Delhi

North

CC/258/2024

BINDIYA - Complainant(s)

Versus

HDFC LIFE INSURANCE COMPANY LTD - Opp.Party(s)

26 Mar 2024

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

 

CONSUMER COMPLAINT NO.: 258/2024

Date of filing: 23.03.2024

Date of decision: 26.03.2024

In the matter of

Bindiya

W/o Late Anil

R/o H.No.A-259, Sangam Park,

North-Delhi, Delhi-110007                                   …      Complainant

Versus

HDFC Life Insurance Company Ltd.

Through its Manager

11th Floor, Lodha Excelus,

Apollo Mills Compound N.M. Joshi Marg,

Mahalaxmi, Mumbai-400011                               …      Opposite Party

ORDER

26.03.2024

Present: Shri S P Sharma, Ld. Advocate for Complainant along with Complainant in person

(Divya Jyoti Jaipuriar)

1. The complaint is scheduled to be listed on 28.03.2024 for admission hearing. However, upon mentioning and on the request of Ld. Advocate for the Complainant, this matter is taken up today for consideration for admission hearing today itself.
2. Arguments of Shri S P Sharma, Ld. Advocate for the Complainant heard on admissibility of this complaint. At the onset, it is noted that the Complainant had initially filed the complaint on the same cause of action vide CC No. 439/2022, which was subsequently dismissed withdrawn at admission stage itself on 16.12.2022. By the said order dated 16.12.2022, the Complainant was given liberty to approach the forum/ Court of appropriate jurisdiction for Redressal of her complaint. Thereafter, this second complaint has been filed on the same cause of action before this Commission itself.
3. The case of the Complainant is that her husband namely Late Shri Anil purchased the “HDFC Life Group Health Shield” policy issued by M/s HDFC Life Insurance Company Limited (OP herein), which was effective for a period of 5 years since 29.09.2019. The policy also covered critical benefit for the same period of 5 years. The Complainant herein is the nominee in the said policy.
4. The said policyholder Late Shri Anil was admitted to Tirath Ram Shah Charitable Hospital (not a party) on 04.09.2020 at 14:59 hrs. for the complaint of breathlessness, generalised weakness and vomiting. He was diagnosed to have “acute respiratory failure with sudden cardiac arrest with hepatitis renal involvement with covid suspect”. During the treatment in the hospital, the policyholder expired on the same day at 18:00 hrs. Thereafter, the Complainant herein lodged insurance claim with the OP. Although the date of lodging claim is not indicated in the complaint, the repudiation letter indicates that the claim was intimated on 17.08.2022 and the claim documents were also filed on the same date.
5. Vide its letter dated 18.08.2022, the OP has repudiated the claim on two grounds- the illness for which the policyholder was admitted in Tirath Ram Hospital was not a critical illness and secondly the policyholder has to survive for a period of 30 days from the date of diagnosis for coming under the purview of policy terms and conditions. The exact wording of the claim repudiation is as under:

“Life assured Mr. Anil Update was admitted with complaint of severe dyspnoea, generalized weakness, vomiting with history of fever on 04/09/2020 at Tirath Ram Shah Charitable Hospital. The Insured was diagnosed with Acute respiratory failure ? Sudden cardiac arrest with? Hepatitis? Renal involvement with? Covid suspect. The submitted documents indicate medical management. The Discharge Summary submitted/retrieved in the documents indicate that life assured was admicted with diagnosis Acute respiratory failure ? Sudden cardiac arrest with? Hepatit s? Renal involvement with? Covid suspect treated with medical management. According to policy T&C the said diagnosis does not fall under Critical Illnesses listed in policy document. Also life assured was admitted on 04/09/2020 and expired on 04/09/2020. According to policy T&C, life assured has to survive for 30 days from the date of diagnosis. Hence claim is not admissible.”

6. The Complainant has alleged that at the time of sale of policy, it was informed that every medical condition will be covered under the policy without any restrictions. Hence, the Complainant herein alleges mis-selling of the insurance policy and also unreasonable repudiation of the claim.
7. Regarding mis-selling of the policy, we have observed that the policy along with its complete terms and conditions were supplied to the Policy Holder, which also indicated the free-look period in case the policy holder was not satisfied with the policy terms and conditions. It is not the case of the Complainant that the terms and conditions were not supplied along with the policy. As a matter of fact, the Complainant has annexed the policy certificate along with its terms and conditions, which clearly indicates that the policy terms and conditions were supplied to the policyholder. The policy terms and conditions with respect to the free look period is as under:

“(1) Free Look Cancelation: In case you are not agreeable to any of the provisions stated in the Certificate of Insurance, you have the option to return the Certificate of Insurance to us stating the reasons thereof, within 15 days (or 30 days in case the COI has been issued through distance marketing mode) from the date of receipt of the Certificate of Insurance. On receipt of the letter along with the original Certificate of Insurance, we shall arrange to refund the Premium paid by you subject to deduction of the proportionate risk Premium for the period on cover, expenses incurred for medical examination, if any and stamp duty (if any), provided you have not made any claim under this Certificate of Insurance, within 15 days from the date of receipt of request for Free-Look cancellation. For administrative purposes, all Free-Look requests should be registered by the Master Policyholder, on your behalf.”

8. As the policyholder did not exercise the “free look period” option, it is safely assumed that the policyholder was in agreement with the policy terms and conditions including the terms and conditions regarding the critical illness benefits. Once the action of policyholder has established that the he has accepted the policy terms and conditions, the Complainant herein cannot raise the issue of the mis-selling of the policy. Hence, the argument of the Complainant that the policy was sold to the policy holder promising complete coverage of the health benefits without any restrictions cannot be accepted. Hence we do not find any force in this argument of mis-selling of the policy.
9. Now coming on to the repudiation of the claim by the OP, the repudiation letter dated 18.08.2022 indicates that the OP has relied on policy conditions (i), (ii), and (iii) of the heading “Critical Illness Benefit” in support of the repudiation of the claim. The said conditions read as under:

“Critical Illness Benefit:

i. This Benefit shall be payable to the Scheme Member in the event of

a. The Scheme Member being diagnosed on first occurrence of any of the Critical Illnesses covered under Category A, B and C below during the Cover Term; or

b. The Scheme Member undergoing any of the surgeries listed in the Categories A B and C below during the Cover Term.

ii. The Critical Illnesses covered under this Benefit are as mentioned below:

Category A. Cardiac related

1. Myocardial Infarction (First Heart Attack of specific severity)

2. Open Heart Replacement or Repair of Heart Valves

Category B.           Cancer related

1. Cancer of specified severity

Category C. Others

1. Kidney failure requiring regular dialysis	14. Multiple Sclerosis with persisting Symptoms
2. Stroke resulting in permanent Symptoms	15. Motor Neuron. Disease with permanent Symptoms
3. Alzheimer's Disease	16. Benign Brain Tumour
4. Apallic Syndrome	17. Major Organ/ Bone Marrow Transplant
5. Coma of specified severity	18. Progressive Scleroderma
6. End Stage Liver Failure	19. Muscular Dystrophy
7. End Stage Lung Failure	20. Poliomyelitis
8. Loss of Independent Existence	21. Loss of Limbs
9. Blindness	22. Deafness
10. Third Degree Burns	23. Loss of Speech
11. Major Head Trauma	24. Medullary Cystic Disease
12. Parkinson's Disease	25. Systematic lupus Eryth with Renal Involvement
13. Permanent paralysis of limbs	26. Aplastic Anaemia

iii. The Scheme Member must survive for a period of 30 days following the date of occurrence of the Critical Illness or undergoing Surgery covered under this Benefit, as the case may be, for the Benefit to be payable.”

10. On the ground of  repudiation of claim under policy terms and conditions (i), (ii) and (iii) under the heading “Critical Illness Benefit”, we are of the opinion as the OP has relied on the policy terms and conditions, the onus to prove deficiency of service on part of OP lies on the Complainant. The Complainant can show deficiency of service either by arguing that the OP has wrongly applied the said terms and conditions or by way of challenging the said terms and conditions being unfair.
11. In the case in hand, the medical record so filed clearly indicates that the Complainant was diagnosed with “acute respiratory failure with sudden cardiac arrest with hepatitis renal involvement with covid suspect”. The policyholder was having sudden cardiac arrest, which indeed is not listed in the categories of critical illness in the policy terms and conditions. In the policy terms and conditions, the critical illness includes Myocardial Infarction, which is different from cardiac arrest. Myocardial Infarction (also referred to as Heart Attack) happens when there is a blockage that prevents the oxygen-rich blood from getting to the heart. On the other hand, Cardiac Arrest is when the heart suddenly stops functioning and stops beating and pumping blood to the vital organs of the body. Both these conditions affect heart, but are medically different. The policy terms and conditions include the cardiac related Myocardial Infarction, and not the Cardiac Arrest as critical illness.
12. Further, the policy terms and conditions also indicate that the policyholder must survive for a period of 30 days following the date of occurrence of the critical illness. In the case in hand, the policy holder expired on the same day, when he was diagnosed with the cardiac arrest. Even if we assume that the cardiac arrest is also covered under cardiac related critical illness, as the policyholder did not survive for a period of 30 days, the claim becomes non-payable in accordance with policy terms and conditions.
13. In such a situation, the repudiation appears to be in consonance with the policy terms and conditions. As the repudiation is in accordance with policy terms and conditions, there is no prima facie alleged deficiency of service on part of the OP. Hence, this complaint is liable to be dismissed.
14. Before parting, we would like to record that the policy terms and conditions appear to be unreasonable and unfair. However, we do not have powers to examine the unfair nature of contract including policy terms and conditions. The unfair contract including policy terms and conditions can only be examined by Hon’ble State Commission in its original jurisdiction under section 47 (1) (a) (ii) of the CPA, 2019 or by Hon’ble National Commission in its original jurisdiction under section 58 (1) (a) (ii) of the CPA, 2019. Similar power to examine the unfair nature of contract has not been conferred upon the District Commissions under the provisions of the CPA, 2019. As a result, while dismissing the complaint, we grant liberty to the Complainant to file an appropriate consumer complaint before Hon’ble State Commission or Hon’ble National Commission, as the case may be, if so advised.
15. Accordingly this complaint is dismissed at admission stage itself with above liberty. Office is directed to return all original document filed by the Complainant, if any, after retaining photocopy of the same for the records. Copy of the order be also supplied to the parties in accordance with the rules. Thereafter file be consigned to the record room.

 

 

___________________________

Divya Jyoti Jaipuriar, President

 

 

___________________________

Ashwani Kumar Mehta, Member

 

 

___________________________

Harpreet Kaur Charya, Member