PER:
Charanjit Singh, President
1 The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 34, 35 and 36 against the opposite party on the allegations that the complainant was having service bank account with the O.P No.3 and the officials of the O.P No.3 told the complainant about the insurance policies initiated by the O.P No.1 & 2 i.e. HDFC Standard Life Insurance Company. After hearing and knowing about the offers, the complainant purchased a Life insurance policy namely "HDFC LIFE SUPER INCOME PLAN" bearing policy No.19908086 from the O.P No.1 & 2 and the policy term was 16 years, premium paying term is 8 years and the date of commencement of risk is 22.12.2017, the policy issue date is 03.01.2018, the annualised premium was fixed as Rs.8,35,212, the final premium due date is 22.12.2024 and the Maturity date is 22.12.2033. The Sum assured on death was fixed as Rs.58,46,484/- and the sum assured on maturity was fixed as Rs. 47,95,107/-. The above policy includes the HDFC Life Critical Illness Plus Rider plan bearing UIN 101B014V01 and the rider sum assured is fixed as 47,95,109/- and the said rider sum assured is the lump sum benefit for which the life insured is entitled if he is diagnosed with any of the specific critical illness. The complainant has paid the first premium amount of Rs.9,99,999/- to the opposite parties i.e. the insurance company vide receipt dated 3.1.2018 and as such since the commencement of this policy, the complainant has been making premium payment regularly without any default. In September, 2022, the complainant suffered Chest Pain and on 20.9.2022 he was admitted in GMC Hospital, Amritsar wherein doctor diagnosed him with heart attack and treated him accordingly and the complainant was discharged from hospital on 22.9.2022. After suffering with the above illness, the doctor has assessed the illness and the case of the complainant falls in the critical illness for which the complainant is entitled for the rider sum assured. The complainant presented his claim case before the opposite parties and the complainant was so much assured that the company .i.e. the opposite parties will abide by its words and will pass the genuine case of the complainant as the policy is super income plan policy, which cover rider sum assured on critical illness but despite of doing legal duty towards the complainant, the opposite parties has served the complainant a letter dt. 21.11.2022 vide which the claim of the complainant was repudiated and further no plausible reason was mentioned for repudiating the claim of the complainant. While rejecting the claim of the complainant, the opposite parties have suggested "Critical illness claim submitted by you for the first attack of specified gravity does not fulfill the definition, hence claim for heart attack cannot be admitted". The said submission of the OPs is nothing but a false excuse made by the O.Ps for rejection of claim. On contacting the officials of the company, they have told that his claim was repudiated due to certain terms and conditions. The complainant has several times asked about the same but no official has given satisfactory reply. No alleged terms and conditions have been ever dictated to the complainant by the opposite parties on the basis of which the claim of the complainant was repudiated. The base of excuse given by the opposite party for rejection of genuine claim has no legal value in the eyes of law. The whole medical record, the doctor's interpretation of the complainant's illness and the medical terminology clarifies beyond any doubt that the illness of the complainant comes within the definition of the critical illness as covered by the policy. Thus the reason for rejection of claim was only lamed objection and has no iota of logical reasoning. The complainant has several times asked the officials of the company that to reconsider his claim to pass the claim in his favor but none of the official has ever paid heed towards the genuine requests made by the complainant. As such the complainant served the opp. parties with legal notice dated 03.01.2023 for passing his claim but the opp. parties did not pay any response to the said legal notice. The claim of the complainant was repudiated on flimsy grounds by the opp. Parties. The complainant has prayed the following relieves against the opposite parties No. 1 and 2.
- The opposite parties may be directed to pay the rider sum assured i.e. the lump sum benefit for the amount of Rs. 47,95,109/- alongwith interest @ 12% per annum from the date of entitlement till actual realisation to the complainant in the interest of justice.
- The opposite parties be also directed to pay compensation of Rs. 55,000/- to the complainant on account of mental pain, agony, harassment and inconvenience suffered by the complainants from the hands of the opposite parties.
- The costs of proceedings/ litigation expenses to the tune of Rs. 55,000/- .
Alongwith the complaint, the complainant has placed on record his affidavit Ex. C-1, self attested copy of insurance policy Ex. C-2, Self attested copy of receipt Ex. C-3, Self attested copy of test report of Shri Guru Angad Dev Charitable Clinic Lab Ex. C-4, Self attested copies of four bills of medicines etc. are having total amount of Rs. 67,999/- Approx Ex. C-5 to C-8, Self attested copies of discharge summary/ record Ex. C-9, Self attested copy of letter of repudiation Ex. C-10, Self attested copy of certificate issued by Guru Nanak Dev Hospital Ex. C-11, Self attested copy of legal notice Ex. C-12, self attested copy of Adhar Card of complainant Ex. C-13.
2 Notice of this complaint was sent to the opposite parties and opposite parties No. 1 and 2 appeared through counsel and filed written version by interalia pleadings that the present complaint is not maintainable and liable to be rejected on the ground that earlier also the complainant had filed a complaint before this Commission on the same subject matter in June, 2023. However the same was withdrawn in October, 2023 without assigning any reason whatsoever and now again the present complaint has been filed on the same cause of action, hence the present complaint is not maintainable and liable to be rejected. The present complaint is liable to be rejected as the complainant has concealed major facts from this Commission. The claim submitted on account of critical illness due to first heart attack to the insured was scrutinized and it was established that the critical claim submitted by the insured for the First Heart Attack of the specified severity did not fulfill the definition of First Heart attack as contained in additional policy provisions Part B Critical illness Plus Rider Benefit detailed in the policy issued to the insured, hence the claim was denied under as the alleged illness was not covered under the terms and conditions of the policy and fell under the exclusion clause contained in the policy which contains the following exclusions:
i) Non-ST segment elevation myocardial infraction (NSTEMI) with elevation of Troponin I or T,
ii) Other acute Coronary Syndromes
iii) Any type of angina pectoris
Therefore the claim of the complainant was repudiated and conveyed by the opposite party vide letter dated 21.11.2022 The claim of the complainant was rightly rejected by the opposite party on the fact that the alleged critical Illness is not covered as per terms and conditions of the insurance policy and excluded. The complainant is debarred to file the instant complaint due to his own act and conduct. The complainant tried to defraud the opposite party No. 1 and 2 and knowingly concealing the details of the critical illness claim lodged with the opposite party No. 1 and 2 which clearly reveals that mala fide intention of the complainant to grab the public money; hence the complaint is liable to be dismissed. The complaint against the Opposite party does not lie before this commission under the Consumer Protection Act with regard to the rejected claim. The matter is also to be decided by a civil court at full scale trial requiring the complete pleadings and evidence according to law the summary trial under the Consumer Protection Act, 1986 is not the proper remedy for the complaints. The Opposite party had rightly refused the death claim of the Life Insurance policies of the deceased. In view of the provisions contained in the Insurance Act, 1938 which is a specific statue meant for dealing with the disputes under the contract of insurance the provisions of the Consumer Protection Act cannot be invoked for dealing with the matter covered by Insurance Act. However the said policy is subject to its terms and conditions and the parties are bound to abide by the said terms and conditions. As per terms and conditions of the policy, critical illness if any suffered by the insured is always subject to exclusions contained therein keeping in view the medical diagnosis and cause of the alleged critical illness. The opposite party has not committed any gross negligence and deficiency in providing services. The complainant is not entitled to the claim. The opposite party Nos. 1 and 2 have denied the other contents of the complaint and prayed for dismissal of the same. Alongwith the written version, the opposite party Nos. 1 and 2 have placed on record affidavit of Gurpreet Singh Ex. OP1/A alongwith documents Ex. OP1,2/1 to Ex. OP1,2/7.
3 The opposite party No. 3 appeared through counsel and filed written version by interalia pleadings that the present complaint is liable to be dismissed for want of cause of action against opposite party No.3. From the Pleadings of the complaint it reveals that no relief has been sought against the opposite party No. 3 and has been arrayed as Performa Party. The present complaint is liable to be dismissed against the opposite party No.3. The present complaint is malifide and opposite party No.3 has been dragged into unwanted litigation. In fact there is no deficiency in service on part of replying opposite party No.3. The present complaint is liable to be dismissed. The complaint is not verified in accordance with provisions of law and deserves dismissal. The complainant has got no locus-standi to file the present Complaint. The present complaint is liable to be rejected on the ground of concealment of facts as earlier complaint bearing Nо.CC/24/2023 on the same facts was withdrawn by the complaint on 26.10.2023, hence present complaint is not maintainable and liable to be rejected. The agreement of the insurance policy has been duly executed between the complainant and opposite parties No.1 & 2, opposite party No. 3 is not a party to that very insurance policy & privity of insurance contract executed between complainant and opposite parties No.1 & 2. If there is any dispute regarding the terms and conditions of the insurance policy or with regard to the insurance claim lodged by the complainant as alleged, that is between the complainant and opposite parties No.1 & 2 and opposite party No.3 has no concern with the alleged dispute. There is no deficiency on the part of the opposite party No.3 as alleged. As such Complaint in hand is required to be dismissed. The complainant is having his service bank account with the opposite party No. 3 is matter of record. The opposite party No. 1& 2 which is different and distinct identity and replying opposite party has nothing to do with the business concern of opposite party No. 1& 2. There is no deficiency in service on the part of the opposite party No. 3. The opposite party No. 3 has denied the other contents of the complaint and prayed for dismissal of the same. Alongwith the written version, the opposite party No. 3 has placed on record affidavit of Arvinder Pal Singh Branch Manager Ex. OP3/1.
4 We have heard the Ld. counsels for the complainant and opposite parties and have carefully gone through the record placed on the file.
5 From the combined and harmonious reading of documents and pleadings are going to prove on record that
6 Ld. counsel for the complainant contended that the complainant was having service bank account with the O.P No.3 and the officials of the O.P No.3 told the complainant about the insurance policies initiated by the O.P No.1 & 2 i.e. HDFC Standard Life Insurance Company. He further contended that after hearing and knowing about the offers, the complainant purchased a Life insurance policy namely "HDFC LIFE SUPER INCOME PLAN" bearing policy No.19908086 from the O.P No.1 & 2 and the policy term was 16 years, premium paying term is 8 years and the date of commencement of risk is 22.12.2017, the policy issue date is 03.01.2018, the annualised premium was fixed as Rs.8,35,212/-, the final premium due date is 22.12.2024 and the Maturity date is 22.12.2033. He further contended that the sum assured on death was fixed as Rs.58,46,484/- and the sum assured on maturity was fixed as Rs. 47,95,107/-. The above policy includes the HDFC Life Critical Illness Plus Rider plan bearing UIN 101B014V01 and the rider sum assured is fixed as 47,95,109/- and the said rider sum assured is the lump sum benefit for which the life insured is entitled if he is diagnosed with any of the specific critical illness. He further contended that the complainant has paid the first premium amount of Rs.9,99,999/- to the opposite parties i.e. the insurance company vide receipt dated 3.1.2018 and as such since the commencement of this policy, the complainant has been making premium payment regularly without any default. In September, 2022, the complainant suffered Chest Pain and on 20.9.2022 he was admitted in GMC Hospital, Amritsar wherein doctor diagnosed him with heart attack and treated him accordingly and the complainant was discharged from hospital on 22.9.2022. After suffering with the above illness, the doctor has assessed the illness and the case of the complainant falls in the critical illness for which the complainant is entitled for the rider sum assured. He further contended that the complainant presented his claim case before the opposite parties and the complainant was so much assured that the company .i.e. the opposite parties will abide by its words and will pass the genuine case of the complainant as the policy is super income plan policy, which cover rider sum assured on critical illness but despite of doing legal duty towards the complainant, the opposite parties has served the complainant a letter dt. 21.11.2022 vide which the claim of the complainant was repudiated and further no plausible reason was mentioned for repudiating the claim of the complainant. He further contended that while rejecting the claim of the complainant, the opposite parties have suggested "Critical illness claim submitted by you for the first attack of specified gravity does not fulfill the definition, hence claim for heart attack cannot be admitted". The said submission of the OPs is nothing but a false excuse made by the O.Ps for rejection of claim. On contacting the officials of the company, they have told that his claim was repudiated due to certain terms and conditions. The complainant has several times asked about the same but no official has given satisfactory reply. No terms and conditions have been ever dictated to the complainant by the opposite parties on the basis of which the claim of the complainant was repudiated. The base of excuse given by the opposite party for rejection of genuine claim has no legal value in the eyes of law and prayed that the present complaint may be allowed.
7 Ld. counsel for the opposite parties No. 1 and 2 contended that the present complaint is not maintainable and liable to be rejected on the ground that earlier also the complainant had filed a complaint before this Commission on the same subject matter in June, 2023. However the same was withdrawn in October, 2023 without assigning any reason whatsoever and now again the present complaint has been filed on the same cause of action, hence the present complaint is not maintainable and liable to be rejected. He further contended that the present complaint is liable to be rejected as the complainant has concealed major facts from this Commission. The claim submitted on account of critical illness due to first heart attack to the insured was scrutinized and it was established that the critical claim submitted by the insured for the First Heart Attack of the specified severity did not fulfill the definition of First Heart attack as contained in additional policy provisions Part B Critical illness Plus Rider Benefit detailed in the policy issued to the insured, hence the claim was denied under as the alleged illness was not covered under the terms and conditions of the policy and fell under the exclusion clause contained in the policy which contains the following exclusions:
i) Non-ST segment elevation myocardial infraction (NSTEMI) with elevation of Troponin I or T,
ii) Other acute Coronary Syndromes
iii) Any type of angina pectoris
Therefore the claim of the complainant was repudiated and conveyed by the opposite party vide letter dated 21.11.2022. He further contended that the claim of the complainant was rightly rejected by the opposite party on the fact that the alleged critical Illness is not covered as per terms and conditions of the insurance policy and excluded. The complainant is debarred to file the instant complaint due to his own act and conduct. The complainant tried to defraud the opposite party No. 1 and 2 and knowingly concealing the details of the critical illness claim lodged with the opposite party No. 1 and 2 which clearly reveals that mala fide intention of the complainant to grab the public money; hence the complaint is liable to be dismissed. The complaint against the Opposite party does not lie before this commission under the Consumer Protection Act with regard to the rejected claim. The matter is also to be decided by a civil court at full scale trial requiring the complete pleadings and evidence according to law the summary trial under the Consumer Protection Act, 1986 is not the proper remedy for the complaints. He further contended that the Opposite party had rightly refused the death claim of the Life Insurance policies of the deceased. In view of the provisions contained in the Insurance Act, 1938 which is a specific statue meant for dealing with the disputes under the contract of insurance the provisions of the Consumer Protection Act cannot be invoked for dealing with the matter covered by Insurance Act. The said policy is subject to its terms and conditions and the parties are bound to abide by the said terms and conditions. As per terms and conditions of the policy, critical illness if any suffered by the insured is always subject to exclusions contained therein keeping in view the medical diagnosis and cause of the alleged critical illness. The opposite party has not committed any gross negligence and deficiency in providing services. The complainant is not entitled to the claim. In support of his case, the opposite parties No. 1 and 2 have submitted authority Tata AIG Life Insurance Co. Ltd. & Anr Vs Kuldeep Kumar decided on 27.2.2023 by National Consumer Disputes Redressal Commission.
8 Ld. counsel for the opposite party No. 3 contended that the present complaint is liable to be dismissed for want of cause of action against opposite party No.3. From the Pleadings of the complaint it reveals that no relief has been sought against the opposite party No. 3 and has been arrayed as Performa Party. The present complaint is liable to be dismissed against the opposite party No.3. The present complaint is malifide and opposite party No.3 has been dragged into unwanted litigation. In fact there is no deficiency in service on part of replying opposite party No.3. He further contended that the present complaint is liable to be dismissed. The present complaint is liable to be rejected on the ground of concealment of facts as earlier complaint bearing Nо.CC/24/2023 on the same facts was withdrawn by the complaint on 26.10.2023, hence present complaint is not maintainable and liable to be rejected. He further contended that the agreement of the insurance policy has been duly executed between the complainant and opposite parties No.1 & 2, opposite party No. 3 is not a party to that very insurance policy & privity of insurance contract executed between complainant and opposite parties No.1 & 2. If there is any dispute regarding the terms and conditions of the insurance policy or with regard to the insurance claim lodged by the complainant as alleged, that is between the complainant and opposite parties No.1 & 2 and opposite party No.3 has no concern with the alleged dispute. There is no deficiency on the part of the opposite party No.3 as alleged. As such Complaint in hand is required to be dismissed. The complainant is having his service bank account with the opposite party No. 3 is matter of record. The opposite party No. 1& 2 which is different and distinct identity and replying opposite party has nothing to do with the business concern of opposite party No. 1& 2. There is no deficiency in service on the part of the opposite party No. 3 and prayed that the present complaint may be dismissed.
9 We have carefully gone through the rival contentions of the parties.
10 The bare perusal of Ex. OP1 i.e. repudiation letter/ critical illness claim decision letter vide which opposite parties No. 1 and 2 repudiated the claim on the ground:-
“Please refer to the Additional Policy Provisions: Part B critical illness Plus rider Benefit details in the policy document provided to you. This rider benefit provides the definition for “First Heart Attack- of specified severity as under:-
First Heart Attack- of specified severity:
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.
- a history of typical clinical symptoms consistent with the diagnosis of Acute Myocardial Infarction (for e.g. typical chest pain)
- new characteristic electrocardiogram changes
- elevation of infarction specific enzymes, Troponins or other specific biochemical markers.
The following are excluded:-
- Non-ST-segment elevation myocardial infraction (NSTEMI) with elevation of Troponin I or T
- Other acute Coronary Syndromes
- Any type of angina pectoris.
However, critical illness claim submitted by you for the “First Heart Attack- of specified severity” does not fulfill the definition. Hence, claim of Heart Attack cannot be admitted. We are unable to process the claim any further. Also wish to inform you that the Critical illness Benefit Rider under the above-mentioned policy still continues.”
Meaning thereby as per Opposite Parties No. 1 and 2 the complainant has not fulfilling the contention of First Heart Attack that of specified severity and as such claim of the complainant was not admitted.
11 The claim of the opposite party was duly investigated by the claim assessor (claim investigator). The opposite party has placed on record copy of investigation report i.e. Ex. OP-4, whereby investigator has investigated the case of the complainant thoroughly and found the same as a genuine one. This is beyond imagination that how the opposite party has repudiated the claim just on the severity of the First Heart Attack. The discharge summary of the complainant as well as the treatment obtained by the complainant in the hospital and the reports of the various tests like ECHO Cardiography report, ultrasound report as well as the Coronary Angiography Report are placed on the record by the opposite parties. The discharge summary of Government Medical College Amritsar, Department of Cardiology, whereby, in column of diagnosis it is mentioned “ACS NSTEMI/CART-Double Vessel disease PCI to LCA (1DES)/NYHAII/NSR)” which clearly indicates that complainant is suffering from the same critical illness related to heart and the patient was presented to this hospital with chest pain and various tests were conducted upon the complainant and as per ECG report, it is written standard Depression in V2 to V5. Meaning thereby the ECG of patient was abnormal at the time of admission. Further ECHO was conducted on the patient and it is written in the discharge summary ECHO LCX Territory hypokinetic LVEF=42%. The study suggests that if it is less than 50% then it is critical illness. Moreover, the report of Coronary Angiography of Govt. Medical College Guru Nanak Dev Hospital, Amritsar also shows that there is acute Blockage in Coronaries of patient. Further the report of Coronary Angiography also shows that 2 stents have been implanted in the coronaries of the patient. All reports and investigations prove that the patient has history of Typical clinical symptoms consists with diagnosis of acute myocardial infarction (for example typical chest pain). There is abnormal ECG reports which reveals that the patient has severe heart attack as well as severe heart disease.
12 While repudiating the claim of the complainant, the opposite party has not placed on record any Expert opinion whereas the complainant has placed on record a certificate of Dr. Parminder Singh Manghera DM (International Cardiology) Gold Medalist Assistant Professor Cardiology Govt. Medial College, Amritsar as Ex. C-10 which is reproduced as follows:-
“The definition of Acute Myocardial Infarction Includes ST Elevation Myocardial Infarction and Non ST Elevation Myocardial Infarction (Troponin T or I Positive).
Hence, the definition picked up by the company is on wrongful grounds (Reference in attached below)
The claim of Mr. Surinderpal Singh son of Gurmej Singh (Policy Number 19908086) should not be rejected on such grounds.”
Moreover, the opposite parties No. 1, 2 have not placed on record any conclusive document of any doctor alongwith affidavit as expert opinion to prove their stand. Hence the plea taken by the opposite parties No. 1 and 2 cannot be accepted. Only treating doctor can explain the severity of heart attack and in the present matter opposite parties No. 1 and 2 have not obtained any opinion from treating doctor.
Hence, all investigation indicates the severity of the Heart Attack in one line. The complainant has alleged that no terms and conditions were supplied and explained to the complainant at the time of purchasing the policy in question. We placed reliance on citation 2001(1)CPR 93 (Supreme Court) 242 titled as M/s Modern Insulators Ltd Vs The Oriental Insurance Company Ltd, wherein Hon’ble Apex Court held that clauses which are not explained to complainant are not binding upon the insured and are required to be ignored. Furthermore, It is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of DharmendraGoel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.UshaYadav& Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.
Moreover the reliance placed on record by the opposite parties No. 1 and 2 Tata AIG Life Insurance Co. Ltd. Vs Kuldeep Kumar (supra) is not relevant to the present complaint
13 In view of above circumstances, the present complaint is allowed and the opposite parties No. 1 and 2 are directed to make payment of Rs.47,95,109/- to the complainant. The complainant has been harassed by the opposite parties No. 1 and 2 unnecessarily for a long time as such the complainant is also entitled to Rs. 55,000/- as compensation on account of harassment and mental agony and 25,000/- as litigation expenses. Opposite Parties No. 1 and 2 are directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the total awarded amount, from the date of complaint till its realization. The present complaint against the opposite party No 3 is dismissed. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Commission. Copy of order be supplied to the parties as per rules. File be consigned to record room.
Announced in Open Commission
21.08.2024
