Chandigarh

DF-II

CC/650/2021

Sonia Sharma - Complainant(s)

Versus

Max Bupa Health Insurance Company Limited - Opp.Party(s)

Adv.Vishal Sharma

08 Apr 2024

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II,

U.T. CHANDIGARH

 

Consumer Complaint  No	:	650 of 2021
Date  of  Institution	:	28.09.2023
Date   of   Decision	:	08.04.2024

 

 

 

 

 

1]  Sonia Sharma, Aged about 46 years W/o Late Sh.Vinod Kumar Sharma (deceased),

2]  Deepanshi Sharma, Aged 22 years D/o Late Sh. Vinod Kumar Sharma,

3]  Shivam Sharma, aged about 20 years S/o Late Sh.Vinod Kumar Sharma,

    All Residents of House No. 171 Ward No.9, Royal Plaza, Kurali, Kharar, SAS Nagar, Mohali, Punjab and legal heirs and nominee of the deceased Late Sh. Vinod Kumar Sharma in whose favour policy was issued.

 

             …..Complainants

 

Versus

1]  Max Bupa Health Insurance Company Limited, SCO No - 55, 56 & 57, 2nd Floor, Sector 8-C, Madhya Marg, Chandigarh.

Second address:

Max Bupa Health Insurance Company Limited, SCO 84-85, Second Floor, Sector 8C, Madhya Marg, Chandigarh.

2]  Max Bupa Health Insurance Company Limited, C-26, Plot-G, Bandra    Kurla, Complex, Mumbai, Maharashtra-400051, through its Authorized Officer.

3]  Bank of Baroda through its Branch Manager, H.S.No.365, Ward No -D, Opposite Activa Honda Showroom, Kurali, Punjab - 144623.

Second Address:

Bank of Baroda, Near Gupta Hospital, Chandigarh Road Kurali, District Mohali, State Punjab. 140103

4]  Bank of Baroda, Chandigarh Zonal office, 185-187, SECTOR-9-C, Chandigarh 160009

     ….. Opposite Parties

BEFORE:  MR.AMRINDER SINGH SIDHU,       PRESIDENT

                MR.S.K.SARDANA,                MEMBER

                               

Argued by:-     Sh.Sachin Ohri, Counsel for the complainant.

Sh.Gaurav Bhardwaj, Counsel for OPs No.1 & 2.

Sh.Rajeev Bhardwaj, Counsel for OPs No.3 & 4

 

 

ORDER BY AMRINDER SINGH SIDHU, M.A.(Eng.),LLM,PRESIDENT

 

1]       The complainants have filed the present complaint pleading that they are the legal heirs of Sh.Vinod Kumar Sharma, who during his life time had availed two loan of Rs.8 lacs and Rs.18 lacs respectively from OP No.4 Bank.  It is stated that deceased Vinod Kumar Sharma had got the said loans insured from OP No.3 vide two separate policy having Group Master Policy No.50065000202000, one was valid from 01.06.2020 to 31.05.2021 having sum assured Rs.8 lacs (Ann.C-2) with nomination of Sonia Sharma (complainant No.1) and second policy was valid from 29.08.2020 to 28.08.2021 (Ann.C-3) having sum insured of Rs.18 lacs with nomination of Sh.Shivam Sharma (complainant NO.3). It is submitted that as per certificate of insurance, the policy holder Vinod Kumar was also covered under the critical illness cover with sum insured of Rs.18 lacs and Rs.8 lacs respectively.  It is stated that the insured Sh.Vinod Kumar Sharma was admitted in a hospital on 08.05.2021 and unfortunately died there on 14.5.2021 due to acute complications leading to severe respiratory distress, B/L Bronchopneumonia and Cardiac Arrest while he was admitted in Hospital.  Thereafter a claim was lodged with the OP Insurance company for paying the insured outstanding loan amount, but the Company rejected it vide letter dated 15.6.2021   (Ann.C-7) on the ground that the cause of death is due to bronchopneumonia septic shock not covered under the benefits of policy. The complainants further made request to allow the claim and also sent certificate of treating doctor to show that patient never had any chronic lung disease but even then they OP Company was rejected the claim vide email (Ann.C-11 colly.).  It is also stated that the claim has arbitrarily wrongly been rejected by the OP Insurance Company, which amounts to deficiency in service and unfair trade practice. Hence this complaint has been filed with a prayer to allow the claim and award Rs.18 lacs & Rs.8 lacs i.e. the sum insured under the policy as well as to pay compensation and litigation cost.

 

2]       After service of notice, the OPs No.1 & 2 have put in appearance, filed written version and while admitting the factual matrix of the case about issuance of the policy in question and receipt of death claim of insured, stated that after scrutiny of the claim form and other documents, the claim was denied vide letter Ann.E as the case of death was due to bronchopneumonia, septic shock not covered under benefit policy. It is also stated that the Clause No.15 of the policy provides only for End Stage Lung Failure and on the other hand, the diagnosis and symptoms as per the death summary does not comply with the criteria mentioned in clause 15 of the policy (Ann.F). Further the policy opted by the deceased insured is critic care product for which the diagnosis and symptoms does not comply with Clause 15 of the policy. It is pleaded that the present complaint has been filed only on account of proceedings initiated by the OP No.3 under SARFAESI Act. Denying other allegations, the OPs No.1 & 2 have prayed for dismissal of the complaint with cost.

 

3]       The OPs No.3 & 4 (Bank of Baroda) have also filed written version stating that the answering OPs have nothing to do with the policy, if any, issued by the OPs No.1 & 2 nor they charged any insurance premium. It is stated that the answering OPs are not liable for any dispute regarding the policy issued by the OPs No.1 & 2.  It is submitted that OP No.3 had granted CC Limit of Rs.18 lacs to late Sh.Vinod Kumar Sharma, husband of the complainant No.1 and father of the complainant No.2 & 3. Other allegations have been denied for want of knowledge and not related to answering OPs.  Lastly it is prayed that the complaint qua OPs No.3 & 4 be dismissed.

        

4]       Parties led evidence in support of their contentions.

5]       We have heard the ld.Counsel for the contesting parties and have gone through the entire record including written submission. 

 

6]      The question to be decided is whether there is deficiency in service or unfair trade practice on the part of the OPs No.1 & 2 in repudiating the death claim of the Life Assured Vinod Kumar Sharma or not ?

 

7]       To find out answer to this issue, it is important to take into consideration the following facts and circumstances of the present complaint:-

         The OPs No.1 & 2 (Insurance Company) have admittedly rejected the death claim of the life assured Vinod Kumar Sharma under both insurance policies Ann.C-2 & C-3 on the ground that the cause of death is due to bronchopneumonia, septic shock, which is not covered under the benefit of the policies vide repudiation letters Ann.C-6 & C-7.

8]       However, the complainant has placed on record the Certificate dated 30-07-2021 issued by the treating doctor i.e. Dr.Vivek Sabharwal, MBBS, DNB (Medicine, PGDCBD (UK), AMCARE Super-Speciality Hospital, Zirakpur, Punjab who certified that:-

“The patient by the name Vinod Kumar Sharma 52 Y/M died due to Acute Complications leading to severe Respiratory distress, bronchopneumonia and Cardiac Arrest. The patient never had any chronic lung disease.  All the complications and death was due to Acute Viral Infection leading to Acute Lung failure.”

9]       It is observed that from the above referred certificate issued by the treating doctor of the complainant i.e. Dr.Vivek Sabharwal, MBBS, DNB (Medicine, PGDCBD (UK), AMCARE Super-Speciality Hospital, Zirakpur, Punjab, it is clear that the cause of death of life assured Vinod Kumar Sharma was due to Acute Viral Infection leading to Acute Lung failure.  Therefore, the stand of the OPs NO.1 & 2 that the cause of death of life assured Vinod Kumar Sharma was bronchopneumonia, septic shock is totally wrong & unjustified. Therefore, it is held that the claims of the complainants have wrongly been rejected by the OPs No.1 & 2.

10]      It is observed that the repudiation made by the OPs-Insurance Company regarding genuine claim of the complainants have been made without application of mind. It is usual with the insurance company to show all types of green pasters to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sorts of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. 

11]      It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-

    “It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.  The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

 

12]      Taking into consideration the above discussion & findings, it can be safely concluded that OP Insurance Company has committed deficiency in service by wrongly and illegally rejecting the genuine claim of the complainants. Therefore, the present complaint deserves to be partly allowed and the same is accordingly allowed against OP No.1 & 2.  The OP No.1 & 2 are directed to pay the entire sum insured amounts of both policies i.e. Rs.18,00,000/- & Rs.8,00,000/- respectively to the complainants, in equal share, along with interest @6% per annum from the date of repudiation of claims i.e. 15.6.2021 till its actual payment to the complainants.

         This order be complied with by the OP No.1 & 2 within 60 days from the date of receipt of its certified copy.

13]      The complaint qua remaining OPs stands dismissed.

 

14]      Pending application(s) if any, stands disposed of accordingly.

        The Office is directed to send certified copy of this order to the parties, free of cost, as per rules & law under The Consumer Protection Rules & Act accordingly. After compliance file be consigned to record room.

Announced

08.04.2024                                                                    Sd/-

                                                            (AMRINDER SINGH SIDHU)

PRESIDENT

 

 

Sd/-

(Mr.S.K.SARDANA)

MEMBER