Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 293.
Instituted on : 29.06.2018.
Decided on : 14.03.2022.
Kuldeep age 49 years s/o Sh. Ratia R/o Vilage-Nindana, Teh.-Meham,, Distt. Rohtak.
.......................Complainant.
Vs.
- HDFC ERGO General Insurance Company Limited, 6th Floor, Business Park, Andheri Kulrla Road, Andheri(East) Mumbai-400059 through its Manager.
- HDFC ERGO General Insurance Company Limited, 2nd Floor, SCO 237, Sector-12, Karnal through its Manager.
- HBD Financials Ltd. Shop No.1152/22 Sonipat Stand, Near Enfield Showroom, Delhi Road, Rohtak through its Manager.
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. TRIPTI PANNU, MEMBER.
DR. SHYAM LAL, MEMBER.
Present: Sh.Dharmender Singh Advocate for complainant.
Sh. Gulshan Chawla, Advocate for opposite party No.1 & 2. Sh.Ankit Joon, Advocate for opposite party No.3.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case are that complainant had purchased a truck bearing registration No.HR-55R-8851 which was got financed from respondent no.3 and was insured with respondent no.1 & 2 vide policy No.2999201378577301 for the period from 05.06.2017 to 04.05.2020. As per the scheme of the respondent no.1 & 2 health insurance was also provided with the said vehicle insurance by the respondent no.1 & 2 under the name of Sarva Suraksha Advantage. On 13.10.2017 the complainant become unconscious and got admitted in PGIMS, Rohtak where he was treated by the doctors and remained admitted there upto 17.10.2017. Thereafter the complainant was got admitted in Sri Balaji Action Medical Institute, Delhi where he was treated by the doctor and an amount of more than Rs.350000/- was spent on his treatment and complainant became permanent disabled due to his illness. Complainant intimated the officials of respondents about his illness and treatment and has applied for insurance claim by duly submitting all the required treatment papers and bills. Due to his long illness the complainant could not pay the installments of finance amount to respondent no.3 and they started threatening the complainant to take possession of his vehicle. Complainant requested the opposite parties to consider the claim but the opposite parties have refused to accede the genuine request of the complainant. The act of opposite parties is illegal and amounts to deficiency in service. Hence this complaint and it is prayed that opposite parties may kindly be directed to pay the claim amount of Rs.350000/- as treatment charges and Rs.1000000/- as disability amount alongwith interest, compensation and litigation expenses to the complainant as explained in relief clause.
2. After registration of complaint, notice was issued to the opposite parties. Opposite party No.1 & 2 in their reply has submitted that complainant is not entitled for any claim under the policy in question as the present policy covers only Accident Death, Credit Shield Insurance and Permanent Total Disability/Permanent Partial Disability. As per Discharge Summary, the complainant underwent treatment for Acute MCA infract with Aphasia(Middle cerebral artery(MCA) stroke. The said ailment describes the sudden onset of focal neurologic deficit resulting from brain infraction or ischemia in the territory supplied by the MCA) and the same is a medical ailment and not accidental in nature. As per terms and condition of the policy, the term “Accident” is defined as given below: “Accident or accidental means a sudden, unforeseen and involuntary event caused by external, visible and violent means”. In the present case, the hospitalization was for Acute MCA infract with Aphasia (Middle cerebral artery (MCA) stroke, which did not occur due to any external and visible means, which is required to bring the claim under the purview of Accident as per policy wording. As the death is not accidental in nature, therefore the benefit under the Credit Shield is also not payable. All the other contents of the complaint were stated to be wrong and denied and opposite parties prayed for dismissal of complaint with costs. It is prayed that complaint is not tenable in the eyes of law and the complainant is not entitled for any relief. As such it is prayed that complaint may kindly be dismissed with costs.
3. Respondent no.3 in its reply has submitted that the complainant had entered into Vehicle Loan Cum Hypothecation Agreement with the answering opposite parties to purchase a vehicle model Tata KLPT 2518 and the said vehicle was financed by the answering opposite parties. It is further submitted that as per the Hypothecation Agreement the complainant had to repay the loan in 35 monthly installments of Rs.39000/- each but the complainant has failed to repay his installments within the stipulated due dates, however the complainant has closed his loan account on dated 26.07.2018 and respondent has issued the NOC to the complainant. All the other contents of the complaint were stated to be wrong and denied and opposite parties prayed for dismissal of complaint with costs.
4. Ld. Counsel for the complainant in his evidence has tendered his affidavits Ex.CW1/A to Ex.CW1/C, documents Ex.CW1 to Ex.CW55 and closed his evidence on dated 14.10.2019. At the time of arguments, ld. counsel for the complainant has also placed on record document Annexure-JN-A(8 pages). Ld. Counsel for opposite party No.1 & 2 has tendered affidavit Ex.RW1/A, documents Ex.RW1/1 to Ex.RW1/4 and closed his evidence on dated 06.04.2021. Ld. counsel for the opposite party No.3 made a statement that reply already filed on behalf of opposite party No.3 be read in evidence and closed his evidence on dated 06.04.2021.
5. We have heard learned counsel for the parties and have gone through the documents placed on record very carefully.
6. In the present case, as per the complainant he insured his vehicle with respondent no.1 & 2 and as per the scheme of the respondent no.1 & 2 health insurance was also provided with the said vehicle insurance by the respondent no.1 & 2 under the name of Sarva Suraksha Advantage. It is further contended that on 13.10.2017, he became unconscious and was treated by the doctor and spent an amount of more than Rs.350000/- on his treatment. Her also became permanent disabled due to his illness. Complainant applied for insurance claim with the opposite party No.1 & 2 but the opposite parties have refused to accede the genuine request of the complainant but the same has been refused by the opposite parties. We have minutely perused the documents placed on record by both the parties. As per Ex.CW5, policy certificate, the insurance coverage is as under:-
(i) Credit Shield insurance amounting to Rs.10720000/-, (ii) accidental death Rs.10 lac and (iii) Permanent total disability/permanent partial disability Rs.10 lac. In this cover note it has been further mentioned that: “The policy wording attached herewith includes all the standard coverage offered by the company to its customers. Your entitlement for coverage/benefits shall be restricted to the coverage/benefits as mentioned in this Certificate of Insurance issued to you”. We have minutely perused the terms and conditions of the policy attached with policy Ex.RW1/1. Under Section 2 sub section 1.1, Insured Event, it is mentioned that : “In the event of Accidental Bodily injury sustained by the insured during the policy period, the company will make payment under such coverage parts as are specified in the Schedule as being operative. And under the head Permanent total disability under section 2.2.1, Part B, : “In the event of Accidental Bodily Injury causing the insured’s Permanent total disability within 12 months of the Accidental Bodily injury being sustained, the company will pay 125% of the Sum insured, whereas after this policy shall expire”. Under the head Permanent partial disability under section 2.2.1, Part C, : “In the event of Accidental Bodily Injury causing the insured’s Permanent partial disability as mentioned in the PPD table below within 12 months of the Accidental Bodily injury being sustained, the company will pay the percentage of the Sum insured specified for each and every form of impairment mentioned in the PPD Table”. The alleged terms and conditions of the policy shows that the company is liable to pay the claim in case of accidental injury only but in the present case, complainant suffered Acute MCA infract with Aphasia (Middle cerebral artery (MCA) stroke, which did not occur due to any external and visible means, which is required to bring the claim under the purview of Accident as per policy wording. Meaning thereby the complainant had not suffered any injury caused by external, visible and violent means. No doubt, the complainant is having a permanent disability certificate upto 70% and he demanded an amount of Rs.10 lacs under this head. But as per terms and conditions of the policy as explained earlier, the respondents have covered only accidental Permanent total/Partial disability. In the present case, complainant has not suffered any injuries in accident. He suffered disability regarding ailment of Acute MCA infract with Aphasia (Middle cerebral artery (MCA) stroke. He has not suffered any injury in the accident and also not became permanent disable due to accident. Hence the complainant is not entitled for any relief as per terms and conditions of the policy and as such present complaint stands dismissed with no order as to costs.
7. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
14.03.2022.
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Nagender Singh Kadian, President
………………………………..
Tripti Pannu, Member.
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Shyam Lal, Member.
