As per Hon’ble President. Mr. Atul Alshi.
1. The complainant has filed this compliant against OP for repudiation of insurance claim for the reason of the deceased ailment does not cover under medical illness section of policy as the ailment does not critical illness as per exclusion claim of policy and thereby claim the sum assured alongwith compensation of Rs.25,000/- and cost of litigation. The complaint’s complaint in short as under-
2. The complainant is legal heir of deceased her husband Satish Punje and OP No. 1 insurance company and OP No. 2 is finance company. The deceased had raised loan from OP No. 2 finance company to construct house of Rs.13,00,000/- for security of loan amount. The loan is insured under Home Suraksha Policy which had been purchased from OP No.1. On 21.08.2018 the complainant’s husband died for the reason brain tumor. The complainant had submitted insurance claim with OP alongwith documents but OP No. 1 repudiated insurance claim for the reason of the deceased ailment is not cover under major medical illness of section 3 of the policy specified the said ailment is not covered and payable under the policy as major medical illness as per repudiation letter issued the complainant on 11.10.2018. As per medical case summary of insured rejection of claim arbitrarily does amounts deficiency of service, therefore, this complaint is filed.
3. OP No. 1 submitted reply and denied allegations and admitted insurance policy to cover Home Suraksha Plus covering major medical illness and said policy is linked with home loan account. As per section 3 of 1.2 of terms and conditions of policy the deceased policy is insured for Rs.11,06,165/- for various illness which are mentioned below- cancer, Renal failure end stage, multiple sclerosis, major organ transplant, heart valve replacement, coronary artery bypass graft, stroke, paralysis, Myocardial infarction and other disease are specially excluded therefore, the claim of above 9 specified illness only are payable. The 9 critical illnesses has specifically mentioned in policy. The deceased was treated benign nerve sheath tumor and said ailment is not cover under major illness section 3 as not critical illness and therefore as per policy exclusion clause the insurer is not payable. Therefore, rejection of insurance claim does not amount to unfair practice on the part of OP No, 1.
4. The OP No. 2 is finance company and therefore OP No. 2 has right to recover loan amount as per provision of law. The OP No. 2 no role in adjudication of insurance claim hence OP No. 2 is not necessary party. The OP No. 2 has right to recover outstanding loan amount under SARFAISI Act. Hence, case is liable to dismissed.
5. The counsel for complainant argued that the OP No. 1 has not supplied the terms and conditions of policy at the time of purchasing of policy. As per Home Suraksha Plus policy, the coverage details has mention major illness and procedure and therefore, the deceased illness is tumor and it cover under the policy therefore rejection of insurance claim arbitrarily does amounts unfair practice on the part of OP No. 1.
6. The counsel for OP No, 1 argued that as per terms and condition of policy the deceased illness of tumor does not cover the ailment mentioned in critical illness category therefore the benefit of policy cannot be payable to decease therefore rejection of claim does not amounts deficiency of service and unfair practice.
7. The OP No. 2 argued that OP No. 2 has no role in adjudication of claim and OP No. 2 has right to recover outstanding loan as per provision of law. Therefore, the complaint may be dismissed against OP No. 2.
8. Both the parties argued the case on merit at length. After hearing of case the following points arose for consideration.
POINTS FINDINGS
1) Whether the complainant is consumer ? Yes.
- Whether there is deficiency in service on the part of OP? Yes.
- What order ? As per final order.
REASONING
9. Point No. 1 to 3 - The complainant availed housing loan of Rs.13,00,000/- from OP No. 2 and for security of loan amount the insurance policy has been purchased from OP No. 1 for sum assured Rs.11,06,167/- under coverage of major medical illness. The OP No. 1 has issued policy bearing no. 29182013647354000 for the period 31.03.2016 to 30.03.2021 to the deceased complainant husband is against the premium paid Rs.1,06,167/. The cause of death of complainant’s husband is tumor. Under the key benefits of Critical illness mention in annexure of policy (a) to (i) the sum assured is payable for 9 critical illness and procedure only. The sum assured mentioned in 9 critical ailments and the sum insured is payable upto maximum loan amount only. But it has not mentioned in policy that the sum assured is payable or restricted on 9 critical illnesses only. On the other hand on the first basic documents of policy it has been mentioned that the sum assured for the major medical illness and procedure is payable Rs.11,06,165/-, therefore, the contention of OP no. 1 that complainant’s husband death occur due to tumor is not covers under policy cannot be accepted. Moreover the OP No.1 failed to file the evidence of doctor on affidavit that the death of complainant’s husband does not coming under any major illness and therefore the complainant is entitled to sum assured in the policy payable Rs.11,06,165/- alongwith compensation for mental torture of Rs.25,000/- and cost of litigation Rs.10,000/-.
Therefore, the commission passes following order.
ORDER
- The complaint is partly allowed.
2. The OP No. 1 is hereby directed to pay insurance claim amount of Rs.11,06,165 to the complainant.
3. The OP No.1 is further directed to pay Rs.25,000/- towards mental torture and Rs.10,000/- for towards litigation charges to the complainant.
4. The OP No.2 has no role in adjudication of insurance claim hence no order is passed against OP No.2.
5. Copy of the order shall be supplied to all the parties free of cost.
