Haryana

StateCommission

A/204/2017

GULAB SINGH - Complainant(s)

Versus

HDFC ERGO GENERAL INSURANCE - Opp.Party(s)

SANDEEP KOTLA

27 Jul 2018

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeal No  :    204 of 2017

Date of Institution:    23.02.2017

Date of Decision :    27.07.2018

 

Gulab Singh s/o Sh. Amar Singh, Resident of Village Gorakhpur, Tehsil and District Fatehabad.

                                      Appellant-Complainant

Versus

 

1.      HDFC ERGO General Insurance Company Limited registered & Corporate Office, 1^st Floor, 165-166, Backbay Reclamation, HT Parekh Marg, Churchgate, Mumbai-400020 through its Chairman-cum-Managing Director.

2.      HDFC ERGO General Insurance Company Limited, Red Square Market, Behind HDFC Bank, Tehsil and District Hisar through its Divisional/Branch Manager.

3.      Aantar Singh Khanna s/o Sh. Om Parkash, Resident of Village Kharakheri, Tehsil and District Fatehabad.

                                       Respondents-Opposite Parties

 

CORAM:             Hon’ble Mr. Justice Nawab Singh, President.

                             Mr. Balbir Singh, Judicial Member.

 

Argued by:          Shri K. Vardhan Verma, proxy on behalf of Shri Sandeep Kotla, Advocate for appellant.

                             Shri Vishal Aggarwal, Advocate for respondents No.1 and 2.

                             None for respondent No.3 (service dispensed with).

 

                                                   O R D E R

 

BALBIR SINGH, JUDICIAL MEMBER

 

        This complainant’s appeal is directed against the order dated January 18^th, 2017 passed by District Consumer Disputes Redressal Forum, Fatehabad (for short ‘the District Forum’) whereby complaint No.11 of 2016 was dismissed.      

2.                Ved Pal (since deceased) son of Gulab Singh during his life time obtained a life insurance policy No.2950201076240400000 (Exhibit C-9) regarding the period from May 26^th, 2015 up to May 25^th, 2020 mentioning total Sum Assured as Rs.5,05,000/- from HDFC ERGO General Insurance Company Limited (for short ‘the Insurance Company’)-Opposite Parties No.1 and 2 (respondents No.1 & 2 herein). Gulab Singh –complainant (appellant herein) is the nominee of the deceased Ved Pal (hereinafter referred to as ‘the insured’). The insured died on June 28^th, 2015 during the insurance period. After death of the insured, the complainant submitted insurance claim before the Insurance Company. The Insurance Company did not make payment of the insurance claim despite time and again requests of the complainant and service of legal notice dated October 06^th, 2015. The Insurance Company refused to make payment of the insurance claim. It is the case of the complainant that he had to face un-necessary harassment and mental agony due to faults of the Insurance Company.

3.                The complainant filed complaint under Section 12 of the Consumer Protection Act, 1986 before the District Forum with a prayer to direct the opposite parties- Insurance Company to pay the total sum assured Rs.5,05,000/- to the complainant with interest at the rate of 18% per annum; to pay an amount of Rs.1,00,000/- as compensation on account of un-necessary harassment, mental agony and costs of litigation.

4.                The opposite parties No.1 and 2 filed written version on the plea that the complainant has no locus standi to file the present complaint and that the complainant has no cause of action. It is admitted fact that the insured Ved Pal was provided Sarv Suraksha Policy bearing No.2950201076240400000 regarding the period from May 26^th, 2015 up to May 25^th, 2020 mentioning total Sum Assured as Rs.5,05,000/-. The insured died on June 28^th, 2015. Before that Ved Pal insured was complaining in relation to myocardial infarction from June 26^th, 2015. The date of commencement of the insurance policy was May 26^th, 2015.  Ved Pal died on June 28^th, 2015 within 90 days from the date of commencement of the insurance policy. As per exclusion clause applicable to Section 1 of the Insurance Policy, the Insurance Company shall not be liable to make any payment under this policy in connection or in respect of any insured event, as stated in this Section, occurred or suffered before commencement of insurance or arising within the 1^st 90 days of the commencement of the period of insurance. Parties to the contract are governed as per term of the contract. Insurance Policy is also like a contract. It is pleaded that due to exclusion clause, as mentioned above, the complainant is not entitled to receive any amount as insurance claim. It is prayed that the complaint filed by the complainant be dismissed with cost.

5.                Opposite Party No.3 was given up being un-necessary. The opposite party No.4 – Aantar Singh Khanna, an agent of the insurance company/opposite parties filed his written version mentioning that the complaint is not maintainable in the present form and that the complainant is not entitled for any amount from the answering opposite party. It is not a case of deficiency in service and prayed that the complaint filed by the complainant be dismissed with cost.

6.                Parties led evidence in support of their respective claims before the District Forum.

7.                After hearing arguments, vide impugned order dated January 18^th, 2017 complaint filed by the complainant was dismissed by the learned District Forum.

8.                Aggrieved with the impugned order dated January 18^th, 2017, the appellant-complainant has filed the present First Appeal No.204 of 2017 with a prayer to set aside the impugned order and to grant relief to the complainant.

9.                We have heard learned counsel for the parties and perused the case file.

10.              During the course of arguments, it was common case of both the parties that the deceased Ved Pal, father of the complainant, during his life time was provided insurance policy regarding the period from May 26^th, 2015 up to May 25^th, 2020 mentioning total Sum Assured as Rs.5,05,000/-. Copy of the Insurance Policy is Exhibit C-9 and copy of General Conditions of the policy is Annexure R-2. The insured died on June 28^th, 2015 during the insurance period on account of heart attack. The opposite parties No.1 and 2 have also mentioned in their written version that the insured Ved Pal was having complaint in relation to myocardial infarction w.e.f. June 26^th, 2015 and he died on June 28^th, 2015. It is an admitted fact that the insured Ved Pal died within a period of 90 days from the date of commencement of the insurance policy. The date of commencement of the insurance policy was May 26^th, 2015. Learned District Forum has also given findings that the insured died due to heart attack.

11.              Learned counsel for the opposite parties argued that the complainant is not entitled to receive the insurance claim as he died within 90 days from the date of commencement of the insurance policy and he died due to heart attack. The case of the complainant falls under exclusion clause. Under Clause 1 and 2 of Section 1 of the insurance policy Annexure R-2 Critical Illness coverage is mentioned as under:-

                   “Critical Illness Coverage:

                   1)      First Heart Attack (Myocardial Infarction)

Diagnosis by a Physician of the death of a portion of heart muscle as a result of inadequate blood supply to the relevant area. The diagnosis will be evidence by all of the following criteria

• History or clinical presentation consistent with the diagnosis of Myocardial Infarction
• New and recent electrocardiographic changes indicating myocardial infarction
• Elevation of infarction specific enzymes
• Non-ST segment elevation myocardial infarction (NSTEMI) with elevation of Troponin I or T is excluded. Specific Exclusion: Angina or chest pain.

2)      Coronary Artery Disease Requiring Surgery

The undergoing of open chest surgery for the treatment of a blockage of Coronary Arteries with Bypass Grafts (CABG)

Specific Exclusion

Non-surgical techniques including but not limited to balloon angioplasty, laser relief of an obstruction or other forms of coronary artery cleaning through catheters or similar devices.”

12.              It is clear from Clause 1 of the insurance policy that case of the claimant is covered under Critical Illness Coverage as he died due to heart attack. Under Clause 2 of specific exclusion applicable it is provided that any critical illness diagnosed within the first 90 days of the date of commencement of the policy is excluded. This exclusion shall not apply to an insured for whom coverage has been renewed by the Named Insured, without a break, for subsequent years. Clause 2 of Specific Exclusions applicable to Section 1 is reproduced as under:-

“2)     Any critical illness diagnosed within the first 90 days of the date of commencement of the policy is excluded. This exclusion shall not apply to an insured for whom coverage has been renewed by the Named Insured, without a break, for subsequent years.”

13.              Facts and circumstances of this case are quite clear. The insured Ved Pal died within 90 days from the date of commencement of the insurance policy due to heart attack. This insurance claim case is covered under Critical Illness Coverage and Specific Exclusions applicable to Section 1 as provided in the insurance policy Annexure R-2.  Terms and conditions of the insurance policy are quite clear and the case is covered under the above mentioned terms and conditions of the insurance policy. As the case of the complainant was under exclusion clause, the complainant being nominee of the deceased insured is not entitled to receive any amount as insurance claim.

14.              As per discussions above in detail, we find no illegality in the impugned order dated January 18^th, 2017 passed by the learned District Forum. Hence, findings of the learned District Forum stand affirmed and the appeal stands dismissed.

 

 

Announced: 27.07.2018

(Balbir Singh) Judicial Member

(Nawab Singh) President

 

CL