Haryana

Ambala

CC/67/2021

Smt Reena - Complainant(s)

Versus

M/s HDFC ERGO General Assurance Co Ltd - Opp.Party(s)

Anil Kumar

17 Apr 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA

Complaint case no.	:	67 of 2021
Date of Institution	:	08.02.2021
Date of decision	:	17.04.2023

Smt. Reena, aged about 35 Yrs w/o Late Sh. Baljeet Singh, Resident of village and P.O. Matheri Sekhon, Tehsil and Distt. Ambala

          ……. Complainant

                                                Versus

1. M/s HDFC ERGO General Assurance Company Ltd. Registered and Corporate Office 1^st  Floor, 165-166 Backbay Reclamation, H.T. Parekh Marg, Churchgate, Mumbai-4000001
2. M/s HDFC ERGO General Assurance Company Ltd. Registered and Corporate Office 6^th Floor, Leela Business Park, Andheri Kurla Road, Andheri (E), Mumbai-4000001
3. M/s HDFC ERGO General Assurance Company Ltd. through its Branch office, Karnal 2^nd  Floor, SCO No.237, Sec. 12, Karnal (Haryana)-132001
4. M/s HDFC ERGO General Assurance Company Ltd. through its Branch Office, Policy issuing office, Near Geeta Gopal Chowk, HDFC Bank, Ambala Cantt.

                                                                                   ….…. Opposite Parties.

Before:        Smt. Neena Sandhu, President.

                             Smt. Ruby Sharma, Member,

          Shri Vinod Kumar Sharma, Member.           

 

Present:       Shri B.B. Chawla, Advocate, counsel for the complainant.

                     Shri Mohinder Bindal, Advocate, counsel for the OPs.

Order:        Smt. Neena Sandhu, President.

1.                Complainant has filed this complaint under Section 35 of the Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

i) To pay the amount of Rs.1,00,000/- qua the Insurance Policy in question alongwith interest till realization.

ii) To pay compensation to the tune of Rs.1,00,000/- for harassment, mental pain, agony and financial loss.

iii) To pay litigation expenses to the tune of Rs.25,000/- to the complainant.

2.             Brief facts of the case are that the husband of the complainant namely-Baljeet Singh s/o Sh.Prem Chand (now deceased) had purchased a car, make-Wagonr bearing registration no.HR-01AR-9150 on 30.08.2017. He also purchased insurance policy having no. 2999201363863001 for his car from the OPs, which was valid for the period from 19.07.2017 to 18.07.2020, on payment of Rs.4598/- as premium. At the time of issuance of the said policy, O.P.No.4 assured the husband of the complainant that if he lost his job or on account of his accidental death or permanent total disability or accidental hospitalization or critical illness or credit shield insurance or garbage cash or house hold coverage, he will be compensated by the OPs. The husband of the complainant was regular in making installment but unfortunately he fell ill and was admitted in Sant Hospital on 10.03.2020 in emergency. During treatment, the husband of the complainant died on 17.03.2020 due to critical illness.  Thereafter, the complainant contacted the OPs and told about the death of her husband and showed insurance policy issued by them for claim but the official of the OPs became adamant and refused to hear any request of the complainant and behaved very rudely with the complainant, which act amounts to deficiency in service on their part, thereby causing facing great hardship, huge financial loss and physical harassment and mental agony. Hence, the present complaint.
3.           Upon notice, OPs appeared and filed written version and raised preliminary objections to the effect that this Commission has no territorial jurisdiction to try this complaint; the complaint of the complainant is premature because the complainant never lodged/registered any claim with the OPs etc. On merits, while admitting the factual matrix of the case regarding issuance of the insurance policy in favour of the insured, it has been stated that  as per record of the OPs, no claim was registered as alleged by the complainant under the policy in question. Had the complainant lodged any claim, a claim number would have been allotted and the claim would have been registered. However, in the complaint, the complainant has failed to put forward any claim no. on record in order to establish that actually the claim was registered as alleged. Rest of the averments of the complainant were denied by the OPs and prayed for dismissal of the present complaint with costs.
4.           Learned counsel for the complainant tendered affidavit of complainant as Annexure CA alongwith documents as Annexure C-1 to C-10 and closed the evidence on behalf of the complainant. On the other hand, learned counsel for the OPs tendered affidavit of Manoj Parajapati, Authorized Signatory, HDFC ERGO General Insurance Company Ltd., Registered Office, Noida as Annexure OP-A, alongwith documents as Annexure OP-1 to OP-4 and closed the evidence on behalf of OPs
5.           We have heard the learned counsel for the parties and have also carefully gone through the case file.
6.           Learned counsel for the complainant submitted that since the husband of the complainant has taken the insurance policy in question, for the subject vehicle, therefore she being her wife was entitled to get the claim amount on his death, yet, her genuine claim has been repudiated by the OPs, which act amounts to deficiency in providing service and adoption of unfair trade practice on their part. 
7.           On the contrary, the learned counsel for the OPs submitted that the claim of the complainant was rightly rejected because the disease with which her husband died was not covered under the critical illness.
8.           It is significant to mention here that though in their written version, the OPs have taken the main plea that because the claim was never lodged by the complainant with them, as such, they could not settle or reject the same, yet, while going through the  documents, tendered by the OPs, it is evident that the claim of the complainant  has been repudiated by the OPs vide letter dated 18.07.2020, Annexure OP-3 on the ground that the insured had died due to Acute Encephalitis, which disease was not covered under the critical illnesses as specified in the insurance policy, Annexure OP-4. 

Be that as it may, the moot question which falls for consideration is, as to whether, the claim of the complainant has been rightly repudiated by the OPs or not. For coming to any conclusion, we need to refer relevant Section 1:- Critical Illness Coverage of the policy Annexure OP-4, which says that the claim is payable to the insured if he is diagnosed as suffering from 1. first heart 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 organ/bone marrow transplant, 7. multiple sclerosis with persistent symptoms, 8. surgery of aorta, 9. primary pulmonary arterial hypertension, 10.permanent paralysis of limbs. Specially, various diseases coming under critical illnesses are also found mentioned under the said critical illness. As per the medical literature Encephalitis produced by the Ld. counsel for the OP, which is marked as ‘A’ Encephalitis is inflation of brain. In the medical certificate issued by Dr.SR Arora, Sant Hospital, Ambala, which has been produced by the Ld. Counsel for complainant and same is marked as ‘B’, it is mentioned that Encephalitis is brain fever. However, if we go through Section 1:- Critical Illness Coverage of the policy conjointly with the diseases/treatments mentioned thereunder, it is evident that Acute Encephalitis, from which the insured had died, as is evident from the certificate Annexure C-9 of the Doctor concerned, is not found mentioned thereunder i.e. it is not covered under the policy in question, as critical illness. Under these circumstances, we are of the considered view that since the disease Acute Encephalitis was not covered under the policy in question as critical illness, the OPs were not under obligation to pay any amount under the policy in question to the complainant. It is significant to mention here that the insurance policy between the insurer and the insured represents a contract between the parties and the insured cannot claim anything more than what is covered by the insurance policy. Our this view is supported by the ratio of law laid down by the Hon’ble Supreme Court of India in Oriental Insurance Co. Ltd Vs Sony Cherian (II 1999 CPJ 13 SC) wherein it was held that- ― “..The insurance policy between the insurer and the insured represents a contract between the parties. Since the insurer undertakes to compensate the loss suffered by the insured on account of risks covered by the insurance policy, the terms of the agreement have to be strictly construed to determine the extent of liability of the insurer. The insured cannot claim anything more than what is covered by the insurance policy. That being so, the insured has also to act strictly in accordance with the statutory limitations or terms of the policy expressly set out therein…”.

9.           In view of peculiar facts and circumstances of this case, it is held that because the complainant has failed to prove her case, therefore, no relief can be given to her. Resultantly, this complaint stands dismissed with no order as to costs. Certified copy of the order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced:- 17.04.2023

 

(Vinod Kumar Sharma)	(Ruby Sharma)	(Neena Sandhu)
Member	Member	President