Chandigarh

DF-I

CC/1/2024

RAJESH SHARMA - Complainant(s)

Versus

LIBERTY GENERAL INSURANCE - Opp.Party(s)

GAURAV SHARMA

03 Sep 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                               

Consumer Complaint No.	:	CC/01/2024
Date of Institution	:	12/12/2023
Date of Decision	:	03/09/2024

Rajesh Sharma aged 40 years son of Sh. Odah Raj Sharma, resident of House No.242, Phase-1, Ramdarbar, Chandigarh (UT).

2^nd Address, House No.364, Ward No.17, Modern Complex Dappar Colony, Dera Bassi, SAS Nagar (Mohali)

… Complainant

V E R S U S

1. Liberty General Insurance, 2nd Floor of S.C.O No.145-146, Sector 9-C, Madhya Marg, Chandigarh 160009, through its Branch Manager/Authorized Officer.

2 Liberty General Insurance, Head Office, 10^th Floor, Tower A, Peninsula Business Park, Ganpatrao Kadam Marg, Lower Parel, Mumbai-400013, through its Branch Manager/ Authorized Officer.

3 Aditya Birla Housing Finance Ltd., UN 38A and 39, CCC Chandigarh City Centre, VIP Road, Block B, Zirakpur, Punjab 140603, through its Branch Manager/Authorised Officer.

… Opposite Parties

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

       

ARGUED BY	:	Sh. Gaurav Sharma, Advocate for complainant
	:	Sh. Aayush Goyal, Advocate for OPs 1 & 2
	:	Sh. Nakul Sharma, Advocate for OP-3

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Rajesh Sharma, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations, as projected in the consumer complaint, that the wife of the complainant namely Smt.Phool Mati had taken home loan from OP-1 against property (Plot in village Dappar measuring 1 Biswa 16 Biswasi).  The total loan amount sanctioned was ₹13,20,000/- vide two loan accounts dated 13.1.2021. OP-3/ financier had compelled the complainant’s wife to purchase insurance policy from OP-1 for securing home loan for an amount of ₹8,83,985/-.  Accordingly, on 8.4.2019, she had purchased the master policy (Annexure C-1) from OP-1.  The wife of the complainant had initially taken loan from HDFC but on the assurances of OP-3, the same was transferred with OP-3.  On 31.10.2022, wife of complainant had fallen ill and was immediately taken to the PGI, Chandigarh where she was given treatment.  However, on 1.11.2022, she was declared dead due to dengue.  Copies of the death certificate and other medical record of late Smt. Phool Mati i.e. the Deceased Life Assured (hereinafter referred to as “DLA”) are Annexure C-3. Thereafter the complainant approached the office of OPs 1 & 3 and requested them to release the claim since DLA was covered under the subject insurance policy, but the officials of OPs had directed the complainant to submit certain documents which were accordingly submitted by him, but, nothing was done by the OPs. On 15.4.2023, complainant sent an email (Annexure C-4) to the OPs and requested them to release the amount, but, again nothing has been done by the OPs.  Thereafter the complainant again approached the office of OPs 1 & 3 at Chandigarh, but, OP-1 refused to settle the claim and rather repudiated the claim vide letter dated  23.10.2023 (Annexure C-5).  In this manner, the aforesaid act of the OPs amounts to deficiency in service and unfair trade practice. OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OPs resisted the consumer complaint and filed their separate written versions.
3. OPs 1&2 in their written version, inter alia, took preliminary objections of maintainability, cause of action and concealment of facts.   However, it is admitted that the subject policy was issued by the answering OPs which was valid w.e.f 2.4.2019 to 1.4.2024.  It is also admitted that the DLA was declared dead on 1.11.2022 and the cause of her death was declared as Refractory Hypovolemic Shock with an antecedent of Dengue shock syndrome with Acute kidney injury.  It is further alleged that the claim of complainant was repudiated vide letter (Annexure OP-1/2) as per the terms & conditions of the subject policy on finding that the disease from which DLA was suffering was not covered under the subject policy i.e. not covered under “Section 1 : Critical illness and procedures”.  On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
4. OP-3 in its written version, inter alia, took preliminary objections of maintainability and cause of action.  However, it is admitted that the two loans i.e. home loan of ₹12,60,000/- and loan of ₹60,000/- were sanctioned in favour of DLA and the amount of second loan to the tune of ₹60,000/- was credited in the account of OP-1 for the subject policy and copies of loan sanction letter and loan agreement are Annexure R-3/2 & Annexure R-3/3. In this manner, total amount of ₹13,20,000/- was sanctioned in favour of the DLA.  However, it is admitted that the cause of death of the DLA as per the death certificate is Refractory Hypovolemic Shock and antecedent cause was Dengue shock syndrome with Acute kidney injury
5. In rejoinder, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that  the total loan of ₹13,20,000/- was sanctioned by OP-3/ financer in favour of the DLA i.e. home loan of ₹12,60,000/- and ₹60,000/- towards premium amount for obtaining the subject policy (Annexure C-1), which was valid w.e.f. 2.4.2019 to 1.4.2024 and the DLA died on 1.11.2022 due to Refractory Hypovolemic Shock and antecedent cause was Dengue shock syndrome with Acute kidney injury, as is also evident from the medical certificate of cause of death (Annexure C-3) issued by PGI, Chandigarh and the claim raised by the complainant was repudiated by OPs 1 & 2/insurers vide letter dated 23.10.2023 (Annexure C-5) on the ground that ailment suffered by the DLA did not fall within the scope of listed critical illness benefit  under the subject policy, the case is reduced to a narrow compass as it is to be determined if OPs are unjustified in repudiating the genuine claim of the complainant and the complainant being nominee/husband of the DLA is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the OPs have rightly repudiated the claim of the complainant, as per the terms and conditions of the subject policy and the consumer complaint of the complainant, being false and frivolous, is liable to be dismissed, as is the defence of the OPs.
   2. Perusal of the medical certificate of cause of death (Annexure C-3) clearly indicates that the DLA had died due to Refractory Hypovolemic Shock and antecedent cause was Dengue shock syndrome with Acute kidney injury and the relevant portion of same is reproduced below for ready reference :-

CAUSE OF DEATH
I. Immediate Cause State the disease, injury of complication which caused death, not the mode of dying such as heart failure, asthma, etc. Antecedent Cause Morbid Conditions, if any, giving rise to the above cause, stating underlying condition last	(a) Refractory due to (or as a consequences of) HYPOVOLEMIC SHOCK       (b)DENGUE SHOCK SYNDROME  due to (or as a consequences of) with ACUTE KIDNEY INJURY

 

3. Perusal of the repudiation letter clearly indicates that the claim of the complainant was repudiated by the OPs/insurers on the ground that the ailment suffered by the DLA, due to which she died, does not fall within the scope of listed critical illness benefit as the Group Secure future connect policy opted by the insured provides coverage for the listed illness. The relevant portion of the repudiation letter as well as “Part 2: Benefits Under The Policy” on the basis of which the OPs repudiated the claim of the complainant is reproduced below for ready reference :-

“As per available information, it transpires that Insured Mrs. Phool Mati was admitted at Government Multi speciality hospital on 31-10-2022 with the complaints of fever from 3 days, epigastric pain along with Loose motion and Vomiting. She was diagnosed for Tropical fever with shock. Later she was referred to PGIMER Chandigarh, for further treatment on 01-11-2022. Later she died during the treatment on same day at 03:49 PM.

cause of death as per medical certificate was Refractory Hypovolemic Shock and antecedent cause was Dengue shock syndrome with Acute kidney injury.

In view of the above, we wish to inform that the ailment suffered by insured does not fall within the scope of listed critical illness benefit as the Group Secure future connect policy opted by insured provides coverage only for listed critical illnesses, hence claim is not admissible under policy.

We reiterate the below policy wordings for ready reference.

Part 2: BENEFITS UNDER THE POLICY

1. SECTION I: CRITICAL ILLNESS

The Company hereby agrees, subject to the terms, conditions and exclusions applicable to this Section and the terms, conditions, general exclusions stated in this Policy, to pay the benefit Sum Insured in relation to the Insured Person/s as per the option selected and as stated under Schedule to this Policy on the occurrence of an Insured Event as stated below, under this Section.

Insured event: For the purposes of this Section and the determination of the Company's liability under it, the Insured Event in relation to the Insured Person/s, shall mean any illness, medical event or surgical procedure as specifically defined below whose signs or symptoms first commence more than 90 days after the commencement of Policy Period and shall mean:

1. First Diagnosis of the below-mentioned Illnesses more specifically described below:

1.  Cancer of Specified Severity:

2.  End Stage Renal Failure

3.  Benign Brain Tumor:

4.  Parkinson's Disease,

5.  End Stage Liver Disease

6.  Alzheimer's Disease,

7.  Motor Neuron disease with permanent symptoms

8.  Multiple sclerosis with persisting symptoms

9. Muscular Dystrophy

10. Systemic Lupus Erythematosis with Lupus Nephritis

11. Medullary cystic disease

              xxx            xxx            xxx

We therefore regret to convey our inability to consider the above captioned loss under the policy and the claim thus stands repudiated.”

4. As it is an admitted case of the parties that the DLA had died due to Refractory Hypovolemic Shock and antecedent cause was Dengue shock syndrome with Acute kidney injury and OPs 1 &2/ insurers have repudiated the claim of the complainant on the ground that the ailment from which the DLA had suffered does not fall within the scope of listed critical illness, it is to be determined if the ailment suffered by the DLA falls in any category of the critical illness or not?
5. Sub clause (a) of “1.1 Section I : Critical Illness” of the subject policy indicates that the End Stage Renal Failure falls under the first diagnosis of the critical illness. As perusal of the death certificate (Annexure C-3) specifically refers that the cause of death of DLA was Acute Kidney Injury (AKI), it is further clear that the AKI can be a cause of End Stage Renal failure since as per medical term, AKI involves a sudden decline in kidney function which can lead to serious complications, and if not managed properly can progress to chronic kidney disease and eventually ‘End Stage Renal Failure’.
6. Thus, one thing is clear from the above that the case of the complainant is squarely covered under the definition of critical illness referred in Part 2, 1.1 Section I of the subject policy as it stands proved on record that the DLA had died due to Refractory Hypovolemic Shock and antecedent cause was Dengue shock syndrome with Acute kidney injury which led to End Stage renal failure, as a result of which DLA died and it is safe to hold that OPs 1 & 2/insurers are unjustified in repudiating the claim of the complainant and the present consumer complaint deserves to succeed

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OP 1 & 2 are directed as under :-

1. to pay the sum insured i.e. ₹8,83,925/-  to the complainant alongwith interest @ 9% per annum (simple) from the date of repudiation of the claim i.e. 23.10.2023 onwards.
2. to pay ₹15,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by OPs 1 & 2, jointly and severally, within a period of 45 days from the date of receipt of certified copy thereof, failing which the amounts mentioned at Sr.No.(i) & (ii) above shall carry penal interest @ 12% per annum (simple) from the date of expiry of said period of 45 days, instead of 9% [mentioned at Sr.No.(i)], till realisation, over and above payment of ligation expenses. It is, however, made clear that the financier (OP-3) shall have first charge over the aforesaid awarded amount, to the extent the same is due to be paid by the complainant towards the discharge of loan liability, if any, of the DLA.
6. Since no deficiency in service or unfair trade practice has been proved against OP-3, the consumer complaint against it stands dismissed with no order as to costs.
7. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
8. Certified copies of this order be sent to the parties free of charge. The file be consigned.

03/09/2024	Sd/- [Pawanjit Singh] President
	Sd/-
	[Surjeet Kaur] Member
	Sd/-
	[Suresh Kumar Sardana] Member