Haryana

Kurukshetra

122/2018

Parminder Kaur - Complainant(s)

Versus

HDFC - Opp.Party(s)

O.P.Paruthi

02 Feb 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION KURUKSHETRA.

 

Consumer Complaint No.122 of 2018.

Date of instt.:01.06.2018. 

                                                                        Date of Decision: 02.02.2021

 

Parminder Kaur w/o late Shri Jagjit Singh, r/o House No.107/05-A, Bhagwan Nagar Colony, Pipli, Kurukshetra, Tehsil Thanesar, District Kurukshetra. 

                                                                                      …….Complainant.                                                   Versus

 

1. HDFC Ergo General Insurance Co. Ltd., Office: 6^th Floor, Leela Business Mark, Andheri Kurla Road, Andheri (East), Mumbai-400059, through its Managing Director.
2. HDFC Ergo General Insurance Co. Ltd., Sector-17, HUDA, Branch Office Opp. Old Bus Stand, Kurukshetra.

                   ….…Opposite parties.

 

Complaint under Section 12 of Consumer Protection Act.

 

Before        Smt. Neelam Kashyap, President.    

                   Ms. Neelam, Member. 

                   Shri Issam Singh Sagwal, Member.                                                       

Present:      Shri O.P. Paruthi, Advocate for the complainant.   

Shri Atul Mittal, Advocate for the opposite parties.

             

ORDER

                                                                         

                    This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by complainant Parminder Kaur against HDFC Ergo General Insurance Co. Ltd., the opposite parties.

2.                The brief facts of the complaint are that the OP No.1 is a company who is doing business of General Insurance after taking premium and OP No.2 is a branch at Kurukshetra. The husband of the complainant had purchased insurance policy HDFC ERGO Claim Sarva Suraksha Policy vide policy No.2950201277791200000 dated 28.12.2015 and paid a premium of Rs.1276/- for a sum insured of Rs.1,00,000/- and the said policy is valid for the period from 28.12.2015 to 27.12.2020. That her husband namely Jagjit Singh was admitted in Nagpal Nursing Home, Kurukshetra as he was suffering from loose motion and bloody stool. At the time of admission, his condition was serious and he had died in the hospital during the treatment on 08.5.2016 leaving behind her and his minor son namely Gurjaswinder Singh. She approached the OPs for insured amount and on the direction of OPs, she submitted the requisite documents with them, upon which, the OPs assured her that they would release the insured amount to her shortly. That after sometime, she approached the OPs for releasing the amount, but the OPs postponed the matter on one pretext or the other and finally repudiated the claim vide letter dated 07.4.2017. Her husband was not the patient of Hypoproteinemia prior to the insurance policy. Her husband was medically fit. According to the death certificate issued by the Sub-Registrar, Birth and Death, Kurukshetra, the death of her husband was due to illness, which proved that her husband had not died due to Hypoproteinemia. She requested the OPs verbally as well as over telephone against their illegal repudiation of the claim, but they did not pay any heed to her genuine requests. By not paying her genuine claim, the OPs are deficient in services. Hence, this complaint.

 

3.                Upon notice, the opposite parties appeared and filed written statement stating therein that the deceased insured was admitted in Nagpal Nursing Home on 05.5.2016 with the complaints of loose motions and bloody stool since last 3-4 months and unfortunately died on 08.5.2016. After his death, the complainant lodged 3 different claims with the OPs seeking benefits under (a) Accidental Death, (b) Credit Shield Insurance and (c) Critical Illness Section of the policy.

Claim under Critical Illness: It is submitted that as per the documents submitted by the complainant, the deceased insured was diagnosed with Anaemia with Hypoproteinemia. The said ailment is not covered under the Critical Illness mentioned in the policy. It is to be noted that the liability of the OPs is restricted and limited to the policy terms and conditions. As per the policy terms and conditions, only the following diseases are covered under Critical Illness Section of the policy:-

1. First Heath Attack of Specified Severity.
2. Open Chest CABG
3. Stroke resulting in Permanent symptoms
4. Cancer of Specified Severity.
5. Kidney Failure Requiring Regular Dialysis.
6. Major Orgon/Bone Marrow Transplant.
7. Multiple Sclerosis with persistent symptoms
8. Surgery of Aorta
9. Primary Pulmonary Arterial Hypertension
10. Permanent Paralysis of Limbs.

                   Hence, in the present case the ailment i.e. Hypoproteinemia was not included in the policy coverage, hence the claim under Critical Illness was repudiated and the same was communicated to the complainant vide letter dated 07.4.2017.

Claim under Accidental Death: The complainant had also lodged a claim seeking benefit under the Accidental Death coverage of the policy. After the claim was lodged, the OPs requested the complainant to submit the following documents:

• Claim form duly filled and signed by claimant.
• Copy of Photo ID card of insured and claimant.
• Copy of FIR and Panchnama.
• Copy of PMR.
• Death Certificate.
• Treating Doctor’s Certificate giving details of injuries and treatments given.
• Copy of succession certificate, if claimant is other than Nominee.
• Outstanding loan statement as on date of loss.
• Original cancelled cheque of insured/nominee.
• KYC Form.

                   That despite various reminder letters, the complainant failed to provide the relevant documents to the OPs, as such, the claim under Accidental Death and Credit Shield is not maintainable. The claim of the complainant has never been rejected, but has been closed to non-receipt of documents from the complainant. It is submitted that in addition to the above submission, the complainant is not entitled to any benefit under the Accidental Death section of the policy, because Accidental Death is triggered only in situations where the death is caused by Accidental Bodily Injury. The term “Accidental or Accidental” is defined in the policy as follows:-

                   “Accident or Accidental means a sudden, unforeseen and involuntary event caused by external, visible and violent means”.

                   Since the death of insured was due to Hypoproteinemia, and not due to any accidental bodily injury, hence, the claim under Accidental Death is not payable. It is admitted fact that the insured has died due to illness and thus, this fact rules out any involvement of Accident. Thus, the claim for Accidental Death and Credit Shield is prima facie not maintainable. There is no deficiency on the part of the OPs. On merits, the rest of the contents of the complaint are denied and prayed for dismissal the same.

4.                The complainant tendered affidavit Ex.CW1/A alongwith documents Ex.C-1 to Ex.C-8 and closed the evidence.

5.                On the other hand, learned counsel for OPs tendered affidavit Ex.RW1/A alongwith documents Ex.R-1 to Ex.R-8 and closed the evidence.

 

6.                We have heard the learned counsel of the parties and carefully gone through the case file.

 

7.                The learned counsel for the complainant has reiterated all the averments mentioned in the complaint. He argued that the husband of the complainant had purchased insurance policy HDFC ERGO Claim Sarva Suraksha Policy from OPs after paying premium of Rs.1276/- for a sum insured of Rs.1,00,000/- valid for the period from 8.12.2015 to 27.12.2020. The husband of the complainant namely Jagjit Singh was suffering from loose motion and bloody stool and admitted in Nagpal Nursing Home, Kurukshetra, where he was died during the treatment on 08.5.2016. The complainant approached the OPs for insured amount by submitting the requisite documents, but the OPs repudiated the claim vide letter dated 07.4.2017. He further argued that at the time of issuance of the said policy, the OPs neither provided nor disclosed the terms & conditions of the policy to the husband of the complainant. He further argued that the OPs are deficient by not releasing the genuine claim of the complainant. In support to his contention, the learned counsel for the complainant produced case law titled The National Insurance Co. Ltd. & Others Vs. Jammaluddin Mondal, 2014 (3) CLT, 619 (Chandigarh State Commission,  Chandigarh).

 

8.                Contrary to it, the learned counsel for the OPs has also reiterated all the averments mentioned in the reply. He argued that as per the documents submitted by the complainant, the deceased insured was diagnosed with Anaemia with Hypoproteinemia. The said ailment is not covered under the Critical Illness mentioned in the policy. He further argued that despite various reminder letters, the complainant failed to provide the relevant documents to the OPs, as such, the claim under Accidental Death and Credit Shield is not maintainable. He further argued that complainant is not entitled to any benefit under the Accidental Death section of the policy, because Accidental Death is triggered only in situations where the death is caused by Accidental Bodily Injury. Since the death of insured was due to Hypoproteinemia, and not due to any accidental bodily injury, hence, the claim under Accidental Death is not payable. So, the complainant is not entitled to any claim and there is no deficiency on the part of the OPs.

 

9.                In this case obtaining of insurance policy by deceased Jagjit Singh, its validity as on the date of death are not in dispute.  The complainant has stated that she is entitled to claim of Rs.1.00 lacs due to death of her husband whereas the OPs have stated that the policy in question was issued for critical diseases and alleged death of husband of the complainant is not covered under the policy. The Ailment due to which deceased died is not covered under the policy. Critical illness means an illness, sickness or a disease or corrective measure as specified in Section 1 of the policy (Ex.R-3) as re-produced below:-

 

1. First Heath Attack of Specified Severity.
2. Open Chest CABG
3. Stroke resulting in Permanent symptoms
4. Cancer of Specified Severity.
5. Kidney Failure Requiring Regular Dialysis.
6. Major Orgon/Bone Marrow Transplant.
7. Multiple Sclerosis with persistent symptoms
8. Surgery of Aorta
9. Primary Pulmonary Arterial Hypertension
10. Permanent Paralysis of Limbs.

           

                 From the perusal of document Ex.C-7, it is clear that deceased Jagjit Singh was admitted in Nagpal Hospital, Kurukshetra on  5.05.2016 with the history of  loose motion, bloody stools for the last three to four months. He died on 8.5.2016 (Death certificate Ex.C-4 attached with the case file.   Perusal of the file shows that the said disease i.e.  due to which life assured died is not a critical disease as mentioned above under the table of critical diseases. Therefore, the complainant is not entitled to any claim under the policy in question.

 

 10.                    In view of our aforesaid discussion, we do not find any merit in the present complaint and the same is hereby dismissed. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the record-room, after due compliance.

 

Announced in open Commission.

Dt.:02.02.2021.                                                       (Neelam Kashyap)

                                                                                     President.

 

 

(Issam Singh Sagwal),              (Neelam)         

 Member                                     Member.