Date of Filing      : 01.02.2023
                                                                                                                  Date of Disposal: 11.07.2023

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION
THIRUVALLUR

 BEFORE  TMT. Dr.S.M. LATHA MAHESWARI, M.A.,M.L, Ph.D (Law)                          .…. PRESIDENT
                 THIRU.P.VINODH KUMAR, B.Sc., BL.,                                                                .....MEMBER-I
                 THIRU.P.MURUGAN,M.Com.,ICWA(Inter)., B.L.,                                            ....MEMBER-II

CC. No.12/2023
THIS TUESDAY, THE 11th DAY OF JULY 2023

Mrs.A.Thangarasi,
W/o.Arumugam,
No.42A, Ashok Nandavanam,
Vayalanallur“A“ village,
 Chennai -600 072.                                                                                   ……Complainant.
                                                                               //Vs//

1.ICICI Lombard General Insurance Company Limited,
    ICICI Lombard Health Care,
    ICICI Bank Tower,
   Plot No.12, Financial District, Nanakram Guda,
   Gachibowli, Hyderabaed,
   Telangana – 500 032.

   And also at
   ICICI Lombard General Insurance Company Limited,
   ICICI Lombard House,
   414, Veer Sarvakar Marg,
   Near Siddhi Vinayaka Temple,
   Prabhadevi, Mumbai 400 025.

2.India Bulls Housing Finance,
   Corporate Office: 448-451,
   Udyog Vihar, Phase V,
   Gurugram – 16.
   Reg Off: 5th Floor,
   Building No.27, KG Marg, Connaugh Place,
   New Delhi 01.

   One of the Branch at
   No.20, Apex Chamber, 1st Floor,
   Theagaraya Road, T.Nagar,
   Chennai 600 017.                                                                           .......Opposite parties.

Counsel for the complainant                             :   M/s.T.Muthamil Selvi, Advocate.
Counsel for the 1st opposite party                    :   Mrs.A.Lathamaheswari, Advocate.
Counsel for the 2nd opposite party                   :   M/s.K.Kumaraguru, Advocate.
                        
This complaint is coming before us on various dates and finally on 27.06.2023 in the presence of M/s.T.Muthamil Selvi, counsel for the complainant and Mrs.A.Lathamaheswari, counsel for the 1st oppostie party and M/s.K.Kumaraguru, counsel for the 2nd opposite party and upon perusing the documents and evidences of both sides, this Commission delivered the following:
ORDER
PRONOUNCED BY TMT. Dr.S.M. LATHA MAHESWARI,   PRESIDENT.

This complaint has been filed by the complainant u/s 35 of the Consumer Protection Act, 2019 alleging deficiency in service in repudiating the Home Insurance claim of the complainant by the 1st opposite party with respect to the housing loan taken by the complainant’s son along with a prayer to direct the 1st opposite party to clear the Insurance amount of Rs.27,00,000/- with respect of housing loan of the complainant’s deceased son and direct the 1st opposite party to pay a sum of Rs.10,00,000/- towards compensation for the mental agony and hardship caused to the complainant and to direct the 2nd opposite party to pay a sum of Rs.5,00,000/- towards compensation for the mental agony caused to the complainant along with cost of the proceedings.
Summary of facts culminating into complaint:-

It was submitted that the complainant’s son Mr.A.Vinothkumar had obtained a housing term loan from T. Nagar branch of 2nd opposite party during the year 2018 and the complainant was co-applicant to the loan. The 2nd opposite party was the agent of the 1st opposite party and instructed the complainant’s son to take Insurance policy for life from the 1st opposite party and the same was accepted by the complainant’s son and has taken Home Insurance on 27.06.2018 vide policy No.4080/IBULL/150589866/00/000 and the cover period of insurance was from 04.06.2018 to 03.06.2023.  The complainant states that her son had another insurance policy for home vide 4013/H/IBHOm/150591816/00/000 with the 1st opposite party and the cover period of insurance was from 04.06.2018 to 03.06.2038. Complainant’s son also deposited the title deeds of his property situated at Plot No.42A, being the western portion of plot No.42, measuring to an extent of 1355 square feet of land from an approval layout known as “Ashok Nandavanam”, comprised in S.No.246/2A part of Vyalanallur Village, Poonamallee Taluk and Thiruvallur District and obtained housing loan from 2nd opposite party.  The complainant’s son was regularly repaying the installments towards the housing loan until his death 12.10.2021. The complainant who was a house wife was very much affected mentally, morally and financially due to the sudden demise of her son. Complainant applied for waive off the claim under the life policy 4080/IBULL/150589866/00/000 due to the death of her son before 1st opposite party through the 2nd opposite party which has erroneously rejected her claim on 03.01.2022 citing “policy wordings part II of schedule 2.1 Section I (Major Medical Illness and Procedures): Stroke resulting in permanent symptoms” and the remarks of repudiation stated the reason as “verification of the claim document it is evident that insured expired at home on 12.10.2021 and there is no evident of stroke resulting in permanent symptoms as defined under the policy.  Hence the claim falls outside the purview of the major medical illnesses and procedures defined and covered under the policy”. The Medical Certificate of Cause of Death shows the immediate cause of her son’s death as “Cardio Respiratory Arrest” showing the “Interval between Onset & Death (approx) as 10 minutes.” The 1st opposite party quote the policy condition in their rejection letter dated 03.01.2022. No chronic disease had affected the complainant’s son because he regularly went to job until 07.10.2021. Complainant’s son was admitted in Neuro Life Hospital at No.25, Alapakkam Main Road, Madhuravoyal, Chennai 95 on 10.10.2021 and had taken all the test.  The complainant’s husband tried to take their son to another hospital for further treatment so they discharged the complainant’s son on 11.10.2021. Complainant and her husband decided to admit their son at another hospital but unfortunately he died in the next day morning 07.45 am due to Cardiac Arrest.  At the time of verification by the Doctor the complainant disclosed that in the last three days her son was affected by severe headache.  This was noted by the Doctor in the death report Clause I –Antecedent Cause Cerebrovascular accident. The 2nd opposite party had issued a demand notice dated 12.01.2022 under section 13(2) of SARFAESI Act to the complainant demanding a sum of Rs.27,00,000/-. The reasons stated in the remarks for repudiation of the claim and the clause cited by the 1st opposite party was not proper.  The repudiation was made without any application of mind. The 2nd opposite party was a finance company and insurance agent of 1st opposite party.  As per the words of the 2nd opposite party the complainant’s son took two policies from 1st opposite party but the 2nd opposite party was not at all supporting the complainant to recover the risk covered amount from the 1st opposite party. Thus aggrieved by the act of the opposite parties the present complaint was filed to direct the 1st opposite party to clear the Insurance amount of Rs.27,00,000/- with respect of housing loan of the complainant’s deceased son and direct the 1st opposite party to pay a sum of Rs.10,00,000/- towards compensation for the mental agony and hardship caused to the complainant and to direct the 2nd opposite party to pay a sum of Rs.5,00,000/- towards compensation for the mental agony caused to the complainant along with cost of the proceedings.
The crux of the defence put forth by the 1st opposite party:-
The complainant’s son had died in his house on 12.10.2021 due to Cardio respiratory Arrest and there was no evidence of Myocardial infarction and Cerebrovascular Accident noted. Hence the claim was repudiated as the incidental cause of death fall outside the purview of Major Critical Illness. It was confirmed by the claimant that Insured had no past history of MI, CAD, IHD or any other heart ailments and there was also no history of chronic illnesses like DM, HTN, Stroke, Kidney Disease or any major medical illness or surgery done in the past.  No treatment was given.  No ECG or any other investigations were done.  No Post-mortem was done to substantiate the cause of death. The policy taken by the insured would include only Major Medical Illness. Even after number of reminders the complainant failed to submit the duly filled in claim form with ID proof and address proof, relevant Investigation report and Discharge Summary related to the treatment taken for the critical illness to process the claim.  Thus they sought for the dismissal of the complaint.

The crux of the defence put forth by the 2nd opposite party:-
The 2nd opposite party was a non-Banking Financial Institution and not an agent to any insurance company. The 2nd opposite party was recognized by National Housing Bank and was in the business of lending to the customers viz. Home loans and was regulated by RBI as on date.  The complaint as filed was vexatious and untenable against the 2nd opposite party. The 2nd opposite party has no direct or indirect role to play and there was no privy to the said contract. Hence all the averment made in the complaint against the 2nd opposite party was denied.  Admittedly the complainant had availed loan facilities from the 2nd opposite party and was bound to repay the same as per the contractually stipulated installments as per the loan agreement executed by the Borrowers and the 2nd opposite party.  The 2nd opposite party has a relationship with Borrowers limited to lender borrower equation and not any insurance company and proposer/nominee.  The 2nd opposite party was not regulated by IRDA which was a regulatory body meant for insurance company and not for financial institutions.  Complainant and her son late Mr.A.Vinothkumar approached the 2nd opposite party to avail a home loan facility and the same was sanctioned vide a Loan Sanction Letter dated 26.05.2018 an amount of Rs.27,00,000/- as home loan for the purpose of the property. The 2nd opposite party only acts as an intermediary between the customers who are interested in obtaining an insurance cover and the insurance company. A home equity loan of Rs.93,088/- was also sanctioned vide a separate loan sanction letter dated 26.05.2018.  In pursuance to this loan sanction letter another loan agreement dated 26.05.2018 was executed for the purpose of payment of insurance policy premium. Complainant failed to maintain the financial discipline, hence Account was declared non-performing asset on 09.02.2023 and a notice under section 13(2) of the Securitization and Reconstruction of Financial Assets and Security Interest, 2002 had been issued to the complainant recalling the loan facility. The payments made by the son of the complainant against the loan accounts duly reflect in the Statement of Accounts of the loan Account. The complainant was the Co-Borrower of the loan account and she failed to pay the EMIs towards the said loan account for more than a period of 90 days.  Accordingly the complainant classified the said loan Account as a Non-Performing Asset as on 09.02.2023 by the 2nd opposite party. The 2nd opposite party denies that they sent the claim of the complainant through email and further stated that they have no role to play to send the claim to 1st opposite party. The 2nd opposite party is not responsible for the acceptance and rejection of the insurance claim, thus they sought for the dismissal of the complaint. 
On the side of complainant proof affidavit was filed and documents marked as Ex.A1 to Ex.20 was submitted.  On the side of 1st opposite party proof affidavit was filed and documents marked as Ex.B1 and Ex.B4 was submitted. On the side of 2nd opposite party proof affidavit was filed and documents marked as Ex.B5 to Ex.B10 were submitted.
 Points for consideration:-
Whether the repudiation of Home Insurance claim of the complainant by the 1st opposite party with respect to the housing loan taken by the complainant’s deceased son amounts to deficiency in service and whether the same has been successfully proved by the complainant?
Whether the alleged deficiency in service on the part of 2nd opposite party has been successfully proved by the complainant by admissible evidence?
If so to what reliefs the complainant is entitled?
Point Nos.1&2:-
On the side of complainant the following documents were filed for proving the complaint allegations;
ID card of the complainant’s son Mr.Vinothkumar was marked as Ex.A1;
Salary revision of complainant’s son dated 13.08.2021 was marked as Ex.A2;
Construction agreement of complainant and her son dated 07.05.2018 was marked as Ex.A3;
Loan sanction letter dated 26.05.2018 was marked as Ex.A4;
Copy of insurance policy No.4080/IBULL/150589866/00/000 dated 27.06.2018 was marked as Ex.A5;
Copy of insurance policy No.4013/H/IBHOm/150591816/00/000 dated 27.06.2018 was marked as Ex.A6;
Policy terms and conditions of the 1st opposite party was marked as Ex.A7;
Sale deed of complainant and her son dated 13.07.2018 was marked as Ex.A8;
Medical prescriptions and test reports of complainant’s son dated 10.10.2021 & 11.10.2021 was marked as Ex.A9;
Discharge summary of the complainant’s son dated 11.10.2021 was marked as Ex.A10;
Copy of medical certificate of cause of death dated 20.10.2021 was marked as Ex.A11;
Death certificate of complainant’s son dated 23.10.2021 was marked as Ex.A12;
Legal heir certificate of complainant’s son dated 11.11.2021 was marked as Ex.A13;
Rejection letter issued by 1st opposite party dated 03.01.2022 was marked as Ex.A14;
Medical prescription and disclaimer of the complainant dated 17.03.2022 was marked as Ex.A15;
SARFAESI notice issued by 2nd opposite party dated 19.05.2022 was marked as Ex.A16;
Request letter of complainant along with courier receipt dated 24.06.2022 was marked as Ex.A17;
Legal notice issued by the complainant to the opposite parties dated 29.12.2022 was marked as Ex.18;
Acknowledgement card for proof of delivery was marked as Ex.A19;
Smart card of the complainant was marked as Ex.A20;
 On the side of 1st opposite party the following documents were filed for their defence;
Copy of policy wording was marked as Ex.B1;
Difference between Cardiac Arrest and Myocardial was marked as Ex.B2;
Investigation Report was marked as Ex.B3;
Final Closure Report was marked as Ex.B4;
On the side of 2nd opposite party the following documents were filed in proof of their defence;
Loan sanction letter dated 26.05.2018 was marked as Ex.B5;
Loan Agreement respect to the Loan Account No.HHLCHE00440804 was marked as Ex.B6;
Loan Agreement respect to the Loan Account No.HHECHE00443476 was marked as Ex.B7;
Demand notice issued by the 2nd opposite party dated 22.02.2023 was marked as Ex.B8;
Statement of due in respect to the Loan Account No.HHECHE00443476 was marked as Ex.B9;
Statement of due in respect to the Loan Account No.HHLCHE00440804 was marked as Ex.B10;
       Heard the oral arguments adduced by the complainant and 2nd opposite party.  It is represented by learned counsel appearing for the 1st opposite party that the written arguments may be treated as oral arguments. Thus, on perusal of the available pleadings and evidences this commission proceeded to dispose of the complaint on merits.
The crux of the arguments adduced by the learned counsel appearing for the complainant is that the housing loan was obtained by the complainant along with her son for which a home insurance was taken with the 1st opposite party at the instigation of 2nd opposite party. The complainant’s son met with an unfortunate death on 12.10.2021 due to Cardio Respiratory Arrest. However, when the claim was raised the same was repudiated by the 1st opposite party stating that the death was not covered under the policy’s terms and conditions as it is Stroke resulting in permanent symptoms.  It is however argued that the complainant’s son was not affected by any chronic decease and when he showed severe Headache, Neck pain, Fever, vomiting, decreased appetite, burning mictutition only from on 08.10.2021 immediately he was hospitalized and treatment was taken.  However when after getting discharged on 11.10.2021 and deciding to admit him in Sundharam Foundation Hospital at Anna Nagar, he died unfortunately the next day morning at 07.45 am due to Cardiac Arrest. Hence stating that the 1st opposite party ought not to have rejected the claim based on the clause “Stroke resulting in permanent symptoms” the complainant sought for the complaint to be allowed as prayed for.
The written arguments of the 1st opposite party was perused in which it was submitted that the complainant’s son had died in his house on 12.10.2021 due to Cardio respiratory Arrest and there was no evidence of Myocardial infarction and Cerebrovascular Accident. Hence the claim was repudiated as the incidental cause of death fall outside the purview of “Major Critical Illness“.  Further it was also confirmed that the deceased had no past history of MI, CAD, IHD or any other heart ailments and there was also no history of chronic illnesses like DM, HTN, Stroke, Kidney Disease or any major medical illness or surgery done in the past and no treatment was given.  No ECG or any other investigations were done.  No Post-mortem was done to substantiate the cause of death. Thus stating that the policy would include only major medical illness, the repudiation itself was denied by the 1st opposite party.  It is also submitted that the complainant had failed to submit necessary documents like duly filled in claim form with ID proof and address proof, relevant investigation report, Discharge Summary related to the treatment taken for the critical illness, probable cause of death from family physician or last attending Doctor, Principal outstanding of loan as on date of loss for which policy was issued with statement of Account and CKYC form of claimant etc. Thus the 1st opposite party sought for the dismissal of the complaint.
The learned counsel appearing for the 2nd opposite party argued in short that there is no cause of action for the complaint to be filed against them and that no allegations was made against them in the complaint.  Further, he also argued that the present complaint is barred as per section 34 of SARFAESI Act. 
 We perused the available pleadings and materials. The factum of availing housing loan and home insurance for the same from the 2nd opposite party and the 1st opposite party respectively was not denied by either parties.   The main issue to be decided is only whether the repudiation of Housing/Home insurance claim by the 1st opposite party is proper or not.
 The reason cited by the 1st opposite party for repudiation of the claim is as follows;
“policy wordings part II of schedule 2.1 Section I (Major Medical Illness and Procedures): Stroke resulting in permanent symptoms” and the remarks of repudiation stated the reason as “as verification of the claim document it is evident that insured expired at home on 12.10.2021 and there is no evident of stroke resulting in permanent symptoms as defined under the policy.  Hence the claim falls outside the purview of the major medical illnesses and procedures defined and covered under the policy”.
 However, the medical certificate produced by complainant for the cause of death shows the death was sudden and as Cardio Respiratory Arrest showing the interval between Onset & Death (approx) as 10 minutes which is produced as Ex.A11.  Ex.A9 & Ex.A10 clearly proves that before the death happened on 12.10.2021 the deceased was treated for “Giddiness and headache for 3 days associated fever” for one day in ‘NEURO life Hospital’. The Discharge Summary Ex.A10 dated 11.10.2021 supports the version of the complainant that deceased was treated and discharged on 11.10.2021 and was about to be admitted in another hospital.  Further, it is also proved by the Medical Reports that the deceased was not a known case of HTN, DM, TD and had no past surgical history. No allergic history was also proved. The advice on discharge was provided as “MRI-BRAIN” Take Immediately, advice to get admitted elsewhere ‘for further management, to return to hospital if fever, lethargy, breathing difficulty, reduced urine’.  The above referred documents shows that the death was only due to Cardio Respiratory Arrest and not as contended by 1st opposite party that the deceased died without any treatment.  The 1st opposite party contended that the complainant failed to produce the required documents for processing the claim as if no repudiation was made by them. However, vide letter dated 03.01.2022 the 1st opposite party has clearly rejected the claim of the complainant stating that there is no evidence of stroke resulting in permanent symptoms as defined under the policy and hence the claim falls outside the purview of the major medical illnesses and procedures defined and covered under the policy.  Hence, the defence raised by the 1st opposite party that the complainant failed to submit the necessary documents and hence they could not process the claim was proved to be an utter false statement.  It is also seen that in the policy under the section Major medical illness and procedures under clause “c” it is provided as follows;
Occurrence for the first time of the following medical events more specifically described below:
Stroke resulting in permanent symptoms;
Permanent paralysis of limbs;
First heart Attack of specified severity;
Major Burns;
Loss of Speech;
Deafness;
Coma of specified severity.
 Thus it leads to the inference that when the medical event occurs for the first time it could be covered and not when occurs for the 2nd time.  In the present case it is evident that the deceased died on 12.10.2021 and also it was proved that prior to 08.10.2021 there was no symptoms of any illness vide medical records. While so, sub clause “c” very well applies to the present case as “Cranial Hemorrhage” is a sudden illness.  The 1st opposite party ought not to have rejected the claim based on the clause ‘stroke resulting in permanent symptoms’ as the said clause could not be invoked as the complainant’s son was not alive for diagnosing the permanent symptoms.  Also as the complainant’s son illness was very brief i.e. from 08.10.2021 to 12.10.2021,, the rejection letter stating that “evidence of permanent Neurological deficit lasting for at least for three months has to be produced did not seems to be an applicable condition.  Thus when the complainant’s son death clearly falls under Sub section (c) sub clause (3), Heart attack of specified severity and when the immediate cause for death as per the report is Cardio Respiratory Arrest with severity being expressly mentioned that the interval between onset & Death (approx) as 10 minutes, the repudiation of the insurance claim by the 1st opposite party is clearly erroneous and amounts to clear deficiency in service.  The 2nd opposite party who had sanctioned the loan has nothing to do with honoring of insurance claim.  Hence, no deficiency in service could be attributable to the 2nd opposite party.  In the facts and circumstance we hold that the complainantt had successfully proved the deficiency in service against the 1st opposite party.  Thus this point is answered accordingly in favour of complainant and 2nd opposite party and against 1st opposite party.
Point No.3:-

The Home Insurance is taken only to meet out any exigencies caused during the repayment of the housing loan.  Hence, as we have held above that the rejection of the Home Insurance was without any valid reason for the death of complainant’s son and amounts to clear deficiency in service, we direct the 1st opposite party to process the claim submitted by the complainant within four weeks from the date of receipt of copy of this order and to forward the proceeds to the 2nd opposite party towards the loan.  Further, for rejecting the claim on untenable and invalid reasons putting the complainant to suffer mental agony and hardship we also award a compensation of Rs.50,000/-  to be paid by the 1st opposite party to the complainant. Cost of Rs.10,000/- awarded towards litigation expenses to the complainant.
In the result, the complaint is dismissed against the 2nd opposite party and partly allowed against the 1st opposite party directing them
a) To process the Home Insurance Claim of the complainant within four weeks from the date of receipt of copy of this order;
b) To pay a sum of Rs.50,000/- (Rupees fifty thousand only) towards compensation for the mental agony and hardship caused to the complainant;
c)  To pay a sum of Rs.10,000/- (Rupees ten thousand only) towards litigation expenses to the complainant.
 Dictated by the President to the steno-typist, transcribed and computerized by him, corrected by the President and pronounced by us in the open Commission on this the 11th day of July 2023.

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MEMBER-II                                        MEMBER-I                                               PRESIDENT

List of document filed by the complainant:-

Ex.A1 ............. ID card of the complainant’s son Vinothkumar. Xerox
Ex.A2 13.08.2021 Salary Revision of complainant’s son Vinothkumar. Xerox
Ex.A3 07.05.2018 Consturction agreement of complainant and her son. Xerox
Ex.A4 26.05.2018 Sanction letter. Xerox
Ex.A5 07.06.2018 Insurance policy No.4080 /IBULL/ 150589866/ 00/000 Xerox
Ex.A6 27.06.2018 Insurance policy No.4013/H/IBHOm/150591816/00/000. Xerox
Ex.A7 27.06.2018 Policy terms and condition of the 1st opposite party. Xerox
Ex.A8 13.07.2018 Sale deed of complainant and her son. Xerox
Ex.A9 10.10.2021 &
11.10.2021 Medical prescriptions and test report of complainant’s son. Xerox
Ex.A10 11.10.2021 Discharge Summary of the complainant’s son. Xerox
Ex.A11 12.10.2021 Form No.4A-Medical Certificate of cause of death. Xerox
Ex.A12 12.10.2021 Death Certificate of complainant’s son. Xerox
Ex.A13 11.11.2021 Legal heir certificate of complainant’s son. Xerox
Ex.A14 03.01.2022 Rejection letter issued by 1st opposite party. Xerox
Ex.A15 17.03.2022 Medical prescription and disclaimer of the complainant. Xerox
Ex.A16 19.05.2022 SARFAESI Notice issued by 2nd opposite party. Xerox
Ex.A17 24.06.2022 Request letter of complainant to 2nd opposite party along with courier receipt. Xerox
Ex.A18 29.12.2022 Legal notice issued by the complainant. Xerox
Ex.A19 ............. Acknowledgement card along with proof of service. Xerox
Ex.A20 ............. Smart card of the complainant. Xerox

List of document filed by the opposite party:-

Ex.B1 ………….. Copy of policy. Xerox
Ex.B2 ………….. Different between cardiac Arrest and Myocardial Infarction. Xerox
Ex.B3 ……………. Investigation Report. Xerox
Ex.B4 …………… Final Closure Report. Xerox

  
   List of documents filed by the 2nd opposite party:-

Ex.B5 26.05.2018 Loan sanction letter. Xerox
Ex.B6 26.05.2018 Loan agreement receipt to the loan account No.HHLCHE0044804. Xerox
Ex.B7 26.05.2018 Loan agreement receipt to the loan account No.HHECHE00443476. Xerox
Ex.B8 22.02.2023 Demand notice issued by the opposite party. Xerox
Ex.B9 28.02.2023 Statement of Due in respect to the loan account No.HHECHE00443476. Xerox
Ex.B10 01.03.2023 Statement of Due in respect to the loan account No.HHLCHE00440804 Xerox

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MEMBER-II                                       MEMBER-I                                              PRESIDENT