Haryana

Fatehabad

CC/301/2018

Parmila Devi - Complainant(s)

Versus

HDFC Ergo General Insurance - Opp.Party(s)

M.K Batra

07 Aug 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM; FATEHABAD.

                              Sh. Rajbir Singh, President.                                                           Sh.K.S.Nirania, Member

 

                                                          Complaint case No.301 of 2018.                                                       Date of Instt.: 28.09.2018.                                                                 Date of Decision: 07.08.2023.

 

1.Parmila Devi widow of Sukhdev Kumar 2.Harish Kumar 3.Manish Kumar sons of Sukhdev Kumar residents of H.No.273, Tibba Colony, Ward No.11, Gali No.9,Ratia Tehsil Ratia District Fatehabad.4.Ranjana Devi wife of Sanjeev Tayal (daughter of Shri Sukhdev Kumar) resident of VPO Kaleka, Tehsil Dhanola District Barnala 5.Annu wife of Rakesh Kumar (daughter of Sukhdev Kumar), resident fo Chatte Manehra Tehsil Sunam District Sangruru.

                                                                             ..Complainants.                                  Versus

1.HDFC ERGO General Insurance Company Limited, Regd. Office 6^th Floor, Leela Business Park, Andheri Kurla Road, Andheri (East) Mumbai-400059

2.HDFC Bank Limited Branch Ratia District Fatehabad through its Branch Manager.

 

                                                                   ..Opposite Parties.

 

          Complaint U/S 12 of the CP Act,1986              

Present:                  Sh. M.K.Batra, Advocate for complainant.                                                   Sh. U.K.Gera, Advocate for Op No.1.                                                         Sh. Amit Wadhera, Advocate for Op No.2.

ORDER

Sh.Rajbir Singh, President

                              Briefly stated the facts of the present complaint are that Sukhdev Kumar (insured/deceased) got a car loan to the tune of Rs.2 lakh of his EON car bearing registration No.HR59D-3650 from Op No.1 which was to be repaid in installments; that Op No.1 had issued master policy No. 2999201363863000 dated 19.10.2016  covering the risk from 19.10.2016 to 18.04.2019 and further got issued an insurance policy bearing No.2950 2015 2968 3400 000 under Sarv Suraksha plus Policy through Op No.2 to the insured/deceased for a sum of Rs.5 lac for accidental death, Rs.1 lac for loss of job Rs.1 lac for critical illness and Rs.5 lac  for credit shield insurance besides other losses on different counts; that for insurance of vehicle loan alongwith all above mentioned risks premium amount to the tune of Rs.3844/- was also paid to Op No.2 through Op No.1; that during the currency of the policy Sukhdev Kumar  died on 04.12.2017 due to heart attack, therefore complainant No.3 had written a letter to Op No.1 for making the claim under the policy in question but to no avail; that the complainants kept on requesting the Ops to honour the claim  for making the payment of car loan but they wrongly and illegally repudiated the claim on the ground that the heart failure is not covered under the policy. The act and conduct of the Ops clearly amounts to deficiency in service on their part. In evidence, the complainants have tendered affidavit of complainant No.3 as Ex.CW1/A alongwith documents Ex.C1 to Ex.C7, Annexure C1 to Annexure C22.

2.                On notice, OPs appeared and resisted the claim of the complainant by filing their separate replies. Op No.1 in its reply has submitted that under Section 5 “Credit Shield” of the policy terms and conditions, the company would be liable for accidental death or permanent total disability but in the present case the death of insured/deceased happened due to heart failure and not due to any external means; that the definition of accident mentioned under the personal accident coverage which is as under:

                   “Accident” or “Accidental means” a sudden, unintended                and fortuitous external and visible event”

that the policy in question was issued to insured/deceased Sukhdev Kumar subject to terms and conditions of the insurance policy; that the claim was lodged under critical illness and the supported documents i.e. the certificate issued by Kakar Hopsital clearly mentioned that the Patient was brought dead on 04.12.2017 and the probable cause of death was heart failure. Patient was a case of diabetes with its complications; that the cause of death was not found to be payable as  the same ailment was not covered under the critical illness, therefore, the claim was rightly repudiated; that the insurance is a contract  and both the parties are bound by the terms and conditions mentioned therein and it is not open for the court to add, delete or substitute any word; that there is no deficiency in service and unfair trade practice on the part of Ops. Prayer for dismissal of the complaint has been made.

3.                          Op No.2 in its reply has taken preliminary objections such as cause of action, maintainability, concealment of material facts from this commission and locus standi etc. It has been further submitted that no four wheeler loan was covered under the said policy, therefore, the LRs of the insured/deceased are liable to make the payment of remaining loan amount; that the replying Op is a bank and different entity, therefore, the claim was to be settled by Op No.1/insurance company; that the replying Op has no concern with any correspondence took place between the Op No.1 and any of the complainants;  that there is no deficiency in service or unfair trade practice on the party of replying Op. By denying the all other pleas, prayer for dismissal of the complaint has been made. In evidence, the Op No.1 has tendered affidavit of Mrs.Shweta Pokhriyal, Assistant Manager as Annexure R7 alongwith documents Annexure R1 to Annexure R6 and learned counsel for the Op No.2 has tendered documents Annexure R8 to Annexure R13. Affidavit of Dr.O.P.Kakkar and a certificate issued by him have also been placed on case file as Ex.PW2/A and Ex.PW2/B.

4.                          We have heard learned counsels for the parties and perused the case file minutely.

5.                          The prime question before this Commission for consideration is as to whether the Heart attack/Heart failure falls within the coverage under the critical illness or any other sections mentioned in the policy in question which is placed on the case file as Annexure 1 or not?

6.                         Learned counsel for the complainant has argued that the insured/deceased had obtained a loan to the sum of Rs. 2 lac for his car Eon from Op No.1 which got insured the same from Op No.2 alongwith other coverage such as loss of life, repayment of loan, critical illness, injuries besides other loss under a policy Annexure C6 and regarding this insurance premium to the tune of Rs.3844/- was also charged by Op No.1. It has been further argued that insured Sukhdev Kumar died during the subsistence of the policy due to heart attack, therefore, the Ops are liable to pay the amount of insurance as per terms and conditions.

7.                          Per contra, it has been argued that the death claim of insured Sukhdev Kumar was lodged under the coverage of critical illness (Annexure R2) and the cause of death has been shown as heart attack but the death cause does not fall within any of the converges such as loss of job (3EMI), Accidental Death, Permanent Total Disability/ Permanent partial Disability, Accidental Hospitalization, Critical Illness, Credit Shield Insurance, Garage cash and householders coverage (Annexure C7). Learned counsel for the Ops have further argued that since the death of the insured has happened due to heart attack, therefore, the claim was not found payable as per coverage specially falls within Critical Illness and Credit Shield Insurance. In support of this plea, learned counsel for the Ops has drawn the attention of this Commission towards the Section 5 of the terms and condition of the policy, which is reproduced as under:

Credit Shield: In case of accidental Death or Permanent Total Disability of the insured person during the policy period, the company will make the payment under this policy.

 

Learned counsel for the Ops have also placed on record case law titled as Smt.Alka Shukla Versus Life Insurance Corporation of India 2019 AIR (Supreme Court) 2088  wherein Hon’ble Apex Court has held that insurer repudiated claim under accident benefit component of policy on ground that death of insured occurred due to heart attack and not due to accident-complainant required to show that accident and injuries sustained as result of fall from motor cycle were direct or proximate cause of her husband’s death-No evidence led to show that any bodily injuries were suffered due to fall from motor cycle or that they led to assured suffering heart attack-There is no evidence to show that accident took place as result of any outward, violent and visible means-Assured died as a result of heart attack which was not attributable to accident-Claim rightly repudiated.

8.                          The main ground of the complainant is that the Op No.1 has wrongly and illegally repudiated the claim of the complainants vide repudiation letter Annexure C5. Perusal of this document reveals that the claim was rejected by mentioning that As per case summary received, later Mr.Sukhdev Kumar was diagnosed to be suffering from heart failure. The said ailment is not covered under the policy and the claim is rejected. However, the said disease is not covered under the critical illness section of policy. The critical illness defines coverage of First heart attack of specified severity, open chest CABG, Stroke resulting in permanent symptoms, cancer of specified severity, kidney failure requiring regular dialysis and major organ/bone marrow transplant.

9.                          The fact regarding happening of death of insured Sukhdev Kumar due to heart attack is not disputed and this fact finds  further support from the certificate Ex.PW2/B isused by Dr.O.P.Kakkar. This fact is enough to reach at a conclusion that at the time of death the insured was having no bodily injuries and the death was not accidental. Therefore, the complainants are not entitled for the compensation on account of death of insured Sukhdev Kumar on any converges such as loss of job (3EMI), Accidental Death, Permanent Total Disability/ Permanent partial Disability, Accidental Hospitalization, Critical Illness, Credit Shield Insurance, Garage cash and householders coverage (Annexure C7) specially on the basic of critical illness and Credit Shield Insurance. Further, this Commission finds itself fortify with the view taken by Hon’ble Apex Court in case titled as Smt.Alka Shukla Versus Life Insurance Corporation of India (supra), therefore, we are of the view that the Ops are well justified in denying the claim in question to the complainants keeping in view the above said terms and conditions of the insurance policy in question and the law laid down by Hon’ble Apex Court.   

9.                          In view of the above mentioned reasons/discussions, we do not find any merits in this complaint, as the complainants have not been able to prove any deficiency in service and unfair trade practice on the part of Ops, therefore, the present complaint is hereby dismissed.  In the given facts and circumstances of this case, parties are left to bear their own costs. Copy of this order be supplied to the parties concerned, free of cost, as per rules, and thereafter, the case file be consigned to record room, as per rules, after necessary compliance. This order be also uploaded forthwith on website of this Commission, as per rules, for perusal of parties herein.

          

Announced in open Commission.                                                            Dated: 07.08.2023

 

 

                                                                                                        

                             (K.S.Nirania)                (Rajbir Singh)                                                            Member                             President