Delhi

North East

CC/188/2023

Ms. Kavita - Complainant(s)

Versus

Manipal Cigna, Health Insurance Company Ltd. - Opp.Party(s)

27 Aug 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

Complaint Case No.188/23

 

In the matter of:

	Ms. Kavita W/o Lt. Sh. Sachin R/o C 413, St. No. 17, Khajuri Khas, Delhi-110094	Complainant
	Versus
1.             2.             3.	Manipal Cigna Health Insurance, Service to be Effected Through Its Authorized Signatory, 1/7, SBI Bank, Near Patel Nagar, Metro Station , Patel Nagar, New Delhi-110008   India Bulls Housing Finance Ltd. Service to be Effected Through its Authorized Signatory Manager having its office at:- M 62, & 63, First Floor, Connaught Place, New Delhi-110001   Shri Ram Singh Hospital & Heart Institute at B 25, 26A, East Krishna Nagar, Near Swarn Cinema Road, Delhi-110051	Opposite Parties

 

DATE OF INSTITUTION:         JUDGMENT RESERVED ON:                         DATE OF ORDER  :

25.07.2023 12.07.2024 27.08.2024

 

 

CORAM:

Surinder Kumar Sharma, President

Adarsh Nain, Member

 

 

 

ORDER

Adarsh Nain, Member

The Complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019.

Case of the Complainant

1. The case of the Complainant as revealed from the record is that her late husband had purchased a policy from Opposite Party No. 2 i.e. India Bulls Housing Finance Ltd. which is intermediary of Opposite Party 1 i.e. Manipal Cigna Health Insurance. The period of the said policy was from 14.08.2018 to 13.08.2023 and her late husband was paying the entire premium timely till his death. Complainant stated that suddenly her late husband got a heart attack and during the course of treatment he died on 25.09.2022 in hospital i.e. Opposite Party No. 3. Complainant stated that on 01.11.2022 she informed about her husband death to the Opposite Party No. 2 and asked about the loan and insurance which was taken by her husband from the Opposite Party No. 1. Complainant stated that as per direction of Opposite Party No. 2 she had provided all the documents, demanded by the officials of Opposite Party No. 1 on 01.11.2022. Complainant stated that she provided the documents on 20.02.2023 and 27.02.2023 to the Opposite Party No. 1 and Opposite Party No. 1 without providing any satisfied answer, it refused the claim of her late husband. Complainant stated that she approached the office of insurance Ombudsman and made a complaint dated 15.05.2023 in which Opposite Party No. 1 had demanded the proof/certificate from the Opposite Party No. 3 to confirm that the proximate cause of death was due to accidental fall. Thereafter, Complainant said the Opposite Party No. 1 to call the record from Opposite Party No. 3 then Opposite Party No. 1 told that it is not its duty to collect the record/report. Complainant stated that she approached Opposite Party No. 3 for providing all the relevant documents but Opposite Party No. 3 refused to provide the same. Complainant stated that she went to the office of Opposite Parties several time and made request time to time but Opposite Parties refused to pay the insured amount of her late husband. Complainant stated that office of Insurance Ombudsman of Delhi had resolved the complaint by mentioning reason “Recommendation under Rule 16 dated 20.06.2023.” Complainant stated that she visited the office of Opposite Parties many times for obtaining the insured amount of her late husband but Opposite Parties neither paid any amount nor paid any heed towards the Complainant. Hence, this shows the deficiency of service on the part of Opposite Parties. Complainant has prayed for Rs. 11,09,000/-  i.e. insured amount of her late husband along with interest. Complainant also prayed for an amount of Rs. 5,00,000/- as compensation and Rs. 22,000/- as litigation expenses.

Case of the Opposite Party No. 1

2. Opposite Party No. 1 contested the case and filed its written statement. It is submitted by Opposite Party No. 1 that the deceased insured took a loan of Rs. 50 lacs from Opposite Party No. 2 and secured that loan by purchasing insurance policy from Opposite Party No. 1. It is contended that Complainant (wife of deceased insured) submitted reimbursement claim seeking critical illness benefit under the policy due to death of her husband, the insured. It is alleged that in response to their demand for required documents, the Complainant submitted partial documents without required test reports to assess and identify the critical illness.  Since the claim of the Complainant did not fulfil the basic criteria to be considered under critical illness claim and the Complainant could not provide any medical document to prove that the cause of death was due to accident as no injury was caused due to external means, Opposite Party No. 1 had to deny the claim of the Complainant. Hence, there has been no deficiency on their part and present complaint needs to be dismissed.

Rejoinder to the written statement of Opposite Party No. 1

3. The Complainant filed rejoinder to the written statement of Opposite Party No. 1 wherein the Complainant has denied the pleas raised by the Opposite Party No. 1 and has reiterated the assertion made in the complaint.

 

Case of the Opposite Party No. 2

4. Since the Opposite Party No. 2 had filed its reply beyond stipulated period, same was not taken on record.

Case of the Opposite Party No. 3

5. Opposite Party No. 3 filed its reply to the complaint, however, no evidence has been led on their behalf.

Evidence of the Complainant

6. The Complainant in support of her case filed her affidavit wherein she has supported the assertions made in the complaint.

Evidence of the Opposite Party No. 1

7. To support its case Opposite Party No. 1 has filed affidavit of Shri Jaswinder Singh Shekhawat, wherein, he has supported the case of the Opposite Party No. 1 as mentioned in the written statement.

Arguments & Conclusion

8. We have heard the Ld. Counsel for the Complainant as well as Opposite Party No. 2. We have also gone through the material on record including the pleadings.
9. The perusal of file shows that the case of the Complainant is that her late husband had purchased a policy from Opposite Party No. 1 for securing loan taken from Opposite Party No. 2.  In her complaint, the Complainant makes the averment that suddenly her late husband got a heart attack and during the course of treatment he died on 25.09.2022 in hospital i.e. Opposite Party No. 3. The contention of the Complainant is that Opposite Party No. 1 refused her claim despite the fact that she provided all the required documents. It is also the case of the Complainant that Opposite Party No. 1 had demanded the proof/certificate from the Opposite Party No. 3 to confirm that the proximate cause of death was due to accidental fall as directed by Insurance Ombudsman of Delhi and even at the request of the Complainant, Opposite Party No. 1 refused to call the record from the Opposite Party No. 3 hospital as Opposite Party No. 3 refused to provide the same to her.
10. On the other hand, the case of Opposite Party No. 1 is that the Complainant (wife of deceased insured) submitted reimbursement claim seeking critical illness benefit under the policy due to death of her husband, the insured. Since the claim of the Complainant did not fulfil the basic criteria to be considered under critical illness benefit under the policy and the Complainant could not provide any medical document to prove that the cause of death was due to accident as no injury was caused due to external means, Opposite Party No. 1 had to deny the claim of the Complainant. It is also the case of Opposite Party No. 1 that while deciding the similar issue, they were directed by learned Ombudsman Insurance to review the claim afresh under Accidental Death benefit under the policy upon furnishing the new medical documents by the Complainant which were not submitted by the Complainant. Hence, there has been no deficiency on their part and present complaint needs to be dismissed.
11. It is pertinent to mention here that an application moved by Opposite Party   No. 2 i.e. India Bulls Housing Finance Ltd. under section 34 SARFAESI Act 2002 read with section 151 of the Code of Civil Procedure 1908 seeking rejection of the complaint for want of jurisdiction is pending disposal.
12. It is clear from the perusal of the material on record that loan account of Complainant was declared as Non-performing asset  and by means of Notice u/s 13 (4) of SARFAESI Act, 2002 dated 24.07.2023, Opposite Party No. 2 recalled the loan facility and Complainant was called upon to settle the dues.
13. Since the present matter in respect of Opposite Party No. 2 is already seized under the provisions of the SARFAESI Act, we are of the considered view that it cannot be adjudicated by the Consumer Forum so far as Opposite Party No. 2 is concerned. Thus, the application stands allowed and the present complaint is dismissed against Opposite Party No. 2.
14. It is undisputed that the Opposite Party No. 1 had issued the policy to the Complainant’s husband securing the loan taken by her husband. The  Complainant states that suddenly her late husband got a heart attack and dies during the course of treatment. It is also clear from the record that the Complainant filed death Insurance claim seeking critical illness benefit under the policy which was refused by the Opposite Party No. 1 as the Complainant did not fulfil the basic criteria to be considered under critical illness claim as there were no medical documents to prove the exact cause of death or any critical illness. The perusal of repudiation letter dated 14.12.2022 shows that claim was rejected on basis of non-availability of necessary documents and ailment not listed in policy as critical illness.
15. The Complainant has also filed the copy of proceedings before and award by Ld. Ombudsman Insurance dated 23.06.2023 disposing the complaint of the Complainant on similar issue. Perusal of said documents shows that the Complainant made submissions before Ld. Ombudsman that her husband was not suffering from any disease and he had an accidental fall in office bathroom. On the submissions, the Ld. Ombudsman passed the award recommending the following;-
15. “Accordingly, the Complainant would submt the required documents to the insurers.  The Insurer shall then review the claim afresh under Accidental Death Benefit as per terms ad conditions of the policy.  Both the parties to comply within 30 days.”

 

16. The Complainant herself admitted that she could not file the proof/certificate from the Opposite Party No. 3 to confirm that the proximate cause of death was due to accidental fall as directed by Insurance Ombudsman of Delhi. The grievance of the Complainant is that Opposite Party No. 3 did not provide her the said proof and Opposite Party No. 1 refused to call the record from Opposite Party No. 3 despite the requests of the Complainant. The perusal of the proceedings and award of the Ld. Ombudsman clearly shows that Complainant agreed to provide proof/certificate from the Opposite Party     No. 3 to confirm that the proximate cause of death was due to accidental fall which she did not provide. Moreover, Complainant has not led any cogent evidence to show that Complainant made the requests and Opposite Party No. 3 denied to  provide the said certificate or proof.
17. Moreover, the reply of Opposite Party No. 3 hospital filed before this Commission, clearly shows as follows;-
    • Patient came with history of fall in his office in the washroom and became unconscious.  It was a known case of hypertension.........................The provisional diagnosis was cardio respiratory arrest and history of Acc. HTN ? CVA...”

 

18.  The above facts and discussion clearly shows that the claim under critical illness benefit was rejected by the Opposite Party No. 1 as Complainant did not fulfil the basic criteria to be considered under critical illness claim as there were no medical documents to prove the exact cause of death or any critical illness. Not only this, Complainant herself made the submissions before Ld. Ombudsman that her husband was not suffering from any disease and he had an accidental fall in office bathroom. Keeping those submissions in mind , the Opposite Party No. 1 was directed to review the claim of the Complainant afresh under Accidental Death benefit under the policy upon furnishing the new medical documents by the Complainant and Complainant agreed to the same but those documents were not submitted by the Complainant. Further, the death summary as well as the reply by Opposite Party No. 3 hospital clearly shows the cause of death was Cardio-Respiratory arrest. In such circumstances, Opposite Party No. 1 cannot be held liable for not considering the claim of the Complainant.
19.  In view of above facts and discussion, we do not find any deficiency in services towards the Complainant on the part of any of the Opposite Parties.
20. Thus, present complaint is dismissed with no order as to costs.
21. Order announced on 27.08.2024.

Copy of this order be given to the parties free of cost

File be consigned to Record Room.

(Adarsh Nain)		(Surinder Kumar Sharma)
(Member)		(President)