CONSUMER DISPUTES REDRESSAL COMMISSION – X

GOVERNMENT OF N.C.T. OF DELHI

  Udyog Sadan, C – 22 & 23, Institutional Area

          (Behind Qutub Hotel)

   New Delhi – 110016

    Case No.153/2021

1. Shiv Singh

Nominee/Legal Heir

S/o Late Sh.Darshan Singh

R/o K-45, 1^st Floor

Sector-11, Noida

Uttar Pradesh-201301.

2. Rani Devi

W/o Late Sh. Darshan Singh

Legal Heir (Mother)

R/o K-45, 1^st Floor

Sector-11, NOIDA

Uttar Pradesh-201301

3. Mohan Singh

S/o Late Sh. Darshan Singh

Legal Heir (Brother)

R/o K-45, 1^st Floor

Sector-11, NOIDA

Uttar Pradesh-201301                                               …..COMPLAINANT

Vs.

1. M/s Reliance General Insurance Company Ltd.

Through its Managing Director

Having its Regd. Office at 6^th Floor, Oberoi Commerz-1, International

Business Park Oberoi Garden City, Goregaon, East Mumbai City

Branch Office : M/s Reliance General Insurance

Company Ltd. 260-261, Dev House, Tribhuvan Nagar

Ishwar Nagar, New Friends Colony New Delhi-100065.

Branch Office : M/s Reliance General Insurance

Company Ltd. 1^st Floor A-12, Mohan Co-operative Industrial Estate

Mathura Road, Badarpur, New Delhi-110044.

2. M/s Reliance General Insurance

Company Ltd. Having its Regd. Office at

The Ruby, 11^th Floor, North-West Wingh

Plot No.29, Senapati Bapat Marg, Dadar (West)

Mumbai, Maharashtra-400028

Branch Office : M/s Reliance General Insurance

Company Ltd. 260-261, Dev House, Tribhuvan Nagar

Ishwar Nagar, New Friends Colony

New Delhi-100065.                                                   ....RESPONDENTS

Date of Institution-15.07.2021

Date of Order-19.04.2024

                                                O R D E R

RITU GARODIA-MEMBER

1. The complaint pertains to deficiency in service on the part of OP in rejecting the claim of the complainant.

2. The deceased/insured complainant applied for loan against property from OP2, Reliance Home Finance Limited for a sum of Rs.1,50,00,000/-. The deceased insured was informed by OP1 that he will have to take insurance policy from OP2 to secure the loan amount failing which the loan application will be rejected. Subsequently, the loan was approved and sanctioned on 30.12.2017. The insurance policy was valid from 31.01.2018 to 30.01.2023.

3. The complainant submits that the said policy was to secure the repayment of loan in the event of death or any other medical conditions.

4. The benefits of the insurance policy were divided into five heads as follows:-

5. The complainant further submits that a sum of Rs.1,54,44,532/- has already been paid towards the loan by the deceased insured.

6. The insured deceased, late Shri Satnam Singh, was infected by coronavirus and was admitted in Yatharth Hospital on 27.04.2021. The deceased insured expired on 28.04.2021 and the cause of death was stated as “Cardiopulmonary Arrest with Covid 19 Positive”. In the death report dated 28.04.2021, a column mentioned as “Name of Disease or Actual Cause of Death,” it reveals that the cause of death is “Covid-19 Positive Cardiac Arrest”. The factum of the death of the deceased/insured was communicated to the OP1 and complainant applied for grant of the sum so promised as per the terms of the insurance policy.   However, the claim was rejected by the OP1 vide email dated 07.06.2021.

7. The complainant submits that the Insurance Policy secured a pay-out of Rs.86,09,853/- to the OP2 and if the balance loan amount was less than the amount  payable by the OP1 to the complainant, the remaining amount will be paid to complainant.

8. It is further submitted that the death-of the deceased/insured was an accidental death. Further the death of a deceased is a direct consequence of Covid-19 virus infection and as such the same is also a critical illness apart from being an accidental death.  OP1 has rejected the claim on the limited grounds of Section B of the policy. Even the term ‘accident’ is defined in the accident policy.

9. Notice was issued to OPs which was duly served but none appeared. Right to file reply by OPs was closed on 25.08.2022.

10. The complainant has filed the evidence by way of affidavit and exhibited the following documents:

1. Copy of letter dated 30.12.17 is exhibited as Ex.CW-1/1.
2. Copy of Insurance Certificate is exhibited as Ex.CW-1/2.
3. Copy of policy document is exhibited as Ex.CW-1/3.
4. Copy of sanction letter is exhibited as Ex.CW-1/4.
5. Copy of admission form and treatment papers are exhibited as Ex.CW-1/5.
6. Copy of medical certificates of cause of death is exhibited as Ex.CW-1/6.
7. Copy of death report is exhibited as Ex.CW-1/7.
8. Copy of email rejecting the claim of complainant is exhibited as Ex.CW-1/8.

11. The Commission has considered the documents on record.  A sanction letter dated 30.12.2017 shows that an amount of Rs.1,50,00,000/- was sanctioned to late Satnam Singh. The Insurance Policy dated 07.02.2018 shows that the policy commenced on 31.01.2018. The coverage was to continue till 30.01.2023. The benefits were as follows:

12. The deceased insured expired on 28.09.2021. The claim was rejected. The repudiation letter is as follows:-

As per available claim documents it is observed that Insured had died due to COVID positive complications-cardiac arrest & which cannot be covered under the policy.Please refer to the below coverage of the Policy schedule- Cancer of specified severity,*Open Heart Replacement or Repair of Heart Valves, Major Organ/Bone Marrow Transplant, Third Degree Burns, Total Blindness, Quadriplegia/Permanent Paralysis of all four limbs, Aorta Graft Surgery, Coma of specified severity, Kidney Failure requiring regular dialysis, Multiple Sclerosis with Persisting Symptoms

As the Death is not under above mentioned causes, we regret to inform that the claim cannot be entertained and therefore denied as per policy T & C’s.

13. The medical documents from Yatharth Hospital where the complainant was admitted on 27.04.2021 are placed on record. The medical certificate of cause of death issued by the Medical Officer in Form-6 shows that the complainant died on 28.04.20210 at 9:30 p.m. The cause of death is shown as Cardiopulmonary Arrest with Covid 19 Positive.

14. Accident is defined in the policy is as follows:

15. The policy shows what is covered as follows: “Section A-Accidental Death & Permanent Total Disability.

1.  What Is covered

This Section covers the insured/insured person upto the Sum Insured specified in the Schedule, towards payment of his/her home loan on account of an injury arising out of an accident, sustained during the Policy Period resulting in death or permanent total disablement, as the case may be with 12 (Twelve) calendar months of occurrence of such injury.

The sum insured under this Section will be the outstanding loan amount as opted by the insured and mentioned in the Schedule.In the event of the outstanding home loan amount of the inured, on date of loss is less than the sum insured, an amount equivalent to the principal outstanding home loan as on date of loss including interest on loan accrued (excluding any defaulted payment of monthly instalment by the borrower, prior to the date of loss that adds up into the outstanding loan) and pre-closure charges, if any, will be paid to the financial institution concerned and the balance sum insured, if any, will be paid to the insured or his/her legal representative(s), as the case may be OR as opted by the Insured the initial sum insured under this Section will be the principle outstanding loan amount as opted by the insured and mentioned in the Schedule.In the event of a loss under this Policy an amount equivalent to the principal outstanding home loan as on date of loss including interest on loan accrued (excluding any defaulted payment of monthly instalment by the borrower, prior to the date of loss that adds up into the outstanding loan) and pre-closure charges, if any, will be paid to the financial institution concerned as full and final discharge.”

16.  The Section A also provides for what is not covered under accidental death and permanent disability.

17. The Hon’ble Supreme Court in Smt. Alka Shukla Vs. Life Insurance Corporation of India, 2019/INSC/567 has held that:

10 The plain reading of the policy is to be accepted as our guide. Under the policy, in order for the complainant to prove her claim, she must show direct and positive proof that the accident of the assured falling from his motorcycle caused bodily injury by external/outward, violent and visible means. The complainant will have to prove that the accident and the injuries sustained as a result were a direct or proximate cause of her husband’s death.

11 There is no material on record to indicate that the assured sustained specific injuries as a result of a fall from the motorcycle or that the injuries were caused by outward, violent and visible means, which was the sole and proximate cause of his death. There is no direct nexus or causation between the assured suffering a heart attack and injuries sustained in an accident by outward, violent and visible means. Nothing has been brought on record to show that the injuries sustained by falling from the motorcycle aggravated the assured’s condition that eventually led to his death. In the absence of any evidence to the contrary, the medical evidence on record is itself proof that the insured died due to a heart attack and not due to an accident of falling from the motorcycle. The heart attack had a distinct effect of the insured falling off from his motorcycle.

In a case decided by the NCDRC- LIC of India v Smt. Mamta Rani clause 10.2 of the insurance policy provided an accident benefit cover if the assured sustained any bodily injury resulting solely and directly from the accident caused by outward, violent and visible means. The assured died of a heart attack. The district and state forums allowed the claim of the complainant for accidental benefit. However, the NCDRC rejected the claim and held thus:

“ it is clear that in case of death of life assured, the additional accident benefit equal to the sum assured is payable only if the life assured dies because of any bodily injury resulting solely and directly from an accident by outward, violent and visible means. In the instant case, as per the record, the life assured died on 01.07.2002 due to heart attack. There is no evidence on record to indicate that the life assured died because of some injury suffered in an accident. Thus, the fora below have committed a material illegality in awarding the accident benefit to the respondents against the terms and conditions of the insurance contract.” Similarly, in Swaranjit Kaur v ICICI Lombard General Insurance Co Ltd, the assured while travelling on his scooter, suffered a heart attack and fell from his scooter. The claim for accidental benefit cover was repudiated on the ground that the insured had died a natural death because of heart attack. The state commission set aside the order of the district forum allowing the claim. The NCDRC while upholding the state commission’s judgment, noted that the onus to prove that the insured had died as a result of an accident and not a heart attack was on the claimant. It held thus:

“On perusal of the copy of repudiation letter, it is clear that the respondents repudiated the insurance claim on the ground that cause of death of insured was heart attack. On perusal of the report of the investigator, we find that the stand of the petitioners in the statement made before the investigator on 17.8.2006 was that while driving the scooter insured suffered a heart attack, consequently, he fell down from the scooter and died. From this, it is clear that the accident took place after the insured had suffered heart attack. Otherwise also, in order to succeed in the insurance claim, the onus of proving that the insured had died as a result of accident was on the petitioners. Undisputedly, incident was not reported to the police nor post mortem to establish cause of death was done. No evidence has been produced by the petitioners to prove the cause of death of the insured. There is nothing in the statement of the petitioners as recorded by the investigator that the insured had suffered any bodily injuries due to fall from the scooter. Thus, under the circumstances, the conclusion of the State Commission that cause of death of the insured was heart attack and not an accident cannot be faulted…” The High Court of Madras held in Life Insurance Corporation v Minor Rohini that in the absence of any evidence that the assured had sustained any bodily injury resulting solely and directly from the accident caused by outward, violent or visible means, it cannot be said that the death due to a heart attack would amount to an accident for the purposes of accidental insurance claim under the policy.

• Krishna Wati v LIC of India, the NCDRC had to deal with whether the accidental injuries which resulted in the death of the assured due to a heart attack after three days of the accident could be termed as an accidental death or a natural death. The assured while riding his bicycle was attacked by a cow and upon arriving at the hospital complained of pain in the legs and in the chest, because of a fall from his bicycle. The NCDRC relied on the investigation report and the allowed the claim for accident insurance. It held thus:

“ In our view, from the record as it is, it is apparent that first the accident took place, resulted in injuries and chest pain which ultimately resulted in 'death'. May be, the death in medical terms be described as 'due to heart-attack, but the main cause for leading to heart-attack was injury caused due to accident. Accident is the basis for causing chest pain and thereafter heart-attack…”

12 In the present case, there is no evidence to show that any bodily injuries were suffered due to the fall from the motorcycle or that they led to the assured suffering a heart attack. There is no evidence to show that the accident took place as a result of any outward, violent and visible means. The assured died as a result of a heart attack which was not attributable to the accident.

18. Thus, it is clear that, the complainant was covered under accidental death and permanent total disability at the time of his death which occurred due to Cardiopulmonary Arrest with Covid 19 Positive. However, based on the precedent cited, there is no indication provided by the complainant to suggest that the incident occurred as a result of any external, visible, or violent means, which is a requirement for coverage under this policy. Consequently, the complaint is not eligible for coverage under the policy, and the service provided by the OP was not deficient. The complaint is dismissed with no orders as to cost.

19. Order to be uploaded and file be consigned to be record room.