Tamil Nadu

StateCommission

FA/353/2013

N.S. PALANI SAMY - Complainant(s)

Versus

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

B.L. LAVANYA

23 Dec 2022

ORDER

IN THE STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI

 

                      BEFORE :      Hon’ble Mr. Justice R. SUBBIAH                              PRESIDENT

                                            Thiru R VENKATESAPERUMAL                                          MEMBER

                        

F.A.NO.353/2013

(Against order in CC.NO.67/2010 on the file of the DCDRC, Erode)

 

DATED THIS THE 23^rd DAY OF DECEMBER 2022

 

Dr. N.S. Palanisamy

S/o. S.N.Sabapathy                                                  M/s.B.L. Lavanya

D.No.55, Sakthi Nagar                                                  Counsel for

Thindal, Erode – 9                                              Appellant / Complainant

 

                                                         Vs.

1.       M/s. HDFC Standard Life Insurance Co. Ltd.,

          Rep. by its Manager

          Kumar Arcade II Floor

          Perundurai Road, Erode- 638 011

 

2.       M/s. HDFC Standard Life Insurance Co. Ltd.,

          Rep. by its Manager

          S.F.No.7-A, Guptha Garments, Ground Floor,

Thiru-vi-ka Industrial Estate, Guindy, Chennai – 32

 

3.       M/s. HDFC Standard Life Insurance Co. Ltd.,

          Rep. by its Manager

          1^st Floor, Polymer Building, 48A, Brindavan Road,                               

          New Fairlands, Salem – 636 016                

                                            

4.       M/s. HDFC Standard Life Insurance Co. Ltd.,

          Rep. by its Manager

          Ramon House, H.T.Patel Marge,                      M/s. V. Vijaya Kumar

          169, Backbay Reclamation,                                       Counsel for

          Churchgate, Mumbai – 20                        Respondents / Opposite parties

 

          The Appellant as complainant filed a complaint before the District Commission against the opposite parties praying for certain direction. The District Commission had dismissed the complaint. Against the said order, this appeal is preferred by the complainant praying to set aside the order of the District Commission dt.26.4.2013 in CC.No.67/2010.

 

          This appeal coming before us for hearing finally on 15.9.2022, upon hearing the arguments of the counsel appearing on bothsides and on perusing the documents, lower court records, and the order passed by the District Commission, this commission made the following order:

ORDER

 

JUSTICE R. SUBBIAH,  PRESIDENT   

1.        This appeal has been filed by the complainant as against the order dt.26.4.2013 passed by the District Commission, Erode, in CC.No.67/2010 by dismissing the complaint filed by the appellant/complainant herein. 

 

2.       For the sake of convenience parties are referred as per ranking before the District Commission.

 

 3.      The brief facts of the complaint before the District Commission are as follows:

          The complainant is a retired veterinary doctor.  On the representation of the officials of the opposite parties, the complainant had taken a policy under HDFC Unit Linked Young Star Plan on 14.3.2005 under policy No.10213702.  The petitioner had paid a sum of Rs.1 lakh towards initial premium, which has to be paid yearly for a period of 10 years.  At the time of issuing the policy, the opposite party had stated that “as an evidence of the insurance contract between HDFC Standard Life and you, the insurance policy is enclosed alongside”.  Under the above policy the complainant is entitled to maturity benefit/ death benefit and extra health benefit to the tune of Rs.5 lakhs from 14.3.2005 subject to payment of regular premium. 

          As per clause 3 of the Standard Policy provisions, if the petitioner pays the premium that are due, they will pay the above mentioned benefits.  As per the policy, the complainant is entitled to the maturity benefit/ death benefit and extra health to the tune of Rs.5 lakhs and the effective date of policy was from  14.3.2005.  The opposite parties have verified all the relevant particulars including the physical fitness of the petitioner through medical examinations.  The complainant had also chosen life and health option under the above plan.  Under the HDFC Unit Linked Young Star Plan there are only two options viz. life option and life and health option.  The complainant had taken the policy, only because it covers life and health. 

In such a situation, suddenly the complainant had to undergo bye-pass surgery for the heart at KMCH Hospital, Coimbatore on 22.12.2008.  Before the said operation, the complainant had informed the officials of the opposite parties about the operation he has to undergo, for which the opposite parties informed him to furnish the claim form after the operation and thus they have handed over the claim form to the complainant.  The complainant incurred a medical expenses of Rs.1,77,306/-.  Thereafter, the opposite parties after submitting the claim form, demanded for production of some documents, which were also produced by the complainant.  In such a situation, the appellant received a letter dt.4.2.2009 from the opposite parties stating that the extra health benefit rider was not issued under the above mentioned policy, and hence they are unable to process the claim further.  The rejection of the claim is not valid and justifiable.  The opposite parties have issued the policy having life and health option and in the policy they have clearly stated that the complainant is entitled to receive the extra health benefit.  Relying on the said representation, the complainant had entered into the contract.  Further the policy issued by the opposite parties is very much clear about the health care.  Therefore, the opposite parties are not justified in declining the process and granting of the benefit for which the complainant is lawfully entitled.  Hence the complainant issued a legal notice to the opposite parties on 30.6.2010, for which a reply had been received on 22.7.2010, containing the false allegations.  It is false to say that the extra health benefit on the policy was cancelled with the consent of the petitioner vide letter dt.21.3.2007.  The complainant had never consented for withdrawal of extra benefit.  Thus, the complainant is entitled for the benefit under the policy.  Therefore, he filed a complaint praying for a direction to the opposite parties to pay the medical expenses of Rs.177306/- alongwith 12% interest from 4.2.2009 till date of payment alongwith compensation of Rs.1 lakh towards damages and another Rs.1 lakh for mental agony alongwith cost of Rs.10000/-. 

 

4.       The case of the complainant was resisted by the opposite parties by filing their version as follows:

          It is true that the complainant is entitled to maturity benefit / death benefit and extra health benefit to the tune of Rs.5 lakhs from 14.3.2005, subject to payment of regular premium.  Under (iii) of clause 3 it is stipulated as ‘Extra Health Benefit’.  If the life assured becomes critically ill by suffering one of the illness defined under the provision 18 (Extra Health Benefit), before expiry date, the sum assured stated against extra health in the schedule of benefits is payable.  Upon this payment, the death benefit will lapse without value.  It is false to state that the policy continues to be in force until the expiry date and all premiums becoming payable between the date of diagnosis of the illness and the expiry will be paid.  Under the policy, the complainant is entitled to maturity benefit/ death benefit and extra health benefit to the tune of Rs.5 lakhs and effective date of the policy was from 14.3.2005 and the opposite parties have verified all the relevant particulars including the physical fitness through medical examinations.  In the HDFC Unit Linked Young Star Plan there are only two options viz. life option and life and health option.   In the instant case the extra health benefit on the policy was cancelled with the consent of the complainant vide letter dt.21.3.2007.  The complainant had taken an Unit Linked Young Star Plan by proposal dt.26.2.2005 by way of making a premium payment of Rs.1 lakh.  As per the request and proposal of the complainant, the opposite party issued a policy dt.16.3.2005, alongwith extra benefit cover of Rs.5,00,000/- with risk commencement dt.14.3.2005.  The unit was  also allotted to the complainant on the basis of premium amount of Rs.1 lakh paid by the complainant on 26.2.2005.  If the amount still remains with the opposite party, the units were also maintained from the date of payment of first premium.  If any amount is withdrawn by the consent policy holder, the units shall be reduced as per the withdrawal amount. While so, the complainant requested the opposite party for withdrawal amount of Rs.50000/- and as per the request of the complainant, he was allowed to withdraw Rs.50000/-, and the same is paid by way of cheque dt.11.5.2005.  Therefore, the unit was also automatically reduced to the extent of the withdrawal amount.  The complainant had failed to pay the second year premium within the stipulated time and therefore the policy got lapsed on 14.3.2006 itself.  The complainant approached the opposite party for revival of the policy on 12.2.2007.  As per the policy conditions, if the policy lapsation period was more than 6 months, the policy holder has to compulsorily undergo medical tests and submit the documents and medical report for his health condition.  All the above facts were enlightened to the complainant and the complainant had given the consent letter on 21.3.2007 for declining the extra health benefit.   Thus the policy does not have an extra benefit rider claim.  Therefore, there is no deficiency in service, and thus prayed for dismissal of the complaint. 

 

5.       In order to prove their respective claim proof affidavits were filed, alongwith documents, which were marked as Ex.A1 to A8 on the side of the complainant and Ex.B1 to B10 on the side of the opposite parties. 

 

6.       After hearing the submissions and after analysing the entire materials available on record, the District Commission had dismissed the complaint, stating that there is no deficiency of service on the part of the opposite party.   Aggrieved over the said order, the present appeal is filed by the complainant praying to set aside the order of the District Commission. 

 

7.       Heard the submissions on bothsides, and perused the materials placed on record.

 

8.       It is the case of the complainant that he had taken the policy under HDFC Unit Linked Extra Plan on 14.3.2005 vide policy No.10213702, and paid a sum of Rs.1,00,000/- towards initial premium, which has to be paid yearly for 10 years.  While so, the complainant had undergone a bye-pass surgery at KMCH Hospital, Coimbatore on 22.12.2008.  Thereafter he lodged a claim towards medical expenses for Rs.1,77,306/- spent for the surgery.  On receipt of the claim form, the opposite party sought for certain documents, which were  submitted by the complainant on 30.1.2009.  But inspite of the same, the opposite parties have repudiated the claim of the complainant by letter dt.4.2.2009, by stating that the extra health benefit rider was not issued under the policy.  In this regard, it is the submission of the learned counsel for the complainant under (iii) of clause 3 of the policy, if the petitioner pays the premium that are due, they will pay the above mentioned benefits.  The (iii) of Clause 3 reads as follows:

“Extra Health Benefit”:  If the life assured becomes critically ill by suffering one of the illnesses defined under Provision 18 (Extra Health Benefit) of these provisions, before the expiry date, the sum assured stated against Extra Health Benefit in the schedule of benefits, is payable.  Upon this payment, the death benefit will lapse without value.  The policy continues to be in force until the expiry date.  All premiums becoming payable between the date of diagnosis of the illness (as agreed by us) and the expiry will be paid by us into the policy on your behalf, as and when premiums would have been due to be paid by you.  The total amount of this payment in any year will be the same as that chosen at the inception of this Policy as stated against “Premium payable per annum” in the schedule of Benefits. 

 

Therefore the denial of the benefit of the claimant amounts to deficiency of service. 

 

9.       Per contra,  learned counsel for the Respondent would submit that the actual policy provides maturity benefit for a period of 10 years/ death benefit whichever is earlier and an extra health benefit to an extent of Rs.5 lakhs, with risk commencing from 14.3.2005, subject to payment of regular premium.  In the instant case, the appellant has failed to pay the second premium, within time.  Therefore, the policy got lapsed on 14.3.2006 itself, which the complainant had suppressed in the complaint.  Thereafter, at request of the appellant/ complainant,   since the policy lapsation was more than 6 months, subject to medical test, policy was to be revived.  But by letter dt.21.3.2007 the complainant gave his consent for declining extra health benefit.  Therefore, on the basis of Ex.B8 dt.21.3.2007, revival letter given by the complainant, the policy was given without extra charge covering only to the extent of death benefit, with the knowledge and consent of the complainant.  Thus he is not entitled for any extra health benefit cover, hence his claim was repudiated.  Therefore, there is no deficiency of service on their part.  Thus prayed for upholding the order of the District Commission. 

 

10.     On a careful perusal of Ex.B8, dt.21.3.2007, we find that the extra health benefit have not been opted by the complainant.  Therefore, as submitted by the opposite parties, when there is no such specific cover viz. extra health benefit, as per the current policy, the question of granting claim amount does not arise. The complainant had not produced any document to show that he had opted for extra health benefit at the time of revival. Therefore, we are of the considered opinion that the District Commission has rightly held that the complainant is not entitled for the relief, and thus dismissed the complaint, in which we find no error warranting us to interfere.  The appeal deserves to be dismissed accordingly.

 

11.     In the result, the appeal is dismissed, by confirming the order of the District Commission, Erode, in CC.No.67/2010 dt.26.4.2013.   There is no order as to cost throughout. 

 

 

 

 

  R  VENKATESAPERUMAL                                     R. SUBBIAH

                      MEMBER                                                     PRESIDENT