Haryana

Karnal

CC/453/2022

Sushil Kumar - Complainant(s)

Versus

HDFC Life Insurance Company Limited - Opp.Party(s)

Sanjeev Vohra

10 Oct 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No.453 of 2022

                                                        Date of instt.03.08.2022

                                                        Date of Decision:10.10.2024

 

Sushil Kumar son of Shri Joginder Singh resident of ward no.8, Darbara Colony, Assandh, District Karnal.

                                                                        …….Complainant.

                                              Versus

 

HDFC Life Insurance Co. Ltd. Kunjpura Road, opposite Mahabir Dal Hospital Karnal through Branch Manager.

 

                                                                        …..Opposite Party.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Shri Jaswant Singh……President.     

              Ms. Neeru Agarwal…….Member

      Ms. Sarvjeet Kaur…..Member

 

 Argued by: Shri Sanjeev Rana, counsel for the complainant.

                    Shri Vikas Bakshi, counsel for the OP.

 

                     (Sarvjeet Kaur, Member)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP’) on the averments that complainant and his wife, namely Mukesh obtained home loan of Rs.20,75,176/- for the terms of repayment 240 months, vide loan account no.641148447 from HDFC Bank i.e. sister concern of the OP. The complainant is regularly paying the installments of the home loan. At the same time, the OP issued policy certificate of insurance no.PP00028900RFT00 with master policy no.PP000289 for sum assured to the tune of Rs.11,10,680/- which commenced from 26.06.2019 for critical life option-2 and valid upto 25.06.2029.  As per terms and condition no.2 of the Member’s Certificate of insurance, the benefit payable to whom:

“in case of a valid claim on the death, disability or illness of a scheme member, during the term of the membership, the benefit described in the section headed “Schedule of Benefit” will then be payable to the scheme Member’s nominee. If the benefit is in the form of an acceleration of the death benefit and the scheme member alive, then the benefit shall be payable to the Scheme Member.”

As per the Appendix B of the policy, the critical illness includes 19 critical illness including Heart Attack. On 12.03.2022, the complainant has suffered from heart attack and got admitted in Sanjeev Bansal Cygnus Hospital, Railway Road, Karnal vide UHID no.116666 where he was operated and after treatment the complainant was discharged from the hospital on 15.03.2022. The complainant spent huge amount on his treatment. Thereafter, complainant approached the OP and submitted his claim alongwith medical records seeking claim under critical illness benefit but till date OP has not given any positive response to the complainant. Then complainant sent a legal notice dated 07.07.2022 to the OP but it also did not yield any result. In this way there is deficiency in service and unfair trade practice on the part of the OP. Hence complainant filed the present complaint seeking direction to the OP to pay Rs.11,10,608/- alongwith interest @ 18% per annum from the date of submission of claim till its realization for critical illness benefit and to pay Rs.2,00,000/- as compensation for harassment, mental pain, agony etc and any other relief which this Commission deems fit and proper.

2.             On notice, OP appeared and filed its written version raising preliminary objections with regard to maintainability; jurisdiction; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that the HDFC Bank Ltd. has obtained “HDFC Life Group Credit Protect Plus Insurance Plan having policy no.PP000289.” The complainant had taken a housing loan which was financed by HDFC Bank and the said Bank enrolled the complainant through enrolment form. In the Group Insurance Scheme where the base sum assured was Rs.11,10,608/- under member certificate no.PP000289-00RFT-00 and duration was 120 month with plan option of critical life option 2. It is further pleaded that complainant has submitted critical illness claim alongwith medical records. The claim filed by the complainant has been repudiated, vide letter dated 28.05.2022 on the grounds that “since the diagnosed illness mentioned in the medical records submitted to us does not fulfill the criteria in the above definition.” As per the Appendix-B-Option 2 Specific Exclusion for critical illness benefit; definition and Exclusions in the certificate of Insurance, which is reproduced as under:-

Myocardial Infraction:

The first occurrence of heart attack or myocardial infraction, which means the death of portion of the heart muscle as a result of inadequate blood supply to the relevant area. The diagnosis of Myocardial infraction should be evidenced by all the following criteria:

.       A history of typical symptoms consistent with the diagnosis of acute myocardial infraction (for e.g. Typical Chest pain).

.       New characteristic electrocardiogram.

.       Elevation of infraction specific enzymes, Troponins or other specific biochemical markers.

Following are excluded:

.       Other acute coronary syndromes.

.       Any type of angina pectoris.

.       A rise in cardiac bio-markers or trponin T or I in absence of overtischememic heart disease or following an intra-arterial cardiac procedural.

        “Since the diagnosed illness mentioned in the medical records submitted to OP does not fulfill the criteria in the above definition.” Hence the claim of complainant has rightly been repudiated by the OP. There is no deficiency in service and unfair trade practice on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.C1/A, copy of loan agreement Ex.C1, copy of insurance policy Ex.C2, copy of hospital bills Ex.C3, copy of certificate regarding health Ex.C4, copy of admission and discharge record Ex.C5, copy of discharge summary Ex.C6, copy of legal notice Ex.C7, postal receipt Ex.C8, acknowledgement Ex.C9 and closed the evidence on 10.02.2023 by suffering separate statement.

5.             On the other hand, learned counsel for the OP has tendered into evidence affidavit of Gurpreet Singh Ex.OPW1/A, authority letter Ex.OP1, copy of Member Enrolment Form Ex.OP2, copy of Member’s certificate of insurance Ex.OP3, copy of investigation report Ex.OP4, copy of investigation report Ex.OP5, copy of medical record Ex.OP6, copy of letter dated 20.05.2022 issued by Principal, Government Senior Secondary School Chochra (Karnal) Ex.OP7, copy of repudiation letter dated 28.05.2022 Ex.OP8, copy of email dated 26.06.2019 Ex.OP9 and closed the evidence on 05.03.2024 by suffering separate statement.

6.             We have heard the learned counsel for the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that complainant and his wife obtained a home loan of Rs.20,75,176/- from HDFC Bank. At the time of obtaining the loan, the OP issued an insurance policy for the sum assured of Rs.11,10,680/- which commenced from 26.06.2019 for critical life option-2 and valid upto 25.06.2029. On 12.03.2022, the complainant has suffered from heart attack and got admitted in Sanjeev Bansal Cygnus Hospital, Karnal where he was operated and after treatment he was discharged from the hospital, the complainant spent huge amount on his treatment. Complainant approached the OP and submitted his claim alongwith medical records seeking claim under critical illness benefit but OP did not pay the claim despite repeated requests and repudiated the claim of complainant on the false and frivolous ground and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OP, while reiterating the contents of written version, has vehemently argued that complainant has submitted critical illness claim alongwith medical records. The claim of the complainant was rightly repudiated by the OP, vide letter dated 28.05.2022 on the grounds that “since the diagnosed illness mentioned in the medical records does not fulfill the criteria of the illness as per the Appendix-B option 2 Specific Exclusion for critical illness benefit and lastly prayed for dismissal of the complaint.

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, complainant obtained a home loan of Rs.20,75,176/- from HDFC Bank. It is also admitted that at the time of obtaining the loan, OP issued an insurance policy named as “HDFC Life Group Credit Protect Plus Insurance Plan.” for the sum assured of Rs.11,10,680/-, which commenced from 26.06.2019 for critical life option-2 and valid upto 25.06.2029.

11.           The claim of the complainant has been repudiated by the OP, vide repudiation letter Ex.OP8 dated 28.05.2022, which is reproduced as under:-

“We are in receipt of Critical Illness Claim documents alongwith the Medical records intimating us about the claim under Critical Illness benefit.

Please refer to Appendix B-Option 3 specific Exclusions for Critical Illness benefit: Definitions and Exclusions in the Certificate of Insurance provided to you.

Myocardial Infraction:

The first occurrence of heart attack or myocardial infraction, which means the death of portion of the heart muscle as a result of inadequate blood supply to the relevant area. The diagnosis of Myocardial infraction should be evidenced by all the following criteria:

i.      A history of typical symptoms consistent with the diagnosis of acute myocardial infraction (for e.g. Typical Chest pain).

ii.     New characteristic electrocardiogram.

iii..    Elevation of infraction specific enzymes, Troponins or           other specific biochemical markers.

Following are excluded:

i.      Other acute coronary syndromes.

ii.     Any type of angina pectoris.

iii.     A rise in cardiac bio-markers or trponin T or I in absence of overtischememic heart disease or following an intra-arterial cardiac procedural.

Since the diagnosed illness mentioned in the medical records submitted to us does not fulfill the criteria in the above definition, we regret our inability to process the claim.

12.           The claim of the complainant has been repudiated on the abovesaid ground. Complainant has suffered from heart attack, which comes under the definition of critical illness as per Appendix B of the policy. The onus to prove its version was relied upon the complainant. To prove his case, the complainant has placed on file admission and discharge record Ex.C5 and discharge summary Ex.C6 wherein it has been clearly mentioned that the complainant was admitted for CAD (coronary artery disease), which is a heart disease and relatable to heart attack. As per Appendix-B of terms and conditions, ‘Heart Attack’ falls under the definition of critical illness. The definition of heart attack given in point no.8 of terms and conditions is reproduced as under:-

Heart Attack

The first occurrence of myocardial infarction which means the death of a portion of the heart muscle as a result of inadequate blood supply to the relevant area. The diagnosis for this will be evidenced by all of the following criteria.

1. A history of typical clinical symptoms consistent with the diagnosis of Acute Myocrdial Infraction (for e.g. typical chest pain).
2. New characteristic electrocardiogram changes.
3. Elevation of infarction specific enzymes, Troponins or other specific biochemical markers.

13.           Thus, in view of above clause, Heart Attack falls under the definition of critical illness. Hence, the claim of the complainant has been repudiated by the OP only on the basis of presumption and assumption, which is not admissible in the eyes of law.

14.           Furthermore, now a days it has become a trend of insurance companies, they issue the policies by giving false assurances and when insured amount is claimed, they make such type of excuses. Thus, the denial of the claim of complainant is arbitrary and unjustified. In this regard, we place reliance on the judgment of Hon’ble Punjab and Haryana High Court titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, wherein the Hon’ble Punjab and Haryana High Court has held as under:-

“It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy”.

15.           Keeping in view, the ratio of the law laid down in aforesaid judgment, facts and circumstances of the present complaint, the act of the OP while denying the claim of complainant amounts to deficiency in services and unfair trade practice.

16.           As per insurance policy Ex.C2, the sum insured under the critical illness benefit is Rs.11,10,608/-. Hence, complainant is entitled for the said amount alongwith interest, compensation for mental harassment and litigation expenses etc.

17.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP to pay Rs.11,10,608/- (Rs. eleven lakhs ten thousand six hundred eight only) to the complainant alongwith interest @ 9% per annum from the date of filing the complaint i.e. 03.08.2022 till its realization. We further direct the OP to pay Rs.25,000/- to the complainant on account of mental agony and harassment and Rs.11,000/- towards the litigation expenses. This order shall be complied within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced
Dated: 10.10.2024

         President,

      District Consumer Disputes                            

      Redressal Commission, Karnal.

 

                   (Neeru Agarwal)             (Sarvjeet Kaur)

                          Member                         Member