BEFORE THE DISTT.CONSUMER DISPUTES REDRESSAL FORUM; FATEHABAD.

Complaint Case No.11 of 2016.

Date of Instt.:  06.01.2016.

Date of Order:  18.01.2017.

Gulab Singh son of Amar Singh resident of village Gorakhpur, Tehsil & District Fatehabad.

...Complainant

     Versus

1.HDFC ERGO General Insurance Company Limited Registered & Corporate Office Ist Floor 165-166 Backbay Reclamation, HT Parekh Marg, Churchgate, Mumbai-400020 through its Chairman-cum Managing Director.

2.HDFC ERGO General Insurance Company Limited  Red Square Market, Behind HDFC Bank, Tehsil & District Hisar through its Divisional /Branch Manager.

3.HDFC ERGO General Insurance Company Limited c/o HDFC Bank opposite Delhi Nursing Home, GT Road, Fatehabad Tehsil & District Fatehabad through its Branch Manager. (GIVEN UP)

4.Aantar Singh Khanna son of Om Parkash resident of village Kharakheri Tehsil & District Fatehabad.

..Opposite parties.

Before:       Sh.Raghbir Singh, President.

                  Smt.Ansuya Bishnoi,Member.

Present:       Sh. S.K.Dharnia, counsel for the complainant.

                   Sh. U.K.Gera, counsel for OP Nos. 1 & 2.

                   Sh.S.S.Marothia, counsel for OP No. 4.

                   Op No.3 has been given up.

ORDER     

                   Sh.Gulab Singh has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against the opposite parties (hereinafter to be referred as OPs) with the averments that his son Ved Pal had got himself insured with OP Nos. 3 & 4 vide policy No.2950201076240400000 having validity from 26.05.2015 to 25.05.2020 for a sum of Rs.5,05,000/- and he had been appointed as nominee.  On 28.06.2015 life insured-Ved Pal died and after his death the complainant had submitted all the requisite documents with the OPs and also completed all the formalities but the OPs have not released all the benefits of the insureance. The complainant requested the OPs besides serving of legal notice dated 06.10.2015 upon them to release the insurance benefits but to no avail. The act and conduct of the OPs amount to deficiency in service on their part. The complainant has also claimed compensation on account of mental agony, harassment. Hence, this complaint. In evidence, the complainant has tendered his affidavit as Ex.CW1, affidavit of Ranbir Singh, Numberdar resident of village Gorakhpur as Ex.CW2, affidavit of Krishan Kumar Patwari as Ex.CW3/A and affidavit of Narender, Panch  as Ex.CW4/A and documents Ex.C1 to Ex.C10.

3.                Upon notice, opposite parties No.1, 2 & 4 appeared and contested the complaint of the complainant by filing separate replies. OP Nos.1 & 2 in their joint reply have submitted that the deceased life assured had obtained Sarv Suraksha Insurance Policy   bearing No. 2950201076240400  having validity from 26.05.2015 to 25.05.2020. It had been further submitted that the said policy had been issued with the consent of the insured and its terms and conditions were also supplied to the insured. The life insured had died on 28.0.6.2015 (due to myocardial infraction starts from  26.06.2015) within 90 days of the date of commencement of policy i.e. 26.05.2015 and as per exclusion clause applicable to Section 1 of the policy  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 insurance or arising within the Ist 90 days of the commencement of the period of insurance. It has been further submitted that both the parties are governed by the terms and conditions of the contract, therefore, the claim of the complainant had rightly been closed being ‘No Claim’. OP No.4 in its separate reply has submitted that the complainant is not entitled for any compensation because he had been helping hand in order to fill up the forms only as per his duty qua appraising of customers about instructions. All the appearing OPs have submitted that there is no deficiency in service on their part and prayer of the dismissal of the complaint has been made.  OP No.3 has been given up by learned counsel for the complainant vide separate statement dated 22.04.2016.  In evidence, the appearing OPs have tendered affidavit of Pankaj Kumar, authorized signatory as Annexure R1 and document Annexure R2.

4.                Learned counsel for the complainant has argued that the deceased-life insured had died during the subsistence of the policy. It has also been contended that the deceased life assured was a teacher and was entrusted the duty of V.L.O. by the Government. He died due to sudden heart attack while discharging his duties as V.L.O. The same is evident from the affidavits of village Patwari, Lamberdar of the village and Panch of the ward. Therefore, the case of the complainant for grant of compensation is covered under the policy. It has been further contended that it is a case of accidental death and does not fall within the category of critical illness, therefore, exclusion clause of 90 days is not applicable in the present case and the claim of the complainant has been illegally repudiated by the OPs. It was the duty of the insurance company to release the benefits provided under the insurance policy purchased by the deceased-life insured but the OPs have not paid any heed to the request of the complainant qua releasing of the benefits. It has been further argued that though the OPs have replied the legal notice sent by the complainant but treating the claim of the complainant as No Claim on the ground that the deceased life assured had died within 90 days of the commencement of the policy is illegal and wrong, against the provisions of CP Act and natural justice.

5.                On the other hand learned counsels for the appearing OPs have argued that the deceased-life insured  had died within 90 days of the commencement of the policy, therefore, as per exclusion clause applicable to Section 1 of the policy the claim of the complainant had rightly been closed being ‘No Claim”.

6.                 After hearing the arguments advanced on behalf of both the parties and going through the material available on the case file it transpires that the insurance company has rightly closed the claim of the complainant being ‘No Claim”.  It is well established that the policy was having validity from 26.05.2015 to 25.05.2020 and there is no dispute that the assured died during the subsistence of the policy. It is also not disputed that the assured died on 28.06.2015 i.e. within 90 days from the commencement of policy. Specific exclusions applicable to Section I i.e. critical illness interalia provides that Critical illness diagnosed within 90 days of the date of commencement is excluded. Relevant part of above said clause is reproduced as under:

“Any critical illness diagnosed within the first 90 days of the date of commencement of the policy is excluded. This exclusion shall not apply to an insured for whom coverage has been renewed by the named insured, without a break, for subsequent years”

We are of the considered opinion that in the present case since the assured died within 90 days from the date of commencement of policy as such in view of the above said exclusion clause the complainant is not entitled for insurance claim. On this point reliance can also be taken from case law titled as Kales Gupta Vs. ICICI Lombard General Insurance Company Limited 1 (2017) CPJ 123 (NC) wherein Hon’ble National Commission has held that   As per exclusion clause insurer will not be liable if claim arises within first 90 days of the commencement of the policy- Deceased died within 90 days, insurer is not liable to pay any amount to complainant- Contention regarding non-supply of terms and conditions of policy, deceased being an educated person would have at least written a letter claiming that terms and conditions had not been supplied to him- Since no letter was written, it is presumed that terms and conditions were either supplied to him or brought to his notice-No error in impugned order. The OPs have specifically submitted in the reply filed to the complaint that the terms and conditions were duly supplied to the deceased-life assured at the time of obtaining of policy. It is settled principle of law that both the parties are bound by the terms and conditions of the contract, therefore, we have no hitch to conclude that the insurance company has rightly closed the claim of the complainant as the deceased-life assured had died within 90 days of the commencement of the policy.  As per the version of the complainant, the deceased-life assured had died due to heart attack but he has failed to produce any evidence that  death on account of heart attack was covered under the policy because as per Ex.10 the policy obtained by the deceased-life assured had covered the benefits such as Credit Shield Insurance, Accidental Hospitalization, Accidental Death, Permanent Total disability/Permanent partial disability and critical illness.  We are of the considered opinion that death due to heart attack does not fall within the definition of accidental death.  There is no deficiency in service in service on the part of the OPs, therefore, the complaint deserves dismissal. It is ordered accordingly. A copy of this order be supplied to the parties free of costs. File be consigned to the record room after due compliance.

Announced in open Forum.

Dated: 18.01.2017.

                                                                   (Raghbir Singh)

                                                                   President

(Ansuya Bishnoi)                                Distt.Consumer Disputes

      Member.                                                 Redressal Forum, Fatehabad.