IN THE CONSUMER DISPUTES REDRESSAL FORUM, KOLLAM

   DATED THIS THE 25^TH   DAY OF August 2015

Present: -        Smt. G.Vasanthakumari, President

Adv. Ravisusha, Member

Adv.M.Praveen Kumar, Member

                  CC.No.44/2013

Prasanna                                                                    :                                   Complainant

W/o Late Reghunathan

Residing at Renju Bhavan

Punukkannoor, Perumpuzha P.O

Kollam

[By Adv.Prince Kumar.G, Kollam]

V/S
 

            1.         The Regional Claims Manager        :                                   Opposite parties

                        HDFC ERGO General Insurance Co.Ltd.

                        1^st Floor, Chicago Plaza

                        Near K.S.R.T.C. Bus Stand

                        Rajaji Road

                        Cochin

            2.         The Manager

                        HDFC ERGO General Insurance Co.Ltd.

                        6^th Floor, Bishop Jerome Nagar

                        Chinnakkada

                        Kollam – 691001

                        [By Adv. Saiju.J, Kollam]

ORDER

ADV. RAVISUSHA, MEMBER

            Complainant’s case is that the complainant is the wife of late Reghunathan.K, S/o Kunjiraman, Renju Bhavan, Punakkannoor, Perumpuzha P.O, Kollam. The Reghunathan was the owner and occupier of a Motor Bike (Hero Honda Passion Pro) manufactured by Hero Honda bearing Reg.No.K.L-02-AE-6512. He purchased the vehicle by availing a loan (Loan No.16568523) from H.D.F.C. Bank, Kollam branch. Subsequent to his death, the complainant is using the vehicle being his legal heir. The complainant’s husband while availing loan for purchasing the vehicle above mentioned, the opposite parties insisted him for taking an insurance

(2)

policy to the loan and the loanee and as such complainants husband remitted Rs.2120/- as premium for the “Sarvaa Suraksha Star Policy” (Policy No.40391906) offered by the opposite parties. The said insurance is valid for a period of 36 months ie from 28/05/2010 to 27/05/2013. As per the said policy, complainant is the beneficiary. While availing the insurance, the second opposite party promised the complainant that the insurance policy availed by the complainants husband is having the coverage of critical illness benefit.

            The complainant submits that on 01/05/2012, the complainants husband Reghunadhan sustained a chest pain and on the way to Assisi Atonement Hospital, Perumpuzha, he died. Since the complainant was not aware to the above said insurance policy taken by her deceased husband, she continued the remittance of loan installments and as such she remitted Rs.1426/- on 24/05/2012, Rs.1876/- on 19/06/2012, Rs.1876/- on 29/06/2012 and Rs.1450/- on 01/09/2012. Subsequent to this payments, the complainant find out the policy certificate and then only she came to understand that as per the coverage of said policy she is not liable to pay balance loan installments subsequent to the death  of loanee and also she is entitled to get another Rs.75,000/- as critical illness benefits. Immediately she preferred claim before the opposite parties as claim No. RH/12-13/9938. But the first opposite party without any valid reasons rejected the claim application given by the complainant as per letter dated 18/10/2012. The complainant submits that as per the insurance policy taken by the complainant husband, she is not liable to pay balance loan installments if it is less than rupees one lakh as per the “Credit Shield Insurance” offered by the opposite parties. Moreover she is entitled to get Rs.75,000/- as Critical Illness benefit from the opposite parties. The opposite parties are liable to pay the same to the complainant.  The complainant submits that the above action of the opposite parties is inexcusable deficiency in service and unfair trade practice. Hence filed this complaint.

            Opposite parties 1 and 2 filed version contending that the 1^st and 2^nd opposite parties have no connection with the loan transaction, so the averment in the complaint that the 1^st and 2^nd opposite parties insisted the husband of the complainant for taking an insurance policy is false and hence denied. It is admitted that the husband of the complainant was having the coverages of critical illness benefit. But in this case as per the policy conditions the insured is not entitled to get any of these benefits. The complainant is claiming critical illness benefits. But the benefit of

(3)

critical illness benefit is available only to the following diseases as per the conditions of Sarva Suraksha policy ie,

1. First Heart Attack ( Myocardial Infraction)
2. Coronary Artery Disease Requiring Surgery
3. Stroke
4. Cancer
5. Kidney Failure (End - stage renal disease)
6. Major Organ Transplantation
7. Multiple Sclerosis
8. Surgery of Aorta
9. Primary Pulmonary Arterial Hypertension
10. Paralysis

Moreover that the above said diseases should be diagnosed and certified by a qualified medical practitioner. But in this case the complainant has not produced any medical certificate showing the cause of death or medical history of her husband Reghunathan.K. who is the insured. As per the certificate issued by the CMO Assisi Atonement Hospital Perumpuzha, Kollam it is stated that Mr.Reghunathan was brought dead to causality on 01/05/2012 at      12.45 pm and cause of death not known. Moreover that as per the death certificate of Mr.Reghunathan issued by Elampalloor Grama Panchayath the place of death is Renju Bhavan, Punukkannoor, Kollam. The Sarva Suraksha policy issued has a policy exclusion of 30 days of survival period for any claim. As per Section 1 of Critical Illness coverage- the insured person in the schedule is diagnosed as suffering from a critical illness which first occurs or manifests itself during the policy period, and the insured survives for a minimum of 30 days from the date of diagnosis, the company shall pay the critical illness benefit. In this case same criteria is not fulfilled. Therefore the complainant is not entitled to get the claim of critical illness benefit.

As per section 1 of the Sarva Suraksha policy “If the insured person named in the schedule is diagnosed as suffering from a critical illness which first occurs or manifests itself during the policy period, and the insured survives for a minimum of 30 days from the date of diagnosis, the company shall pay the critical illness benefit as shown in the schedule” Since the loss claimed is not covered as per above policy wordings, the opposite parties are not liable to

(4)

pay any amount to  the complainant. The 1^st and 2^nd opposite parties have no connections with the alleged loan transactions. The opposite parties have not received any loan installments and hence they are not liable to repay the loan amount to the complainant. The complainant is not entitled to get the critical illness benefit since the policy criteria are not fulfilled. There is no deficiency in service and unfair trade practice from the part of the opposite parties and hence they are not liable to pay any compensation to the complainant.

The points that would arise for consideration are:-

            (1).Whether there is any deficiency in service or unfair trade practice on the part of the opposite parties?

            (2).Reliefs and costs?

The evidence in this case consists of the oral testimony of PW1, PW2 and PW3 and documentary evidence Exts P1 to P11 and D1.

The Points :-  It is admitted by  both the parties that the husband of the complainant was having the policy coverages. But according to the opposite parties, they rejected the claim petition of the complainant, because as per the policy conditions the insured is not entitled to get the benefit on the basis of the claim application. Here the complainant is claiming critical illness benefits. Opposite parties version is that as per condition of policy the critical illness benefits is available only to certain diseases like First Heart Attack, Coronary artery diseases, Stroke etc and the said diseases should be diagnosed and certified by a qualified medical practitioner. The complainants case is that on 01/05/2012 the complainants husband Reghunathan sustained a chest pain and on the way to Assisi Atonement Hospital, Perumpuzha, he died. The complainant continued the remittance of loan installments, without knowing about insurance policy taken by her husband. Subsequently she find out the policy taken by her husband. According to the complainant, she is not liable to pay balance loan  installments subsequent to the death of loanee and also she is entitled to  get another Rs.75,000/- as critical illness benefits.

            From the side of complainant, she was examined as PW1 and Exts P1 to P11 were marked. Out of Exts P1 to P11 the very material evidences are Ext.P3 and Ext. P4. Ext.P3  is the certificate issued by Assisi Atonement Hospital and Ext.P4 is the death certificate of diseased Reghunathan .

                                                                               (5)

As per Ext.P3 certificate issued by the CMO Assisi Atonement Hospital, Perumpuzha, Kollam the husband of the complainant Mr.Reghunathan was brought dead to causality on 01/05/2012 at 12.45 pm and cause of death not known and as per Ext.P4  death certificate issued by  Elampalloor Grama Panchayath the place of death of Mr.Reghunathan, is Renju Bhavanam, Punukannoor, Kollam . Two witnesses were examined from the side of the complainant. But the oral evidence of those witnesses cannot rebut the documentary evidence of Ext.P3 and Ext.P4. The complainant did not produce any medical certificate showing that the cause of death was due to heart attack.

            Opposite parties main argument is that as per section 1 critical illness of Sarva Suraksha Policy “if the insured person named in the (Ext.D1) schedule is diagnosed as suffering from a critical illness which first occurs or manifest itself during the policy period and the insured survives for a minimum of 30 days from the date of diagnosis is, the company shall pay the critical illness benefits as shown in the schedule”. According to the opposite party since the loss claimed is not covered as per the above policy conditions, the opposite parties are not liable to pay any amount to the complainant. Opposite parties further argument is that they have no connections with the loan transactions, they have not received any loan installments and hence they are not at all liable to repay the loan amount to the complainant.

            On considering the entire facts and circumstances we are of the view that there is no deficiency in service or unfair trade practice on the part of opposite parties in repudiating the claim application of the complainant.

            In the result, the complaint fails and hence the same is dismissed but without cost.

Dated this the 25^th   day of August 2015.                                                                                                                                                                 

G.VASANTHAKUMARI:Sd/-

ADV.RAVISUSHA: Sd/-

ADV.M.PRAVEENKUMAR: :Sd/-

Forwarded/by Order

Senior Superintendent

(6)

I N D E X

PW.1:-  Presanna

PW.2:-Pradeep

PW.3:-Rajesh

Ext.P.1:- R.C. book copy

Ext.P.2:- Copy of policy

Ext.P.3:- Death certificate from hospital

Ext.P.4:- Death certificate from Panchayath

Ext.P.5 :-Claim repudiation letter

Ext.P.6:- Receipt dated 24/05/12

Ext.P.7:- Receipt dated 19/06/12

 Ext.P.8:- Receipt dated 29/06/12

Ext.P.9:- Receipt dated 15/01/2013

Ext.P.10:- Receipt dated 20/03/2013

Ext.P.11:- Receipt dated 20/09/2013

Ext.D.1:-SARVA Suraksha policy