STATE CONSUMER DISPUTES REDRESSAL COMMISSION, HARYANA, PANCHKULA
First Appeal No.181 of 2021
Date of Institution: 23.08.2021
Date of Decision:22.02.2022
Parminder Kaur age 41 years, wife of Late Shri Jagjit Singh, R/o House No.107/05-A, Bhagwan Nagar Colony, Pipli, Kurukshetra, Tehsil Thanesar, District Kurukshetra (Haryana).
….Appellant
Versus
1. HDFC Ergo Genral Insurance Co. Ltd., office:06th Floor, Leela Business Mark, Andheri Kurla Road, Andheri (Esat), Mumbai-400059 through its Managing Director.
2. HDFC Ergo General Insurance Co. Ltd., Sector-17, Branch Office Opp. Old Bus Stand, Kurukshetra.
……Respondents
CORAM: Mr.A S Narang, Judicial Member.
Mr. Suresh Chander Kaushik, Member.
Present:- Mr. Rakesh Kundal, counsel for the appellant.
O R D E R
A.S. NARANG, JUDICIAL MEMBER:
(The matter has been heard through virtual hearing).
Parminder Kaur (Appellant) has filed this appeal against the order dated 02.02.2021, whereby the District Consumer Disputes Redressal Commission, Kurukshetra (DCDRC) has dismissed her complaint under Section 12 of the Consumer Protection Act, 1986 against HDFC Ergo General Insurance Co. Ltd.
2. Admittedly, appellant’s husband had purchased the health insurance policy bearing No.2950201277791200000 dated 28.12.2015 for the assured sum of Rs.1,00,000/-. The premium for the same was Rs.1276/- and the policy was effective from 28.12.2015 to 27.12.2020. Her husband was suffering from loose motion and bloody stool. He was admitted in Nagpal Nursing Home, Kurukshetra. At the time of admission, his condition was serious. Unfortunately, he died on 08.05.2016 in the hospital. After the death of her husband, she approached the respondents for the payment of insured amount. She also submitted all the requisite documents with the respondents. She was assured that they would make the payment of the insured sum. However, respondents delayed the matter on one pretext or the other. Finally, on 07.04.2017, respondents repudiated the claim on the ground that her husband was insured under three heads i.e. (A) Accidental death (B) Credit Shield Insurance and (C) Critical Illness section of the policy. Respondents alleged that her husband was patient of Hypoproteinemia, which is not a critical illness and thus she is not entitled for the claim amount. On these facts, appellant filed the complaint before the DCDRC.
3. Respondents in the reply denied the claim of the appellant. They alleged that as per the documents submitted by the complainant-appellant, her husband was diagnosed of Hypoproteinemia. This illness was not covered under the insurance policy. As per the terms and conditions of the policy, only following diseases were covered under critical illness section of the policy:-
i. First Heath Attack of Specified Severity.
ii. Open Chest CABG
iii. Stroke resulting in Permanent symptoms
iv. Cancer of Specified Severity.
v. Kidney Failure Requiring Regular Dialysis.
vi. Major Orgon/Bone Marrow Transplant.
vii. Multiple Sclerosis with persistent symptoms
viii. Surgery of Aorta
ix. Primary Pulmonary Arterial Hypertension
x. Permanent Paralysis of Limbs.
Respondents also alleged that the appellant is also not entitled under the claim of accidental death as her husband had not died due to accident.
4. Appellant had tendered in evidence her affidavit Ex.CW1/A and documents Sarv Suraksha Policy (Ex.C-1), Sarv Suraksha Claim Document Checklist (Ex.C-2), Insurance Coverage and benefit plans (Ex.C-3), Death Certificate of Jagjit Singh (Ex.C-4), Claim Repudiation Letter (Ex.C-5), Adhaar Card of Parminder Kaur (Ex.C-6), Report of Nagpal Nursing Home, Kurukshetra (Ex.C-7), Report of Nagpal Nursing Home, Kurukshetra (Ex.C-8).
5. On the other hand, respondents tendered in evidence affidavit of Mr. Pankaj Kumar, Legal Manager (Ex.RW-1/A) and documents Sarv Suraksha Plus (Ex.R-1), Sarv Suraksha Policy (Ex.R-2), Sarv Suraksha Policy Wording (Ex.R-3), Letter dated 21.03.2017 (Ex.R-4), Claim Repudiation Letter (Ex.R-5), Sarv Suraksha Claim Report (Ex.R-6), Report of Guru Nanak Hospital (Ex.R-7), Report of Nagpal Nursing Home (Ex.R-8).
6. After hearing the parties and perusing the evidence on the record, vide impugned order dated 02.02.2021, the DCDRC, Kurukshetra dismissed the complaint.
7. Aggrieved by the order passed by the DCDRC, Kurukshetra, appellant has filed this appeal.
8. We have heard Mr. Rakesh Kundal, counsel for the appellant. We have also perused the record of the DCDRC.
9. Assailing the impugned order, Mr. Kundal, counsel for the appellant has argued that the DCDRC has not appraised the evidence on the record in a proper manner. Respondents never apprised the appellant that she would not be entitled to the insurance amount in case her husband dies on account of any illness which is not considered as critical illness. The DCDRC has overlooked this aspect of the matter and dismissed the complaint of the complainant. Accordingly, the impugned order be set-aside.
10. We have perused the record of the DCDRC. A look at Section-1 of Ex.R-3 (Sarv Suraksha Policy Wording) would show that the policy holder is entitled to the assured sum in case the policy holder dies due to critical illness. Further, as per Claim Repudiation Letter (Ex.R-5), the husband of the appellant was diagnosed to be suffering from Hypoproteinemia. Counsel for the appellant has failed to show us that the disease with which the husband of the appellant was diagnosed is critical illness. We are of the considered view that the DCDRC has appraised the evidence on the record properly and rightly dismissed the complaint. We affirm the order of the DCDRC and dismiss the present appeal. A copy of this order be sent to the DCDRC, Kurukshetra and to the parties.
Pronounced in open court.
Suresh Chander Kaushik A S Narang
February 22nd, 2022 Member Judicial Member
Addl. Bench Addl. Bench
R.K
