Haryana

StateCommission

A/540/2016

HDFC ERGO GEN.INSURANCE CO. - Complainant(s)

Versus

SUDESH - Opp.Party(s)

VISHYAL AGGARWAL

03 Jan 2017

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeal No  : 540 of 2016

Date of Institution: 10.06.2016

Date of Decision : 03.01.2017

 

1.      HDFC ERGO General Insurance Company Limited, Corporate Office, 6^th Floor, Leela Business Park, Andheri Kurla Road, Andheri East, Mumbai -400059 and at 5^th Floor, Tower 1, Stellar IT Park, C-25, Sector 62, Noida-201301 through Pankaj Singh.

2.      HDFC ERGO General Insurance Company Limited, First Floor, HDFC Bank, Near D Park, Model Town, through Pankaj Singh.

                                      Appellants-Opposite Parties

Versus

 

Sudesh wife of Sh. Tejbir Singh son of Sh. Nafe Singh, resident of House No.273, Subhash Nagar, Rohtak.

Respondent-Complainant

 

CORAM:             Hon’ble Mr. Justice Nawab Singh, President.

                             Shri B.M. Bedi, Judicial Member.

                             Shri Diwan Singh Chauhan, Member   

 

Argued by:          Sh. Vishal Aggarwal, Advocate for the appellant.

                             None for the respondent

 

                                                   O R D E R

 

NAWAB SINGH J, (ORAL)

 

          Tejbir Singh, deceased purchased Sarv Suraksha Plus Policy (Exhibit C-13) on February 23^rd, 2011 for a period of 60 months.  The policy was to expire on February 22^nd, 2016.  He died on March 21^st, 2011 vide Death Summary (Exhibit C-1) issued by Sonia Hospital, Nangloi, Delhi due to Massive (Myocardial Infarction)-heart attack.  His widow Sudesh-complainant filed claim before HDFC ERGO General Insurance Company Limited-opposite parties (for short, ‘Insurance Company’).  The claim was repudiated on the ground that Tejbir Singh was not covered as per clause 2 of Specific Exclusions applicable Section 1 of the policy.  The complainant filed complaint under Section 12 of the Consumer Protection Act, 1986 before the District Consumer Disputes Redressal Forum, Rohtak (for short, ‘District Forum’).

2.      The District Forum allowed the complaint and directed the Insurance Company to pay Rs.5,00,000/- alongwith interest at the rate of 9% per annum from the date of filing of the complaint till realization and Rs.3500/- litigation expenses to the complainant.

3.      Aggrieved of the order, Insurance Company has filed the present appeal.

4.      Notice was issued to the complainant on September 14^th, 2016. Shri Surya Partap, Advocate appeared for the complainant.  The case was adjourned to October 31^st, 2016 for arguments but none appeared on behalf of the complainant.  Still, in the interest of justice, the case was adjourned to January 03^rd, 2017 for arguments.  Today also, nobody appeared on behalf of the complainant. This Commission thinks it appropriate to decide the appeal on merits after hearing learned counsel for the Insurance Company and going through the case file.

5.      Vide insurance policy (Exhibit C-13), Coverage details is as under:-

Section No	Benefit	Coverage Parameters	Sum Insured (Rs.)
1	Critical Illness	Self	1,00,000
2.1	Accidental Death	Self	5,00,000
2.2/2.3	Permanent Total Disability/Permanent Partial Disability	Self	5,00,000
3	Accidental Hospitalisation	Self	1,00,000
4	Loss of Job	Self	3 EMI’s
5	Credit Shield Insurance	Self	Outstanding Loan Amount
6	Householders Coverage	Self	1,50,000
7	Garage Cash	Self	3,500

 

6.      The illness which are not covered under the policy is mentioned under the heading Critical Illness Coverage.  Specific Exclusions Applicable to Section 1 of the Insurance Policy (Exhibit C-13) reads as under:-

          “No payment will be made by the Company for any claim directly or indirectly caused by based on arising out of a howsoever attributable to any of the following:

1. Any Critical Illness for which care, treatment or advice was recommended by or received from a Physician, or which first manifested itself or was contracted before the start of the Policy Period or for which a claim has or could have been made under the earlier policy.
2. Any Critical Illness diagnosed within the first 90 days of the date of commencement of the Policy is excluded.  This exclusion shall not apply to an Insured for whom coverage has been renewed by the Named Insured, without a break for subsequent years.
3.      xxxxxxxxx
4.      xxxxxxxxx
5.      xxxxxxxxx
6.      xxxxxxxxx
7.      xxxxxxxxx
8.      xxxxxxxxx
9.      xxxxxxxxx
10. xxxxxxxxx
11. xxxxxxxxx

      

7.      First Heart Attack (Myocardial Infarction) is critical illness as mentioned in Section 1: Critical Illness of the insurance policy (Exhibit C-13).  A reading of the aforesaid clause shows that if the Insured dies on account of heart attack, that is, critical illness within the first 90 days of the commencement of the policy, the Insurance Company is not liable to indemnify the Insured under the said policy.  Indisputably, the Insured died on March 21^st, 2011, that is, after 26 days of the commencement of the policy, so, the complainant was not entitled for the benefits of insurance.  The appeal is accepted, impugned order is set aside and the complaint is dismissed. 

8.      The statutory amount of Rs. 25000/- deposited at the time of filing the appeal be refunded to the appellant against proper receipt and identification in accordance with rules.

 

Announced 03.01.2017

(Diwan Singh Chauhan) Member

(B.M. Bedi) Judicial Member

(Nawab Singh) President

UK