Delhi

North

CC/44/2016

PRAHLAD KUMAR - Complainant(s)

Versus

HDFC ERGO GENERAL INSURANCE - Opp.Party(s)

06 Jul 2023

ORDER

District Consumer Disputes Redressal Commission-I (North District)

[Govt. of NCT of Delhi]

Ground Floor, Court Annexe -2 Building, Tis Hazari Court Complex, Delhi- 110054

 

CC No.: 44/2016

Sunil Kumar (deceased)

S/o Prahlad Kumar

 

Through LRs/

Surviving Members

 

Prahlad Kumar

S/o Late. Sh. Gyan Chand                                                     

 

Bimla Devi

W/o Sh. Prahlad Kumar

 

Purva

D/o Late Sh. Sunil Kumar

 

Vaibhav (minor son)

Through Natural

Guardian/ Mother/ Complainant No.5

 

Sonu

W/o Late Sh. Sunil Kumar

 

All resident of J-34A,

Vishnu Garden,

New Delhi-110018      .                                                                              …                                 Complainants

               

                                                                                                Vs

 

HDFC ERGO General Insurance Co. Ltd.

1^st Floor, 165-166, Back Bay Reclamation,

HT Parker Marg, Church gate,

Mumbai-400020, Maharashtra.                                                          …                 Opposite Party No.1

 

HDFC ERGO General Insurance Co. Ltd.

Customer Service, 6^th Floor,

Leela Business Park,

Andheri Kurla road, Andheri (E)

Mumbai-400059, Maharashtra.                                                         …                 Opposite Party No.2

 

Smt. Sandhya Balig

Office of the Insurance Ombudsman,

HDFC ERGO General Insurance Co. Ltd.

2/2 A, Universal Insurance Building                                                                                           

Asaf Ali Road, New Delhi-110002.                                    …                 Opposite Party No.3

 

ORDER

06/07 /2023

 

Ashwani Kumar Mehta, Member:

 

1.            The present complaint has been filed under Section 12 of the Consumer Protection Act, 1986. The brief details of facts, as alleged by the Complainants in the Complaint in hand, are that Sh. Sunil Kumar (now deceased) purchased the medical policy/insurance cover for critical illness vide policy no.2950201051479600000 from HDFC Ergo General Insurance Co. Ltd. (OP-1) for the period of 27.04.2015 to 26.04.2019. The policy holder expired on 17.07.2015 due to critical illness in LNJP hospital and the nominee filed claim  for the insured amount but the OP-1 repudiated the claim vide letter dated 08.09.2015 on the ground that the cause of death is not accident but Alcoholic liver disease. Aggrieved by the conduct of the OP-1, the Complainant through his Counsel sent a legal notice dated 03.10.2015 to OP-1 but the OP-1 did not pay any heed to the request of the Complainant and even did not replied the legal notice. Therefore, the present complaint has been filed praying that the OPs be directed to:-

 

1. release the insured amount to the Complainants for which the Complainants are legally entitled;
2. Compensate the Complainant to the tune of Rs.5,00,000/-;
3. Any other further relief of order which may be deemed fit and proper in the facts and circumstances of the matter.

 

2.            Accordingly, notices were issued to the OPs and in response to the Notice issued, the OPs- 1 & 2 has filed its reply jointly stating that the complaint is not maintainable as there is no deficiency as the Complainants have not come with clean hands before this Hon'ble Consumer Forum and has concealed the material facts, therefore, the petition is liable to be dismissed. It has been stated that the said policy was issued with terms and conditions and the claim, if any, was always subject to terms and condition of the policy. It further sataed by the OP1 & 2 that the claim is lodged claiming benefits under coverage 2 & coverage 5 i.e. accidental death and critical illness respectively. On scrutiny of the claim, it was found that the deceased had died due to “chronic alcoholic liver disease with portal hypertension with aslites with wagucopathy with heratic encephalopathy i.e. alcoholic liver disease with UGI Bleed” as mentioned in the death certificate issued from Lok Nayak Hospital. This is neither the accidental death nor comes 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 in 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".

3.            Accordingly, the complaint has been examined in view of the facts of the case and averments/documents/Evidence put forth by the complainant & OPs and it has been observed that :-

a).          The OP Insurance company, while issuing the policy to sh. Sunil Kumar (now deceased)  no.2950201051479600000  has explained the coverage of benefits  provided in the policy and in the policy schedule also, the sum assured has also been explained in the policy schedule which is mentioned against each category of coverage as under:-

Coverage details
Coverage	Sum Insured
1.Loss of Job (3 EMI)	Rs.1,00,000/-
2. Accidental Death	Rs.5,00,000/-
3. Permanent Total Disability/ Permanent Partial Disability	Rs.5,00,000/-
4. Accidental Hospitalisation	Rs.1,00,000/-
5. Critical illness	Rs.1,00,000/-
6. Credit Shield Insurance	Rs.5,00,000/-
7. Garage Cash	Rs.3,500/-
8. Householders Coverage	Rs.1,50,000/-

 

b)            The terms and conditions applicable for this policy has neither been filed  with the policy schedule by the Complainants nor with the reply of OP-1 & 2 which is sufficient to conclude that these were not supplied to the policy holder with the policy schedule.

c)            However, in the claim repudiation letter dated 08.09.2015, it has been specified that the claim is under category of accidental death/ critical illness whereas from the perusal of the claim Form submitted by the Nominee of the insured person, it has been seen that the claim has been filed only for the critical illness only. No claim has been filed for the category personal accident. It is not clear as to how the OP has come to the conclusion that the claim is under two categories i.e. (1) accidental death and (2) critical illness.

d)            While repudiating the claim under the category of critical illness, the OPs has referred to the specific exclusion clause mentioned under the policy which states 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". From the perusal of the reply/ evidence/ written arguments of the OP, it has been found that the terms and conditions of the policy has not been filed in support of their rebuttal. On the other hand the Complainant has filed copy of forwarding letter of the policy dated 27.04.2015 and the copy of policy schedule (total 2 pages) which is sufficient to prove that the insured was not supplied such terms and conditions. It has also not been contended by the OP that the deceased/ insured person i.e. Sh. Sunil Kumar has died due to the illness covered in critical illness. Besides, nothing has been produced on records by the OP-1 to prove that the deceased/ insured person i.e. Sh. Sunil Kumar had concealed his critical illness at the time of taking insurance coverage from the OPs. Therefore, the repudiation of the claim for the category of critical illness for sum insured of Rs.1,00,000/- is wrong which amounts to deficiency of service on the part of the OP.

4.            In view of the above explained observations, we feel appropriate to direct the OP-1 (M/s. HDFC Ergo General Insurance Co. Ltd.) to pay Rs.1,00,000/- (Rupees One Lakh Only)  in equal shares to the Complainants with interest at the rate of 9% per annum from the date of filing of the claim with the OP-1 from till the date of the payment. Besides, the OP-2 is also directed to pay Rs.25,000/-(Rupees Twenty Five Thousand only) as compensation to the Complainant for the mental pain, agony and harassment. It is clarified that the abovesaid amount shall be paid by the OP to the Complainant within 30 days from the receipt of this order failing which the OP shall be liable to pay interest @12% per annum from the date of expiry of 30 days period.

 

5.            Order be given dasti to the parties in accordance with rules. Order be also uploaded on the website. Thereafter, file be consigned to the record room.

 

 

                                 ASHWANI KUMAR MEHTA                                                  DIVYA JYOTI JAIPURIAR                                                                                    Member                                                                                                President                                                 DCDRC-1 (North)                                                                            DCDRC-1 (North)