Tamil Nadu

South Chennai

CC/204/2013

Mrs.Pramila, - Complainant(s)

Versus

M/s. HDFC ERGO Genral Insurance Company Ltd., - Opp.Party(s)

R. Thirumalai

10 Jun 2019

ORDER

                                                                        Date of Filing  : 21.06.2013

                                                                          Date of Order : 10.06.2019

                                                                                  

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (SOUTH)

@ 2^ND Floor, T.N.P.S.C. Road, V.O.C. Nagar, Park Town, Chennai – 3.

 

PRESENT: THIRU. M. MONY, B.Sc., L.L.B, M.L.                    : PRESIDENT

TR. R. BASKARKUMARAVEL, B.Sc., L.L.M., BPT., PGDCLP.  : MEMBER

 

C.C. No.204/2013

DATED THIS MONDAY THE 10^TH DAY OF JUNE 2019

                                 

Mrs. Pramila,

W/o. Late. P. Ramanujam,

Flat –C/4, Indus Durga Apartments,

No.9, Mani Naicker Street,

Radha Nagar,

Chrompet,

Chennai – 600 044.                                                        .. Complainant.                                                   

 

                                                                                                  ..Versus..

 

1. The Head,

Retail Business Group,

M/s. HDFC ERGO General Insurance Company Ltd.,

6^th Floor, MBC Tower,

Old No.90, New No.199,

Luz Church Road,

Mylapore,

Chennai – 600 004.

 

2. The Managing Director,

M/s. HDFC ERGO General Insurance Company Ltd.,

6^th Floor, Leela Business Park,

Andheri-Kurla Road,

Andheri (East),

Mumbai – 400 059.                                                ..  Opposite parties.

 

Counsel for the complainant                  : M/s. R. Ramani & another

Counsel for the opposite parties 1 & 2  : Mr. Micheal Marie Antony

 

 

ORDER

THIRU. M. MONY, PRESIDENT

       This complaint has been filed by the complainant against the opposite parties 1 & 2 under section 12 of the Consumer Protection Act, 1986 prays to pay a sum of Rs.8,65,248/- towards sum assured under the Policy together with interest at 18% p.a. and to pay a sum of Rs.2,00,000/- towards compensation for mental agony, deficiency in service and unfair trade practice with cost to the complainant.

1.    The averments of the complaint in brief are as follows:-

The complainant submits that she along with her husband Mr. P. Ramanujam has availed ‘Home Suraksha Plus’ Policy bearing No.2918200146613500000 for the period from 27.10.2011 to 26.10.2016 at the time of availing housing loan bearing Account No.602525003 from HDFC Ltd.   The said ‘Home Suraksha Plus’ Policy is coupled with Major Medical Illness and Procedures for an assured sum of Rs.8,65,248/-.  The house property also hypothecated with HDFC Ltd as per the policy. The Major Medical Illness referred in the policy covers the following critical illness:-

1. First Heart Attack.
2. Coronary Artery Disease requiring Surgery.
3. Stroke.
4. Cancer.
5. End Stage Kidney Disease.
6. Major Organ Transplant.
7. Multiple Sclerosis.
8. Heart Valve Replacement.
9. Paralysis. 

2.     The complainant submits that on 05.02.2013 in the early morning, her husband Mr. P. Ramanujam who avail the housing loan form HDFC Ltd, suddenly fell ill with the complaint of burning sensation in his Chest and Nausea.  Immediately, the said Mr. P. Ramanujam was taken to nearby Kamakshi Memorial Hospital Pvt. Ltd., Pallikaranai, Chennai - 100. Even after providing first aid treatment including ET Tube incubation, Assisted Ventilator support, Indropic Support including Dopamine Infusion and other supportive measures like i.v. fluids and dopamine drip.  Inspite of such treatment, Mr. P. Ramanujam  succumbed to death on the same day, at 07.30 am.  The complainant submits that due claim was made by the complainant with the 2^nd opposite party under claim No.C291812000543 claiming compensation/ the sum assured amount on the basis of the policy i.e. Death claim.  The opposite party without any proper clarification after receiving all the documents issued by the Kamakshi Memorial Hospital Pvt. Ltd., Pallikaranai repudiated the claim on 21.03.2013 stating that critical illness does not come under ‘Home Suraksha Policy’. The complainant submits that the cause of death of Mr. P. Ramanujam is only due to Heart Attack i.e. Severe Cardio Respiratory Failure.   Resuscitative measures also given with life saving medicines ended in vain.   The complainant submits that the opposite parties admitted the availing of housing loan and issuance of Home Suraksha Policy covering medical illness and procedures specifically for an assured sum of 8,65,248/-.  The sudden unexpected sad demise of Mr. P. Ramanujam caused great loss and mental agony to the complainant.   As per the terms and conditions of the policy, the opposite parties’ insurance company shall pay the sum assured amount with interest.  The act of the opposite parties 1 & 2 amounts to deficiency in service and unfair trade practice which caused great mental agony.   Hence, the complaint is filed.

3.      The brief averments in the written version filed by opposite parties 1 & 2 is as follows:

The opposite parties 1 & 2 specifically deny each and every allegations made in the complaint and put the complainant to strict proof of the same.    The opposite parties state that the complainant and her husband availed Housing Loan and policy namely; ‘Home Suraksha Policy’ for an insured sum of Rs.8,65,248/- and the policy is subsisting on the date of death of Mr. P. Ramanujam.  The policy provides coverage against Fire & Allied Perils, Burglary & Theft, Major Medical Illness & Procedures, Personal Accident and Loss of Job, subject to terms and conditions as stipulated in the Policy.   The opposite parties state that the complainant has to prove the cause of death and ailment.   The opposite parties state that the complainant has filed claim under critical illness due to death of her husband.  The policy does not cover such critical illness. The opposite parties state that due letters dated:11.02.2013 & 12.03.2013 addressed to the complainant for the production of some documents regarding the complainant has not been duly complied.  Thereafter, the complainant sent an email dated:18.03.2013 with scanned documents which shows very clearly that Mr. P. Ramanujam suffered complaints of Cardio Respiratory Arrest with severe Cardio Respiratory failure who is a known case of diabetes with Hyperglycemia.  The ailment suffered by Mr. P. Ramanujam and treatment given to him are not covered by the policy and thereby, the claim was repudiated.  

4.     The definition of Myocardial Infarction (First Heart Attack) as covered under the policy is as follows:

SECTION: 3

MAJOR MEDICAL ILLNESS AND PROCEDURES

c) Occurrence for the first time of the following medical events more specifically described below:

3. Myocardial Infarction (Heart Attack)

The first occurrence of the acute myocardial infarction leading to the death of a portion of heart muscle (Myocardium) as a result of inadequate blood supply to the relevant area.

The diagnosis for the same must be evidenced by all of the following:

• An episode of typical chest pain.
• The occurance of a typical new acute infarction charges (ST-T elevation) on the electrocardiograph and processing to development of pathological Q waves.
• Elevation of cardiac Troponin (T or I) to atleast 3 times the upper limit of the normal reference range or an elevation in CPK-MB to atleast 200% of the upper limit of the normal reference range.

But excluding non-STEMI which elevation of troponin I or T.  Other acute coronary syndromes including but not limited to angina or chest pain are excluded from this definition.

It is further states that the cover of ‘Major Medical Illness and Procedure” under the policy is an exclusive cover limited to the specifically described Illness and procedure in the Policy Schedule.  As the deceased died due to a condition not covered under the Policy, no claim is payable.  The opposite parties state that the compensation claimed is exorbitant.  Therefore, there is no deficiency in service on the part of the opposite parties 1 & 2 and hence, the complaint is liable to be dismissed.

5.     To prove the averments in the complaint, the complainant has filed proof affidavit as her evidence and documents Ex.A1 to Ex.A8 are marked.  Proof affidavit of the opposite parties 1 & 2 is filed and document Ex.B1 alone is marked on the side of the opposite parties 1 & 2.

6.      The points for consideration is:-

1. Whether the complainant is entitled to a sum of Rs.8,65,248/- towards the sum assured amount under the policy with interest at the rate of 18% p.a. as prayed for?
2. Whether the complainant is entitled to a sum of Rs.2,00,000/- towards compensation for mental agony, deficiency in service, unfair trade practice with cost as prayed for?

7.      On point:-

Both parties filed their respective written arguments.  Heard the complainant’s Counsel also.  Perused the records namely; the complaint, written version, proof affidavits and documents. The complainant has pleaded and contended that she along with her husband Mr. P. Ramanujam  has availed ‘Home Suraksha Plus’ Policy bearing No.2918200146613500000 for the period from 27.10.2011 to 26.10.2016 at the time of availing housing loan bearing Account No.602525003 from HDFC Ltd.  Ex.A1 is the loan sanction letter.  The said ‘Home Suraksha Plus’ Policy is coupled with Major Medical Illness and Procedures for an assured sum of Rs.8,65,248/- as per Ex.A2 & Ex.A3.  The house property also hypothecated with HDFC Ltd  as per the policy.  The Major Medical Illness referred in the policy covers the following critical illness

          (i)   First Heart Attack.

(ii)   Coronary Artery Disease requiring Surgery.

(iii)   Stroke.

(iv)   Cancer.

(v)    End Stage Kidney Disease.

(vi)    Major Organ Transplant.

(vii)   Multiple Sclerosis.

(viiii)  Heart Valve Replacement.

(ix)   Paralysis.  

8.     Further the contention of the complainant is that on 05.02.2013 in the early morning, her husband Mr. P. Ramanujam who avail the housing loan form HDFC Ltd, suddenly fell ill with the complaint of burning sensation in his Chest and Nausea.  Immediately, the said Mr. P. Ramanujam was taken to nearby Kamakshi Memorial Hospital Pvt. Ltd., Pallikaranai, Chennai - 100. Even after providing first aid treatment including ET Tube incubation, Assisted Ventilator support, Indropic Support including Dopamine Infusion and other supportive measures like i.v. fluids and dopamine drip.  Inspite of such treatment, Mr. P. Ramanujam  succumbed to death on the same day, at 07.30 am.  Ex.A5 (S) is the copy of Death Certificate.   

9.     Further the contention of the complainant is that due claim was made by the complainant with the 2^nd opposite party under claim No.C291812000543 claiming compensation/ the assured amount on the basis of the policy i.e. Death claim.  The opposite party without any proper clarification after receiving all the documents issued by the Kamakshi Memorial Hospital Pvt. Ltd., Pallikaranai repudiated the claim on 21.03.2013 as per Ex.A6 stating that critical illness does not come under ‘Home Suraksha Policy’.   But on a careful perusal of the policy, it is very clear that utmost all the critical diseases were covered under the policy.   Further the contention of the complainant is that the cause of death of Mr. P. Ramanujam is only due to Heart Attack i.e. Severe Cardio Respiratory Failure as per Ex.A5.   Resuscitative measures also given with life saving medicines ended in vain. Further the contention of the complainant is that the opposite parties admitted the availing of housing loan and issuance of Home Suraksha Policy covering medical illness and procedures specifically for an assured sum of 8,65,248/-.   The sudden unexpected sad demise of Mr. P. Ramanujam caused great loss and mental agony to the complainant.   As per the terms and conditions of the policy, the opposite parties’ insurance company shall pay the assured amount with interest.  But the opposite parties wantonly and negligently repudiated the claim without proper reason. The complainant is claiming a sum of Rs.8,65,248/-, the assured amount with interest at the rate of 18% p.a. compensation of Rs.20,000/- for mental agony with cost.

10.    The contention of the opposite parties that admittedly, the complainant and her husband availed Housing Loan and policy namely; ‘Home Suraksha Policy’ for an insured sum of Rs.8,65,248/- and the policy is subsisting on the date of death of Mr. P. Ramanujam.  The policy provides coverage against Fire & Allied Perils, Burglary & Theft, Major Medical Illness & Procedures, Personal Accident and Loss of Job, subject to terms and conditions as stipulated in the Policy.  Further the contention of the opposite parties is that the complainant has to prove the cause of death and ailment.  It is also apparently clear from Ex.A5, Death Summary that Mr. P. Ramanujam died due to Heart Attack/ Cardio Respiratory Arrest.   Further the contention of the opposite parties is that the complainant has filed claim under critical illness namely; death of her husband.  The policy does not cover such critical illness.  But on a careful perusal of the policy which covers the major critical illness.   Further the contention of the opposite parties that due letters dated:11.02.2013 & 12.03.2013 as per Ex.A3 & Ex.A4 addressed to the complainant for the production of some documents regarding the complainant has not been duly complied.  Thereafter, the complainant sent an email dated:18.03.2013 as per Ex.A5 with scanned documents which shows very clearly that Mr. P. Ramanujam suffered complaints of Cardio Respiratory Arrest with severe Cardio Respiratory failure who is a known case of diabetes with Hyperglycemia. The ailment suffered by Mr. P. Ramanujam and treatment given to him are not covered by the policy and thereby, the claim was repudiated.  But on a careful perusal of the records, the ailment suffered by Mr. P. Ramanujam was covered under the policy.

11.    The definition of Myocardial Infarction (First Heart Attack) as covered under the policy is as follows:

SECTION: 3

MAJOR MEDICAL ILLNESS AND PROCEDURES

c) Occurrence for the first time of the following medical events more specifically described below:

3. Myocardial Infarction (Heart Attack)

The first occurrence of the acute myocardial infarction leading to the death of a portion of heart muscle (Myocardium) as a result of inadequate blood supply to the relevant area.

The diagnosis for the same must be evidenced by all of the following:

• An episode of typical chest pain.
• The occurance of a typical new acute infarction charges (ST-T elevation) on the electrocardiograph and processing to development of pathological Q waves.
• Elevation of cardiac Troponin (T or I) to atleast 3 times the upper limit of the normal reference range or an elevation in CPK-MB to atleast 200% of the upper limit of the normal reference range.

But excluding non-STEMI which elevation of troponin I or T.  Other acute coronary syndromes including but not limited to angina or chest pain are excluded from this definition.

The medical literatures also squarely applicable Cardio Respiratory Arrest and Cardio Pulmonary Arrest are one and the same.   The repudiation on such ground is unsustainable.  Further the contention of the opposite parties is that the compensation claimed is exorbitant.  Considering the facts and circumstances of the case, this Forum is of the considered view that the opposite parties 1 & 2 are jointly and severally shall pay sum of Rs.8,65,248/- with interest at the rate of 9% from the date of complaint to till the date of this order with a compensation of Rs.50,000/- towards mental agony and cost of Rs.5,000/- to the complainant.

In the result, this complaint is allowed in part.   The opposite parties 1 & 2 are jointly and severally liable to pay a sum of Rs.8,65,248/- (Rupees Eight lakhs sixty five thousand two hundred and forty eight only) along with interest at the rate of 9% p.a. from the date of complaint (i.e.) 21.06.2013 till the date of this order (i.e.)  10.06.2019 and to pay a sum of Rs.50,000/- (Rupees Fifty thousand only) towards compensation for mental agony with cost of Rs.5,000/- (Rupees Five thousand only) to the complainant.

The aboveamounts shall be payablewithin six weeks from the date of receipt of the copy of this order, failing which, the said amounts shall carry interest at the rate of 9% p.a. to till the date of payment.

Dictated  by the President to the Steno-typist, taken down, transcribed and computerized by her, corrected by the President and pronounced by us in the open Forum on this the 10^th day of June 2019. 

 

MEMBER                                                                                PRESIDENT

 

COMPLAINANT SIDE DOCUMENTS:-

Ex.A1	05.09.2011	Copy of loan sanctioning letter by HDFC Ltd. along with enclosures
Ex.A2	27.10.2011	Copy of the Policy No.291820014661350000 along with enclosures
Ex.A3	11.02.2013	Copy of letter from the opposite party to the complainant
Ex.A4	12.03.2013	Copy of letter from the opposite party to the complainant
Ex.A5	18.03.2013	Copy of email from the complainant to the 1st opposite party with attachment
Ex.A6	21.03.2013	Copy of letter from the opposite party to the complainant
Ex.A7	22.03.2013	Copy of email from the opposite party repudiating the claim
Ex.A8	15.04.2013	Copy of legal notice sent by the complainant’s Counsel

 

OPPOSITE PARTIES 1 & 2  SIDE DOCUMENTS:-

Ex.B1

Copy of Insurance Policy with terms and conditions

 

 

 

MEMBER                                                                                PRESIDENT