Punjab

Rupnagar

CC/14/156

Jaspreet Singh - Complainant(s)

Versus

HDFC ERGO General Insurance & Others - Opp.Party(s)

Sh. Sanjeev Verma, Adv

27 May 2015

ORDER

ORDER

          MRS. NEENA SANDHU, PRESIDENT

                             Sh. Jaspreet Singh has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’ only) against the Opposite Parties (hereinafter referred to as O.Ps.) praying for the following reliefs:-

                             i)       To give benefit of Credit Shield Insurance under “Sarv

                                      Suraksha Plus” policy,

          ii)      To pay the outstanding loan amount of Rs.5,82,220.12

                     in respect of the insured vehicle in question,

iii)     To pay Rs. 50,000/- as damages,

          iv)     To pay Rs.20,000/- as litigation expenses.

 

2.                In brief, the case of the complainant is that he is the real son of deceased Avtar Singh. Sh. Avtar Singh had purchased a Bolero ZLX ZWD 7 seater from M/s Raj Motors, who is authorized dealer of M/s Mahindra & Mahindra Ltd., NH-21, Chhoti Gandhon, Chandigarh Road, Rupnagar on 23.6.2014 for a sum of Rs.7,33,009/-, after taking loan of Rs.5,00,000/- from HDFC Bank Ltd., Sugar Mill Road, Morinda, Tehsil Chamkaur Sahib, Distt. Rupnagar. The HDFC Bank Ltd. had made a General Insurance Company in the name & style –‘HDFC ERGO General Insurance Co. Ltd.’ who had issued “Sarv Suraksha” policy (Sarv Suraksha Plus), bearing No. 2950 2007 8775 1400 000 under agent code 201587086428, for the period from 26.6.2014 to 25.6.2019 in the name of father of the complainant, on payment of insurance premium of Rs.6438/- by him. It was told to the complainant and his father that the said policy includes ‘Credit Shield Insurance’ meaning that in case, the owner of the vehicle expires within the period of the said policy, then the insurance company shall make payment to the HDFC Bank Ltd. to the extent of outstanding loan amount. He is the nominee under the said policy. Sh. Avtar Singh had expired on 09.08.2014 at his village Bangian due to heart attack. His post mortem was also got conducted by the doctors of Civil Hospital, Rupnagar. He had informed the O.P. No.1 about his death and the O.P. No. 1 had intimated about the same to O.Ps. No. 2 to 4. Thereafter, the O.P. No. 2 had issued the letter dated 12.9.2014 to him for sending the requisite documents for processing the claim. Accordingly, he had sent the requisite documents to the O.P. No.2 through courier on 31.10.2014. As per under “Credit Shield Insurance” under the said  “Sarv Suraksha Plus” policy, the O.Ps. are liable to pay the outstanding loan amount of the insured vehicle, but they have declined to pay the said  amount  and told him that the claim comes under Critical Illness and they agreed to pay Rs.1 lac only, but did not pay the outstanding loan amount of the above said vehicle i.e. Rs.5,82,220.12, as per the  “Credit Shield Insurance”, inspite of his repeated requests, due to which he has suffered mental agony, physical harassment and huge/irreparable financial loss. Hence, this complaint.

 

3.                On being put to notice, the O.Ps. No. 1 to 3 filed a joint written statement, taking preliminary objections; that this Forum has no jurisdiction to entertain & try the instant complaint, as no branch office of the answering O.Ps. is situated within its jurisdiction; that the complainant has not come to the Forum with clean hands and has suppressed the material facts from this Forum;

that the complaint is not maintainable in the present form and there is no deficiency in service on the part of the answering O.Ps., therefore, the same is liable to dismissed. On merits, the factum of issuance of the insurance policy in question and occurrence of death of the insured, due to heart attack, on 9.8.2014, is admitted. It is stated that on receipt of intimation from the complainant regarding the death of the insured i.e. Avtar Singh, it was found by the answering O.Ps., after scrutiny of the papers supplied by him, that the insured had suffered a sudden heart attack on 09.08.2014, with no prior symptoms and had expired on the same day. The policy inception date in this case was 26.06.2014. As per specific exclusions applicable to Section 1, the insurance company is not liable to make any payment under the policy in connection with or in respect of any insured event, as stated in the said section, having occurred or suffered before the commencement of period of insurance or arising within the first 90 days of the commencement of the period of the insurance. In the instant case, the death having occurred within first 90 days of the inception of the policy, the same was excluded under the policy terms & conditions. Further for the claim under “Critical Illness” to be admissible under the policy, the insured person has to survive for a period of 30 days from the time, he was diagnosed for illness. The said condition was also not fulfilled in the instant case. Since the claim lodged under critical illness was not covered as per policy, as such, the insurance company after applying its mind has rightly repudiated the claim vide letter dated 30.9.2014 on the grounds mentioned above. The claim under the “Credit Shield Insurance”, was also not maintainable because to avail the benefit under the same, it is a condition precedent that the insured person should have suffered accidental death or permanent total disability. However, in the instant case, the death was neither accidental nor it was a case of permanent disability, hence, the benefit under the “Credit Shield” was also not admissible. All other allegations made in the complaint have also been denied and a prayer has been made for dismissal thereof with costs, stating the same to be without any merit.

 

4.                The O.P. No. 4 filed separate written statement stating that the auto loan of Rs.5,56,438/- was provided by the answering O.P. to Avtar Singh, who was to pay back the same in 60 monthly installments of Rs.12,099/- each. He was insured with the O.P. No.1, as per terms & conditions of the policy. All other allegations made in the complaint have been denied and a prayer has been made for dismissal thereof with costs.

 

5.                On being called upon to do so, the complainant tendered his affidavit Ex. C1, photocopies of various documents Ex. C2 to C14 and closed the evidence. On the other hand, the learned counsel for the O.Ps. No.1 to 3  tendered affidavit of Sh. Pankaj Kumar, Manager Legal(Claims) Ex.OP-1, photocopies of documents Ex.OP-2 to Ex.OP-7 and closed the evidence, whereas the learned counsel for the O.P. No.4 closed evidence after tendering affidavit of Sh. Rajesh Bhatia, authorized representative, Ex. OP-8.

 

6.                We have heard the learned counsel for the parties and gone through the record of the file carefully.

 

7.                The first objection raised by the learned counsel for the complainant was that the O.Ps. No. 1 to 3 had sent the policy document in question to the deceased father of the complainant, after about one month of its issuance. The said fact is found mentioned in para No.2 of the affidavit of the complainant, Ex. C1. Since the said O.Ps. did not send the terms & conditions of the policy to his deceased father, in time, therefore, they are not justified in repudiating the claim by relying upon the said terms & conditions. In support of his contention, the learned counsel relied upon the order passed by the Hon’ble National Commission in the case of ‘New India Assurance Company Ltd., New Delhi vs. Pabbati Sridevi & others’ 2013 (1) CLT 589, wherein it was held that the terms & conditions having not been communicated to the insured, the same cannot be relied upon by the insurance company.

 

                   On the contrary, the learned counsel for the O.Ps. No. 1 to 3 submitted that in the complaint, it has nowhere been pleaded in the complaint that his deceased father had not received the policy documents in time, therefore, the plea taken by him, lateron, in his affidavit to that effect ought not to be considered, the same being beyond pleadings. Even otherwise, it is not the case of the complainant that the insurer never supplied the terms & conditions of the policy to his deceased father. Therefore, the plea of the complainant that since his deceased father received the policy documents late by one month, therefore, the terms & conditions of the said policy are not applicable in case of the complainant, is not tenable.

 

                   After going through the contents of the complaint, it is revealed that the complainant has nowhere pleaded that his deceased father did not receive the policy documents in time, therefore, he cannot be allowed to go beyond the pleadings. However, even if for the sake of arguments, we believe the complainant that his deceased father received the policy documents late by one month, even then we do not find any force in his contention that the terms & conditions are not applicable and the insurer cannot decline to pay the benefits which he is legally entitled to.

 

8.                The second objection raised by the learned counsel for the complainant was that the father of the complainant, who was owner of the insured vehicle had died on 09.08.2014 i.e. during the validity period of the said policy, accordingly, the insurer was liable to indemnify the complainant under the coverage “critical illness” and “Credit Shield Insurance”, but the O.Ps. No. 1 to 3 have illegally repudiated the claim lodged by him vide letter dated 30.9.2014 (Ex. OP-3). Therefore, the complaint be accepted and the O.Ps. be directed to pay the amounts as prayed for in it.

 

                   To this effect, the learned counsel for the O.Ps. No. 1 to 3 submitted that since the inception date of the policy in question was 26.6.2014 and the insured had died due to sudden heart attack on 9.8.2014 with no prior symptoms and he expired on the same day, whereas as per the terms & conditions of the policy, the insured has to survive for a period of 30 days from the time, he was diagnosed for illness, but this condition has not been fulfilled in the instant case. Even otherwise, the death of the insurer in this case, being much before expiry of the period 90 days from the date of inception of the insurance policy in question, as such, the insurer is not liable to indemnify the complainant, as per Specific Exclusions Applicable to Section 1. Therefore, the complaint being without any merit is liable to be dismissed.

 

                   There is no dispute that the deceased insured was insured/covered under  “critical illness” and  also “Credit Shield Insurance”, as per insurance policy Ex. OP-2, issued under the name ‘Sarv Suraksha Plus’, valid for the period from 26.6.2014 to 25.6.2019 and the insured had suffered heart attack on 09.08.2014 and died on the same day i.e. 09.08.2014. From the letter dated 30.9.2014 (Ex. OP-3),  it is crystal clear that the insurer has treated the claim as ‘No Claim’ under Specific Exclusions Applicable to Section 1, which reads as under:-

“The company shall not be liable to make any payment under this policy in connection with or in respect of any insured event, as stated in this section, occurred or suffered before the commencement of period of insurance or arising within the first 90 days of the commencement of the period of insurance. If the insured person named in the schedule is diagnosed as suffering from a critical illness which first occurs or manifests itself during the policy period, and the insured survives for a minimum of 30 days from the date of diagnosis, the company shall pay the critical illness benefit.”

 

In the instant case, the insured had suffered heart attack on 09.08.2014 and died on the same day, therefore, the prescribed/requisite condition that the insured must survive for a minimum of 30 days from the date of diagnosis, was not fulfilled. Even the insured died much before the expiry of period of 90 days from the commencement of the policy, even this condition was not fulfilled, in the instant case, so as to arise the liability of the insurer to pay the claim under the “critical illness”.

 

                   Undisputedly, the insured was duly covered under the coverage i.e. “Credit Shield Insurance”.  As per Section 5 of the policy, the insurer was liable to give benefits only in the event of accidental death or permanent total disability of the insured person, during the policy period. Since in the present case, the death of the insured was not due to accident, but due to heart attack, therefore, the same was not covered under the said coverage, as per clause No. (1) of the ‘Specific Exclusions Applicable to Section 5’ of the said policy, according to which no indemnity is available and no payment is to be made by the insurance company, arising out of illness. Therefore, the insurer also cannot be held liable to give benefits to the complainant under the “Credit Shield Insurance”. Consequently, the complaint against O.Ps. No. 1 to 3 is liable to be dismissed.

 

9.                So far as the complaint filed against the O.P. No. 4 i.e. Retail Loan Service Center, Chandigarh, is concerned, the learned counsel for the said O.P. vehemently argued that neither any specific allegation has been made against the O.P. No.4, in the complaint  nor any specific relief against it has been sought, nor it was its duty, either to settle or pay the claim amount, if any, to the complainant, therefore, the complaint qua it is liable to be dismissed. We find force in this contention of the learned counsel for the O.P. No.4 because the grievance of the complainant is regarding non-payment of the claim amount, which, in any case, was to be settled/paid by the insurer only and not by the O.P. No.4, therefore, the complaint qua it is also liable to be dismissed.

 

10.              In view of the above discussion, the complaint against all the O.Ps. is dismissed, with no order as to costs.