the husband of the complainant and opposite party no.1. HDFC Bank has no liability at all. On merits, it was submitted that no Insurance Policy was obtained by the husband of the complainant from the opposite party or through is authorized agent. All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.

5.        Complainant tendered into evidence his own affidavit Ex.C-I , along with the other documents exhibited as Ex. C2  and Ex.C3 and closed the evidence.

6.     On the other hand, counsel for the opposite party no.1 tendered into evidence affidavit of Sh.Pankaj Kumar Ex.OP-1/1, alongwith the other documents Ex.OP1/2 to Ex.OP-1/7 and closed the evidence.

7.     Counsel for the opposite party no.2 tendered into evidence affidavit of Sh.Amit Chatrath Branch Manager, HDFC Bank Ex.OP-W-2/A and closed the evidence.

8.     We have thoroughly examined the available documents/evidence on the records so as to statutorily interpret the meaning and purpose of each document and also the scope of adverse inference on account of some documents ignored to be produced by the contesting litigants against the back-drop of the arguments as put forth by the learned counsels for their respective contestants. We find that the present dispute has arisen at the impugned ‘repudiation’ dated 31.05.2016 (Ex.OP1/7) of the insurance death-claim (Ex.OP1/3) dated 23.05.2016 pertaining to the DLA’s Sarv Suraksha Policy (Ex.C2/Ex.OP1/2) for the assured sum/ amount of Rs 150,000/- per the applicable policy (Ex.C2) on the grounds that his ailment(s) of Jaundice and Alcoholic Liver Disease (ALD) are not included in the List of Critical Illnesses per Policy; And, further in accordance with ‘exclusion’ clause pertaining to claim(s) arising out of use/misuse of intoxicating drugs and/or alcohol, 

9.       We find that the titled opposite party insurers (hereinafter for short ‘the OP insurers’) have duly admitted the repudiation through their written statement and accompanying affidavit (Ex.OP1/1) on the grounds as mentioned out in paragraph 7 of the written statement being in violation/contravention of the terms of the Policy (Ex.OP1/2). Further, the Medical Re-imbursement Certificate (Ex.OP1/4 & Ex.OP1/6) and the Discharge Slip (Ex.OP1/5) clearly mention ailments suffered by the DLA as: Jaundice & Alcoholic Liver Disease against which no claims are payable under the terms of the Policy. Thus, we find that the impugned claim has been in violation of the contracted terms of the Policy and as such the present complainant shall not be entitled to any statutory relief.

10.     Lastly, we find that the complainant here has failed to prove her allegations as made out in the complaint and thus finding the same bereft of any actionable claim/statutory merit etc., we ORDER for its dismissal with however no orders as to its costs.

11.     Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.

                          (Naveen Puri)

                                                                                         President      

ANNOUNCED:                                                                   (Jagdeep Kaur)

December 18, 2017                                                               Member

*MK*