Haryana

Karnal

CC/91/2021

Krishna Devi - Complainant(s)

Versus

Religare Health Insurance Company Limited - Opp.Party(s)

Bhupinder Kumar Jindal

03 Jan 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                      Complaint No. 91 of 2021

                                                      Date of instt.11.02.2021

                                                      Date of Decision: 03.01.2024

 

1.     Krishan Devi widow of Shri Rampal;

2.     Ritu Rani wife of late Shri Pardeep Singh.

3.     Navya minor daughter of late Shri Pardeep Singh.

4.     Navdeep Singh minor son of late Shri Pardeep Singh, minors through their mother and natural guardian Smt.Ritu wife of late Shri Pardeep Singh, all residents of Rahra, Tehsil Assandh, District Karnal.

                                       …….Complainants.

                                              Versus

 

1. Religare Health Insurance Company Limited, registered office: 5^th Floor, 19t, Chawla House, Nehru Palace, New Delhi 110019 through its authorized signatory.
2. Indusind Bank Limited, branch Pipli through its Branch Manager, District Kurukshetra.                                                                                                          …..Opposite Parties.

       

Complaint Under Section 35 of Consumer Protection Act, 2019.

 

Before    Shri Jaswant Singh……President.

              Shri Vineet Kaushik……….Member

              Dr.Suman Singh, ………….Member

          

Argued by: Shri Kartik Jindal, counsel for the complainant.

                  Shri Ashwani Kumar Popli, counsel for OP No.1.

                  Shri Suraj Kanwar, counsel for OP No.2.

 

                  (Dr.Suman Singh, Member)

 

ORDER:     

                 The complainant has filed the present complaint Under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainants No.3 & 4 are minors who are living under the care and custody of their mother Smt.Ritu Rani, having no adverse interests to that of the minors and as such, she is fit and proper person to represent the minors and thus present complaint on behalf of the complainants No.3 & 4 is being filed through their mother complainant No.2 Smt.Ritu Rani. Shri Pardeep Singh was son of complainant No.1 and husband of complainant No.2 and father of complainants No.3 to 4 respectively. Late Shri Pardeep Singh was having a saving account with OP No.2 and was also having KCC limit and term loan. At the time of obtaining KCC limit and term loan, OP No.2 recommended two health care policies. Shri Pardeep Singh obtained two health insurance policies from OP No.1 one for sum assured of Rs.3 lac and another for sum assured of Rs.30 lacs and paid the premium amount of Rs.985/- and Rs.15,790/- respectively. Unfortunately, on 15.04.2018, Shri Pardeep Singh died due to accidentally falling in water. No post mortem and FIR was lodged due to illiteracy. On 10.05.2018, the complainant submitted the claim with the OP No.1 and requested them to pay the amount. In the month of March, 2019, the complainant No.1 approached OP No.1 about the settlement of claim but OP No.1 asked the complainant to submit post mortem report and FIR. Thereafter, Sarpanch of Village Rahra had given in writing about the cremation of Pardeep Singh because of the sad situation in the family, post mortem could not be got conducted. On that basis, DDr No.19 dated 26.04.2019 was registered in Police Station Assandh. Complainant submitted the papers with the OP No.1. Thereafter, complainants received a notice from the legal department of Op No.2 on 19.08.2020 then reply was submitted on 20.10.2020 and a letter was also written to OP No.1 on 20.10.2020 for settlement of claim. Both the OPs are postponing the matter on one pretext or the other. The OP No.1 is bound to pay the insurance amount alongwith interest from the date of due till realization. The complainants have already requested the OP No.1 to pay the insured amount alongwith interest and to clear the KCC limit as well as term loan and excess amount, if any, be paid to the complainants as the complainant No.1 is nominee and other complainants No.2 to 4 are legal heirs of Pardeep Singh being widow, daughter and son respectively. There is deficiency in service and unfair trade practice on the part of OP by not settling the claim of the complainant and for demanding the KCC limit loan amount and term loan from the complainants. Hence, this complaint.

2.             On notice, OP no.1 appeared and filed its written version, raising preliminary objections with regard to maintainability; jurisdiction; locus standi; cause of action; mis-joinder and non-joinder of necessary parties; and concealment of true and material facts, etc. On merits, it is pleaded that OP had issued two accidental insurance policies to the insured subject to policy terms and conditions. Insured Pardeep Singh’s mother was nominee in the policies. The complainants approached the company for reimbursement of the accidental death claim. As per death certificate insured died on 15.04.2018. The claim was received on 17.10.2018. Post receipt of claim form, in order to analyse the claim properly the company raised query and also investigated the claim. After investigation, the claim was rejected vide denial letter dated 23.11.2020. There is no evidence that the deceased died due to fall from the height in the water. If there was such accidental incident, then the complainants have to report the  matter to the concerned police station but there is no such report lodged in the police station regarding death due to the alleged cause. In view of the policy of insurance as well as legal aspects, the present complaint is legally not maintainable and is liable to be dismissed. Hence, prayed for dismissal of complaint.

3.              OP No.2 appeared and filed its written version raising preliminary objections regarding concealment of true and material facts, barred by limitation, jurisdiction, cause of action, etc. On merits, it is pleaded that Pardeep Singh had availed loan from OP No.2 i.e. KCC Limit of Rs.30 lac in which an amount of Rs.40,94,083/- is due against him and a term loan to the tune of Rs.2 lac in which an amount of Rs.91,350/- is due against him as on 12.08.2021.  The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

4.             Parties then led their respective evidence.

5.             Learned counsel for the complainants have tendered into evidence affidavit of Ritu Rani Ex.CW1/A, copy of loan schedule Ex.C1, copy of loan agreement Ex.C2, copy of NOC Ex.C3, copy of policy Ex.C4, copy of letter dated 15.10.2020 Ex.C5, copy of postal receipt Ex.C6, copy of letter dated 15.10.2020 Ex.C7, copy of postal receipt Ex.C8, copy of letter to Kotak Mahindra Bank Ex.C9, copy of DDR Ex.C10, copy of letter to Gram Panchyat Ex.C11, copy of information letter Ex.C12.

6.             In additional evidence, learned counsel for complainants tendered affidavits of Krishan Singh Nambardar Ex.CW2/A and Sanjeev Singh Nambardar Ex.CW3/A and closed the additional evidence on 05.10.2023 by suffering separate statement.

7.             On the other hand, learned counsel for the OP no.1 has tendered into evidence affidavit of Shruti Saxena Manager, Legal as Ex.OP1/A, copy of policy certificate Ex.OP1, copy of proposal form Ex.OP2, copy of policy terms and conditions Ex.OP3, copy of policy certificate Ex.OP4, copy of letter dated 08.02.2019 Ex.OP5, copy of claim form Ex.OP6, copy of death certificate Ex.OP7, copy of letter dated 07.01.2019 Ex.OP8, copy of Reminder letter 18.05.2019 Ex.OP9, copy of reminder letter 29.05.2019 Ex.OP10, copy of reminders Ex.OP11 and Ex.OP12, copy of letter dated 08.03.2019 Ex.OP13, copy of letter dated 09.05.2019 Ex.OP14, copy of investigation Ex.OP15, copy of query reply Ex.OP16, copy of rejection letter Ex.OP17 and copy of judgment Ex.OP18 and closed the evidence on 06.07.2023 by suffering separate statement.

8.             Learned counsel for the OP no.2 has tendered into evidence affidavit of Gourav Gupta, Branch Manager, Indusind Bank as Ex.OP2/A, copy of account statement Ex.OP2/1, copy of account statement Ex.OP2/2 and closed the evidence on 08.08.2023 by suffering separate statement.

9.             We have heard the learned counsel for the parties and perused the case file carefully and have also gone through the evidence led by the parties.

10.           Learned counsel for the complainants while reiterating the contents of the complaint, has vehemently argued that the son of the complainant No.1 in the year 2015 had availed two loan facilities from OP No.2 i.e. one KCC limit and another term loan and same were insured by the OP No.1. The son of the complainant No.1 was regularly paying the EMIs of the said loans. On 15.04.2018, the son of the complainant No.1 namely Pardeep Singh died due to fall in the water accidently. The complainant No.1 and her family members are illiterate and could not get the post mortem conducted on the dead body of deceased and cremated him.  On 10.05.2018, the complainants submitted the insurance claim with the OP No.1 with the request to pay the remaining loan amount to OP No.2 but OP had denied the claim of the complainants on the ground that neither any post mortem was conducted upon the dead body of the deceased nor any FIR was lodged regarding death of Pardeep Singh. The complainants have already informed the OP that neither any post mortem was conducted nor FIR was lodged in this regard. The complainants have lodged the claim with the OP on 10.05.2018 but the OP did not entertain the claim in time and linger on the matter on one pretext or the other and alleged that the claim was submitted on 17.10.2018. in fact, the complainants have lodged the claim on 10.05.2018. He further argued that on 17.05.2017, the deceased had also taken a tractor loan from Kotak Mahindra Bank Limited and after his death, said bank, on the request of the complainants, waived off the remaining loan and issued NOC. He further argued that the deceased was hale and healthy person and was not suffering from psychiatric illness as alleged by the OP. The act of the OP No.1 while repudiating the genuine claim of the complainants amounts to deficiency in service and unfair trade practice and lastly prayed for allowing the complaint. Learned counsel for complainant has placed reliance on the cases titled as Eeta Devi Versus United India Insurance Company Limited 2015 (2) CLT 504 and Rajasthan State and others Versus Mrs.Vidhya Jha 2004 (2) CPJ 621.

11.           Per contra, learned counsel for OP No.1 while reiterating the contents of the written version has vehemently argued that OP had issued two accidental insurance policies to the insured Pardeep Singh. As per record, insured died on 15.04.2018 and claim was received on 17.10.2018. After thorough investigation, the claim was rejected vide denial letter dated 23.11.2020 by stating that there is no evidence that the deceased died due to fall from the height in the water, rather the deceased has committed suicide. If there was such accidental incident, then the complainants have to report the matter to the concerned police station but there is no such report lodged in the police station regarding death due to the alleged cause. Hence, prayed for dismissal of complaint.

12.           Per contra, learned counsel for OP No.2 while reiterating the contents of the written version has vehemently argued that Pardeep Singh had availed KCC limit of Rs.30 lac and a term loan to the tune of Rs.2 lac. More than Rs.40,00,000/- is due qua both the loans. As per terms and conditions of the loan agreements, the OP has every right to recover the loan amount either from the complainant or from the OP No.1. Hence, prayed for dismissal of complaint qua OP No.2.

13.           We have duly considered the rival contentions of the parties.

14.           Admittedly on 31.07.2015, insured namely Pardeep Singh (since deceased) availed two loan facilities from the OP No.2. It is also admitted that OP No.1 had insured the both loan amount and issued two accidental insurance policies bearing No.10348416 (Product Secure-1 as Ex.OP4 dated 31.07.2015) and policy bearing No.10347811 (Product Secure-2 as Ex.OP1 dated 31.07.2015) to the insured Mr.Pardeep Singh (since deceased) w.e.f. 30-06-2015 till 29-06-2018 for sum insured Rs.2,00,000/- and Rs.30,00,000/- respectively. It is also admitted that the complainant No.1 is the nominee in the abovesaid policies. It is also admitted that during the substance of insurance policies, loanee/insured had expired. It is also admitted that neither the post mortem on the body of Pardeep Singh was conducted nor FIR was lodged in the concerned police station.

15.           The claim of the complainants has been repudiated by the OP No.1 vide claim rejection letter Ex.OP17 dated 01.01.2020, on the following ground which is reproduced as under:-

“We have reviewed the claim filed by you pertaining to Health Insurance policy and hereby inform you that the claim is not payable as per policy terms and conditions. For ease of your perusal we have listed the reason for denial below:-

Reject: Benefits not covered. Cause of death cannot be ascertained.

Acts of self destruction or self inflicted injury. Attempted suicide, or suicide while sane or insane or any illness or injury attributable to consumption, use, misuse or abuse of tobacco, intoxicating drugs and alcohol or hallucinogens reject. Deficiency reply not received.”

16.           The claim of the complainants has been repudiated by the OP No.1 on the above-mentioned ground. On receipt of the claim form, OP raised following queries vide letters Ex.OP-5 dated 08-02-2019, Ex.OP-8 dated 07.01.2019, reminder letters Ex.OP-9 dated 18-05-2019, Ex.OP10 dated 29-05-2019, Ex.OP11 dated 18-02-2019, Ex.OP12 dated 28-03-2019, queries letters Ex.OP13 dated 08-03-2019 and Ex.OP14 dated 08-05-2019. In all queries and reminders, OP raised the queries which are reproduced as under:-

• Provide Spot Panchnama report.
• Provide police final Investigation report duly signed and stamped by Court Magistrate.
• Provide Post Mortem Report with exact cause of death.
• Provide details of any other insurance company.
• Provide previous consultation papers for psychiatric illness with.
• First consultation paper since when patient diagnosed for same.
• Provide Loan account statement with breakup of outstanding balance NEFT detail of loan account.
• Provide the certificate from attending doctor for the exact cause of death.
• Provide previous consultation for treatment of critical illness.

 

17.           The complainants had informed the OP in the beginning that neither spot panchnama has been prepared at the spot, nor any FIR had been lodged, nor post mortem was conducted upon the dead body of the deceased. The Insured (now since deceased) was never treated by any doctor for any critical illness or psychiatric illness and had not taken any other health policy from any other insurance company. Hence, the question for raising and demanding the above-mentioned information does not arise at all.

18.           It is pertinent to mention here that on 17.05.2017, the deceased had also taken a vehicle (tractor) loan from Kotak Mahindra Bank Limited. Information with regard to death of loanee was given to the concerned bank and bank after verifying the facts, waived off the remaining loan amount and issued clearance slip dated 18.09.2018. This fact has been proved from the agreement schedule Ex.C1, loan agreement Ex.C2 and clearance slip Ex.C3. These documents have not been rebutted by the OPs.

19.           Insured died on 15.04.2018 due to falling in village pond. As per the version of the complainants, they had submitted the insurance claim on 10.05.2018 with the OP No.1. On the other hand, as per the version of OP No.1, the claim form was received by the company on 17.10.2018. The Kotak Mahindra Bank Limited had issued NOC on 18.09.2018 with regard to vehicle (tractor) loan and from the said NOC it has been proved that the complainants should have applied for waiving of loan with Kotak Mahindra Bank prior to 18.09.2018 and then as to why they have not submitted the waiving of loan request to the OPs in time. Hence, the plea taken by the OP that the complainants had submitted the claim for waiving of loan amount on 17.10.2018 has no force.

20.           The OP alleged that, as per the AVR (Vicinity check), insured had psychiatric problem and he had committed suicide by drowning in the pond. The family members of the insured kept him locked in a room due to his psychiatric issues and on that very day he escaped from the room and jumped in the pond. The AVR sufficiently proves that this was not an accidental death, instead, this was a suicide.

21.           The onus to prove its version was relied upon the OP but OP failed to prove its case by leading cogent and convincing evidence. The case of the OP is only based upon AVR (Vicinity Check) but OP has failed to place on file the alleged AVR (Vicinity check) to prove its version. There is nothing on file to prove that the insured/deceased was suffering from psychiatric problem and due to that problem he had committed suicide. The persons from whom the AVR (Vicinity Check) was conducted by the OP are not disclosed/examined. Rather to prove his case, learned counsel for complainant has tendered affidavit of complainant No.2 Ex.CW1/A and also tendered affidavits of two Nambrdars of the same village, namely Krishan Kumar, Ex.CW2/A and Sanjeev Kumar, Ex.CW3/A. Nambardars of the village are responsible persons and they cannot tender false affidavits. In their affidavits they have specifically stated that insured died accidently due to fall in water pond on 15.04.2018. They further stated in their affidavits that the death was not suspicious one and due to that reason neither matter was reported to the police nor the post mortem was conducted on the dead body of the insured. The DDR Ex.C10 was also recorded by the abovesaid Nambardars and Sarpanch of the Rahra Village. In the said DDR it has been specifically mentioned that the insured had died accidently by falling in the pond. The OP has not examined any witness to rebut the version of the above said witnesses of the village.

22.           Generally, in rural area people go for answering nature’s call in the fields and after finishing the job they go to the pond for cleaning and washing hands if there is no water available in the field. May be the deceased person has gone for the same purpose and slipping/unbalancing and falling in the pond during the course of cleaning and washing of hands cannot be ruled out.

23.           The OP has alleged that without conducting the post mortem on the dead body of the insured, the cause of death can not be ascertained. The insured had expired due to drowning in a pond. If the postmortem was conducted the cause of death would have been the same i.e. due to drowning. Hence, the plea taken by the OP has no weightage at all.   

24.           The OP has tendered the affidavit of Shruti Saxena, Manager, Legal as Ex.OP1/A. In the said affidavit, she has stated that the company triggered claim investigation for better analysis of the claim. The claim was rejected on permanent exclusion of alcohol. As per the statement of complainant’s brother, he used to consume alcohol (one or two peg) for the last 2-3 years.  The claim was rejected on 23.11.2020. The OP has also placed on file affidavit of Rajinder Singh (brother of deceased/insured), wherein, he has specifically mentioned that his brother Pardeep Singh expired on 15.04.2018 due to drowning. It appears that no statement as alleged by the Manager of the OP has ever suffered by the brother of the deceased and the affidavit tendered by the Manager of OP is only on the ground of presumption and assumption and no investigation was conducted by the OP.

25.           Generally, at the time of sanctioning the huge loan amount and getting the loanee insured, the sanctioning bank as well as insurance company medically examine the person and if the loanee is not found fit or suffers from any disease/illness,  neither the loan is sanctioned nor the insurance policy is issued. It is not the case of the OPs that at that time, they had not medically examine the loanee/insured. Thus, it proves that at that time, loanee was medically examined and found to be hale and hearty.    

26.           Moreover, if for the sake of arguments, it is presumed that complainants have violated the terms and conditions of the insurance policy, in that eventuality, the claim of the complainants cannot be repudiated in toto.  In this regard, we relied upon the case laws titled as Amalendu Sahu Vs. Oriental Insurance Company Limited, in Civil appeal no.2703 of 2010, decided on 25.03.2010 of Hon’ble Supreme Court of India; New India Assurance Co. Ltd. Versus Thirath Singh Brar in Revision Petition no.1870 of 2015(NC) decided on 14.08.2018 titled as of Hon’ble National Commission and authority of our own Hon’ble State Commission in First Appeal no.717 of 2016 decided on 6.4.2017 titled as United India Insurance Company Limited and others Versus Anshul Bansal.  In all the judgments it was held that in case of any breach of warranty/condition of the policy the insurer is liable to pay 75% of admissible claim on non-standard basis.

27.           Further,  Hon’ble Punjab and Haryana High Court in case titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, has held as under:-

“It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy”.

28.           Keeping in view the ratio of the law laid down in the abovesaid judgments and the facts and circumstances of the complaint, we are of the considered view that the act of the OP amounts to deficiency in service and unfair trade practice while repudiating the claim of the complainants in toto. Hence, complainants are entitled to get 75% only of the insured amount on non-standard basis. The loan amounts are Rs.32 lacs (Rs.2,00,000/- and Rs.30,00,000/-), hence the OP No.1 is liable to pay 75% of the insured amount alongwith interest, compensation on account of mental agony and harassment and litigation expenses, etc.

29.           The deceased had availed loans facilities from the OP No.2. As per the account statement Ex.OP2/1 and OP2/2, more than Rs.40,00,000/- is outstanding towards both the loans. It is financier who has first right to recover the loan amount. Hence, the awarded amount be paid to the OP No.2 (being financier) by the OP No.1 (being insurer). 

30.           In view of the above discussion, we partly allow the present complaint and direct the OP No.1 (being insurance company) to pay Rs.24,00,000/- (i.e. 75% of the insured amount of both the insurance policies) to OP No.2 (bank being a financier) alongwith interest @ 9% from the date of filing of complaint till its realization. We further direct the OP No.1 to pay Rs.25,000/- to the complainants on account of mental agony and harassment suffered by them and Rs.11,000/- for the litigation expenses. The OP No.2 is also directed not to impose unnecessary penalties/ charges on the outstanding loan amount and after receiving the remaining loan amount issue NOCs to the complainants. This order shall be complied within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

 

Announced

Dated: 03.01.2024

                                                                       

                                                          President,

                                             District Consumer Disputes

                                             Redressal Commission, Karnal.

 

(Vineet Kaushik)        (Dr. Suman Singh)

                          Member                            Member