Punjab

StateCommission

A/561/2017

HDFC Ergo General Insurance Company Limited - Complainant(s)

Versus

Rajwinder Kaur - Opp.Party(s)

Mohan Lal Singhi

08 Dec 2017

ORDER

         2^Nd ADDITIONAL BENCH

STATE  CONSUMER  DISPUTES  REDRESSAL COMMISSION, PUNJAB, CHANDIGARH.

First Appeal No.561 of 2017 

                                                          Date of Institution: 26.07.2017

                                                          Date of Reserved: 28.11.2017

                                                          Date of Decision:   08.12.2017

 

HDFC Ergo General Insurance Company Ltd., having its Registered Office at Raman House, H.T. Parekh Marg-169 Backbay Reclamation Mumbai-400020, through its Managing Director.

                                                                     Appellant/Opposite party No.2

Versus

1. Rajwinder Kaur widow of Sh. Surjit Singh, R/o Village and Post Office Dharamkot Randhawa, Tehsil Dera Baba Nanak, Senior Secondary School, Distt. Gurdaspur.

   Respondent No.1/complainant

2. HDFC Bank Limited, Hanuman Chowk, Tibri Road, Gurdaspur, Through its Manager.

                                                     Respondent/opposite party No.2

First Appeal against order dated 15.05.2017 passed by the District Consumer Disputes Redressal Forum,  Gurdaspur.

Quorum:-

          Shri Gurcharan Singh Saran, Presiding Judicial Member.

         Shri Rajinder Kumar Goyal, Member

Present:-

          For the appellant          :         Sh.Nitesh Singhi, Advocate

          For respondent No.1   :         Sh.Karan Grover, Advocate

          For respondent No.2   :         Ex-parte

           

RAJINDER KUMAR GOYAL MEMBER

ORDER

                    The appellant/opposite party No.2 (hereinreferred to as OP No.2) has filed the present appeal against the order dated 15.05.2017 passed in Consumer Complaint No.360 of 2016 by District Consumer Disputes Redressal Forum,  Gurdaspur (herein referred as District Forum) vide which the complaint filed by the complainant was party allowed and further ordered to OP No.2/insurer to pay the impugned insurance claim under the category of ‘accidental death’ to the complainant besides to pay her Rs.10,000/- as compensation (for the harassment inflicted) and Rs.5000/- as cost (of litigation) within 30 days of the receipt of the copy of these orders otherwise the aggregate awarded amount shall attract interest @9% P.A. from the date of the orders till actual payment.

2.                Complaint was filed by the respondent No.1/complainant (hereinafter referred as complainant) under Consumer Protection Act, 1986 (in short, "the Act") against the OPs on the averments that the husband of the complainant namely Sh. Surjit Singh deceased during his life time, along with his wife (claimant) approached the OP No.1 for borrowing a personal loan. At the time of advancement of the said loan, the concerned employees of the OP No.1 told to the complainant that under the said loan scheme given to deceased Surjit Singh, his life would also be insured to the tune of Rs.1 lakh. The said employee also told that the policy document would be provided by the insurance company at his home address but the during the life time of the deceased Surjit Singh, said policy documents were not delivered to him at his address. As such the husband of the complainant hired the services of the OPs and is their consumer. It was further pleaded that unfortunately on 08.05.2015 husband of the complainant died and the complainant approached the OP No.1, submitted all the required documents with OPs but her claim was repudiated by OP No.2 on the ground that as per the case summary which was received by them deceased Surjit Singh had a sudden heart attack on 08.05.2015 with no prior related symptoms and he expired on the same day whereas the fact on account of which the claim of the complainant was repudiated was not disclosed to the insured at any point of time. It was also pleaded that complainant number of time requested the Ops to consider her claim but they did not consider the same and finally refused to do so.  This act of the Ops amounted to deficiency in service. Hence this complaint. She further prayed that the complaint may be accepted and OPs may kindly be directed to make the payment of insurance claim to the complainant and opposite parties may be burdened with a cost of Rs.5000/- as litigation expenses and Rs.10,000/- for mental harassment and torture.

3.                Upon notice, OP No.1 filed their written reply stating therein  that OP No.1 at the request of deceased Surjit Singh sanctioned  a loan of Rs.2,10,000/- on 03.11.2014. It was further stated that OP No.1 is a banking company and not an insurance company as such Op No.1 is totally separate from Op No.2 and no insurance of deceased Surjit Singh was ever done by Op No.1 i.e. HDFC Bank. It was further stated that insurance was got done by the husband of the complainant with OP No.2 of his own free will and as such liability to pay the insured amount if any, was of Op No.2 i.e. Insurance Company only. OP No.1 has no concern and no liability in the contract of the insurance entered between the parties. All other averments made in the complaint were denied and prayed for dismissal of the complaint with costs.

                   OP No.2 also filed his written reply by taking the preliminary objections that the complainant has no cause of action to file the present complaint. The insured deceased was covered under “Sarv Surkasha Policy” which was issued by the OP No.2 on the request and proposal of the deceased and the said coverage was subject to the terms and conditions of the policy which form the part and parcel of the policy schedule and the said documents were duly supplied and brought to the knowledge of the deceased. It was further stated that the terms and conditions were never disputed by the deceased and the claim was repudiated on the said terms and conditions of the policy. There is no deficiency in service on the part of this OP. It was further stated that the claim of the complainant was repudiated vide letter dated 08.10.2015 that as per the case summary Surjit Singh had a sudden heart attack on 08.05.2015 and as per the terms and conditions of the policy for critical illness to be admissible under the policy, the insured person had to survive for a period of 30 days from the time he was diagnosed for illness. As such claim under critical illness was not covered as per policy terms and the claim was rightly  repudiated.  On merits, it was admitted that the deceased was insured under the policy i.e. “Sarv Surkasha Policy” but the claim was repudiated as the same was not covered under the said policy. All other averments made in the complaint were denied and prayed for dismissal of the complaint with cost.

4.                Before the District Forum the parties were allowed to lead their respective evidence.

5.             In support of his allegations, the complainant had tendered into evidence his affidavit as Ex.C-1 along with documents Ex.C2 to Ex.C5 and closed her evidence. In rebuttal the OP tendered in evidence affidavit of Sh.Hardyal Kohli Officer Ex.OP-1/1 and closed the evidence on behalf of the OP No.1. Counsel for the OP No.2 had tendered into evidence affidavit of Sh. Pankaj Kumar Manager-Legal and authorized signatory Ex.OP-2/1 along with documents Ex.OP-2/2 to Ex.OP-2/11 and closed the evidence on behalf of the OP No.2

6.                After going through the allegations in the complaint, written versions filed by OPs, evidence and documents brought on record, the complaint filed by the complainant was partly allowed as referred above.

7.                Aggrieved with the order passed by the learned District Forum, the appellant/OP No.2 has filed the present appeal.

8.                We have heard learned counsel for the parties and have gone through the record of the case.

9.                It was argued by the learned counsel for the appellant/OP No.2 that there is no deficiency in service on their part and the claim of the complainant was rightly repudiated. As per case summary received, Surjit Singh had a sudden heart attack 08.05.2015 with no prior related symptoms and he expired on the same day. As per terms and conditions of the policy (Annexure A-2/Section 1) for critical illness to be admissible under the policy, the insured person has to survive for a period of 30 days from the time he was diagnosed for critical illness. The learned Forum has failed to apply its judicial mind while directing the OP/Appellant to reimburse the claim of “Accidental Death” to the complainant. Further argued that the term accident is specifically defined under the insurance policy as “Accident or Accidental” means a sudden, unforeseen and involuntary event caused by external, visible and violent means” as such no other meaning of the term accident can be derived whatsoever and by no stretch of imagination, the cause of death of the insured i.e. heart attack can be considered as accident. Further prayed that the present appeal may kindly be accepted and order dated 15.05.2017 may kindly be set aside in the interest of justice. Counsel for the complainant/Respondent argued that as per coverage and benefits of the policy, the claim is covered under personal accident. The sudden heart attack is a personal accident. The District Forum in the order has also considered the death of insured as “Accidental Death” and subsequently the claim. Counsel further prayed to dismiss the appeal and upheld the order of the District Forum.

10.              We are of the opinion that the complainant lodged the claim (Annexure 2 Claim form) under Personal Accident & not in the critical illness as alleged in the repudiation letter issued by the Ops. Further under policy terms and conditions, Annexure 2, coverage Parts- Specific definition applicable to section 2 “Accident or Accidental” means a sudden, unforeseen and involuntary event caused by external, visible & violent means. In this case, there is no evidence that heart attack to the deceased Surjit Singh was caused by external, visible & violent means. As such in view of the above referred  terms and conditions of the insurance Policy, death due to Sudden Heart Attack cannot be considered as Accidental Death. District Forum  while considering the death due to sudden heart attack as Accidental Death has quoted as “to remove all ambiguity, it shall be pertinent here to mention that by the time it has become part of the trite law (by virtue of the apex court judgments duly followed by the other courts) that ‘death’ caused by sudden ‘heart attack’ shall be for all purposes shall be an ‘accidental-death’ with no history of associated ailments”.  The District Forum has not quoted any judgment to authenticate the above view.

11.              The insurance is a contract entered between the parties on the averments of terms and conditions of the insurance policy. Both the parties are bound by the terms and conditions of the contract. No exception or relaxation can be made while interpreting the same. As per terms of conditions of the insurance policy definition of accident has already been given – means a sudden, unforeseen and involuntary event caused by external, visible and violent means. There is no evidence that insured died due to event caused by external, visible and violent means.

12.               Sequel to the above, we accept the appeal and the order of the District Forum is set aside and the complaint filed by the complainant is dismissed.

13.              The appellant/OP No.2 had deposited an amount of Rs.25000/- with this Commission at the time of filing the appeal and also deposited Rs.2,00,000/- in compliance with the order dated 28.07.2017. These amounts with interest accrued thereon, if any, be remitted by the registry to the appellant/OP No.2, after the expiry of 90 days, from the dispatch of the certified copy of the order to the parties; subject to stay, if any, by the higher Fora/Court.  

14.              The appeal could not be decided within the statutory period due to heavy pendency of the Court cases.

15.              Copy of the order be communicated to the parties as per rules. 

 

                                                                     (Gurcharan Singh Saran)

                                                                   Presiding Judicial Member

 

 

                                                                  

December  08, 2017                              (Rajinder Kumar Goyal)

PK/-                                                                     Member