DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,
PATIALA.
Consumer Complaint No. 86 of 29.2.2016
Decided on: 15.3.2017
Karamjit Kaur wd/o Sh. Kuldip Singh r/o Ward No.3, House No.5, Sirhin Road, Bhadson Tehsil Nabha, District Patiala.
…………...Complainant
Versus
- HDFC ERGO General Insurance Company Limited, 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri ( East), Mumbai-400059.
- HDFC Bank, Nabha, District Patiala through its Branch Manager/ Authorized Signatory.
…………Opposite Parties
Complaint under Section 12 of the
Consumer Protection Act, 1986.
QUORUM
Smt. Neena Sandhu, President
Smt. Neelam Gupta, Member
ARGUED BY:
Sh.M.L.Sharma,Advocate, counsel for complainant.
Sh.Dhiraj Puri,Advocate, counsel for opposite party No.1
Opposite Party No.2 ex-parte.
ORDER
SMT.NEELAM GUPTA, MEMBER
The husband of the complainant was holder of Sarv Suraksha Policy (Sarv Suraksha PRO) bearing No.2950 2010 8277 6800 000, issued by O.P. No.1 for the period 2.6.2015 to 1.6.2018. A personal loan, account No.32948804 was taken from OP No.2 and for the insurance coverage of loan, another lumpsum premium for the insurance policy was paid through OP no.2. It is averred that on 1.9.2015, the husband of the complainant was admitted in Kidney Hospital & Lifeline Medical Institutions at Jallandhar for critical illness and was discharged on 3.9.2015.On the same day i.e. on 3.9.2015, the husband of the complainant died at his residence at Bhadson. The complainant being the nominee of her husband lodged the claim with O.P. No.1 after completing all the formalities and documents. It is further averred that on 31.10.2015, O.P. No.1 repudiated the claim of the complainant on the ground, “ 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 commence of period of insurance or arising within the first 90 days of the commencement of the period of insurance”. It is alleged by the complainant that the repudiation of the claim was made wrongly without calculating the days between insured event and the date of insurance, which amounted to deficiency in service on the part of O.P. No.1.As a result, the complainant underwent a lot of sufferings mentally as well as financially. Ultimately she approached this Forum under Section 12 of the Consumer Protection Act( for short the Act), 1986.
2. On notice, OP No.2 failed to appear despite service and was thus proceeded against ex-parte. Whereas OP No.1 appeared through counsel and filed its reply to the complaint. The only plea taken by the O.P No.1 is that the claim was rightly repudiated as per the terms and conditions of the policy. Moreover, the disease of the insured was not covered under the definition of critical illness. As such, no deficiency in service can be attributed on the part of OP no.1 and prayed for dismissal of the complaint.
3. In support of her case, the complainant tendered in evidence Ex.CA, her sworn affidavit alongwith documents Exs.C1 to C7 and her counsel closed the evidence.
Whereas, the ld. counsel for OP No.1 produced in evidence Ex.OPA, sworn affidavit of Sh.Pankaj Kumar, authorized signatory of HDFC ERGO GIC Ltd. and closed the evidence.
4. We have heard the ld. counsel for the parties, gone through the written arguments filed by the ld. counsel for the complainant and have also gone through the record of the case, carefully.
5. Ex.C2 is the insurance policy , purchased by the husband of the complainant covering the period from 2.6.2015 to 1.6.2018. Ex.C1 is the repudiation letter dated 31.10.2015, whereby the O.P. repudiated the claim of the complainant on the following grounds:-
“ As per the hospitalization papers dated 01.09.2015, Late Mr. Kuldip Singh admitted for Crytognic Cirrhosis of Liver, Hepatitis, Diabetes and Diabetic Nephropathy. Insured has complaint of Jaundice with fever and Dyspnoea on exertion, odema since 2 months.
However, the policy inception date is 2.6.2015. Hence the current condition is contracted within first 90 days of the policy and the same is excluded under the policy.
SPECIFIC EXCLUSIONS APPLICABLE TO SECTION 1
The Company shall not be liable to make any payment under this Policy in connection with or in respect of any Insured Event, as stored 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”.
6. Today during the course of arguments, the ld. counsel for the O.P. took only one plea and argued that the insured was admitted in hospital within 90 days of the commencement of the policy that is why her claim falls within exclusion clause. He excluded two days i.e. 2nd June 2015 as well as 1.9.2016 while counting the number of days, whereas , we see that the policy was valid from 2.6.2015 to 1.6.2018, which shows the day of 2nd June,2016 should be included as the policy was valid till 1.6.2018.As per our view the insured was hospitalized on 1.9.2015 i.e. on the 92nd day of the purchase of the insurance policy. Hence the O.Ps. illegally repudiated the claim of the complainant. Also the O.P. failed to produce on record the terms and conditions of the insurance policy whereby it repudiated the claim.
7. In view of the aforesaid discussion, we accept the complaint of the complainant with a direction to OP No.1 to settle the claim of the complainant and make the payment alongwith interest @ 6% p.a. from the date of repudiation till payment. O.P. No.1 is also directed to pay a sum of Rs.5000/- as compensation for the harassment undergone by the complainant alongwith a sum of Rs.4000/- as costs of litigation. Order be complied by OP No.1 within a period of 30 days from the receipt of the certified copy of this order. Certified copy of this order be sent to the parties free of cost under the rules. Thereafter, file be indexed and consigned to the Record Room.
ANNOUNCED
DATED:15.3.2017
NEENA SANDHU
PRESIDENT
NEELAM GUPTA
MEMBER
