Tamil Nadu

South Chennai

CC/35/2022

Mrs. G. Kalpana, - Complainant(s)

Versus

The General Manager, TATA AIG General Insurance Company Limited and 3 others - Opp.Party(s)

M/s. P. Anbarasan

28 Mar 2023

ORDER

                                                    Date of Complaint Filed : 30.09.2021

                                                    Date of Reservation      : 13.03.2023

                                                    Date of Order               : 28.03.2023

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

CHENNAI (SOUTH), CHENNAI-3.

 

PRESENT:    TMT. B. JIJAA, M.L.,                                                 : PRESIDENT

                       THIRU. T.R. SIVAKUMHAR, B.A., B.L.,                 :  MEMBER  I 

                       THIRU. S. NANDAGOPALAN., B.Sc., MBA.,          : MEMBER II

 

CONSUMER COMPLAINT No.35 /2022

TUESDAY, THE 28^th DAY OF MARCH 2023

Mrs. G. Kalpana,

W/o. Late Mr. Gowdhaman K,

90/28, D Block, MMDA Colony,

Arumbakkam,

Chennai-600 106.                                                                                                                            ... Complainant                

..Vs..

1.The General Manager,

   TATA AIG General Insurance Company Limited,

   A-501, Building No. 4. IT Infinity Park.

   Dindoshi, Malad (E. Mumbai),

   Maharashtra - 400097.

 

2.The Branch Manager,

   TATA AIG General Insurance Company Limited,

   2^nd Floor,Samson Towers,

   403 L Pantheon Road,

  Egmore, Chennai-600 008.

 

3.The General Manager,

   PNB Housing Finance Limited,

   9^th Floor, Antriksh Bhawan,

   22, Kasthurba Gandhi Marg,

   New Delhi-110 001.

 

4.The Branch Manager,

   PNB Housing Finance Ltd,

   3^rd Floor, Sudharshan Building,

   14, Whites Road, Royapettah,

   Chennai-600 014.                                                                                                                           …  Opposite Parties

******

Counsel for the Complainant                   : M/s. P. Anbarasan

Counsel for the 1^st & 2^nd Opposite Parties  : M/s. M.B Gopalan Associates

Counsel for the 3^rd & 4^th Opposite Parties  : Exparte

 

On perusal of records and upon treating the written arguments as oral arguments on endorsement made by the Complainant and after having heard the oral arguments of the Counsel for the 1^st & 2^nd Opposite Parties,  we delivered the following:

ORDER

Pronounced by Member-I, Thiru. T.R. Sivakumhar., B.A., B.L.,

1.      The Complainant has filed this complaint as against the Opposite Parties under section 35 of the Consumer Protection Act, 2019 and prays to direct the Opposite Parties to approve the claim of the Complainant under claim No.0821622287A with respect to Master Policy No.0235987720 and release the insured sum of Rs.38,50,000/- and the home protection benefit of Rs.3,85,000/- towards the Complainant’s home loan  and to pay a sum of Rs.10,00,000/- towards compensation for mental agony and financial loss.

2.     The averments of Complaint in brief are as follows:-

        The Complainant’s husband, Late Mr. Gowthaman K, had availed a housing loan from the 3^rd Opposite Party herein to purchase a house. The 3^rd Opposite Party directed her husband to obtain an insurance cover from the 1^st Opposite Party herein. Therefore, on the said advise, her husband availed a Group Credit Secure Plus insurance, a life insurance policy, bearing Master Policy No. 0235987720 for a period of five years from 13.07.2018 to 12.07.2023 from the Opposite Party herein and she is the nominee under the said policy. Her husband was also duly paying the premium thereof and the insured sum was Rs. 38,50,000/-. The said policy was mainly availed by her husband as it was a home protection policy and he was assured that,  in  the

event of anything untoward happes to her husband, the home loan availed by him from PNB Housing Finance Limited under Loan Account No. HOU/AMB/0318/502285 shall be covered under the said insurance policy and it was only on the said pretext that, her husband had even opted for the said policy, despite the premium being an additional and excessive liability. While things stood so, suddenly, due to serious illness, her husband, the insured, passed away on 27.05.2019 she was left in the lurch and was put to great hardship due to the sudden and untimely death of her husband, wanting to protect their home purchased from their hard earned money, intimated the Opposite Party's office of the death of her husband and filed a claim as against the said Master Policy No. 0235987720, with the Opposite Party herein, under Claim No. 0821622287A and the same was duly received by the Opposite Party. To her utter shock and dismay she came to receive a reply dated 01.11.2019 from the Opposite Party, declining the claim, stating that, as per the Medical Certificate, the Insured had died of sickness and that, since he had not opted for critical illness benefit under the policy, the Opposite Party will not assume any liability for the claim made with respect to the said Master Policy, which put her to undue difficulty. Moreover, in the meantime, due to the loss of income, she was also not in a position to pay the dues for the home loan availed by her husband and therefore, the Opposite Party was pleased to declare the said Home Loan Account as a Non Performing Asset and commence proceedings under the SARFAESI Act, apart from having obtained an Arbitral Award dated 15.09.2020, vide exparte proceedings held at New Delhi, during the pandemic. Moreover, the Arbitral proceedings have been continued with and an award was obtained despite the death of the original borrower ie. her husband, which shows, the intention of the 3^rd Opposite Party is only to knock away the house property by hook or by crook. She was under the bonafide hope that the house will be protected by the policy availed from the Opposite Party under any circumstance, has now been made to run from pillar to post to secure their house. She had tried approaching the Opposite Party repeatedly because, the policy was availed only under the bonafide belief that, in the event of the death of the insured under any circumstances, the house will be protected and in fact, the Opposite Party had assured them of the same. However, taking advantage of their limited knowledge as laymen to insurance, both the Opposite Parties herein had set out only accidental death cover under the policy. But, the policy availed i.e. Group Credit Secure Plus is a policy that includes death from critical illness as well as personal accident cover. In fact, even under the General Exclusions set out in brochure of the policy at Section 4, what is excluded is

"1. Any Pre-existing Condition, or its related conditions arising from it, or

2. Any Critical Illness or covered Disease/Illness/Sickness of which, the signs or symptoms first occurred within ninety (90) days following the first risk inception date. This 90 days period shall not be applicable on renewals to the extent of sun insured under the previous policy or

3. Any Critical Illness resulting from a physical condition which existed prior to first risk inception date which was not disclosed"

Hence, they were of the bonafide belief and impression that, accidental death would mean any sudden death. In fact, it is only because cover for illness is covered under the policy availed, the 1^st Opposite Party seeks that medical history should be informed and in fact, the policy document itself states that, if any medical condition has not been informed, the same may be duly informed. Under the said policy documents, one of the additional covers set out in home protection benefit for a sum of Rs.85,000/-, which would go to show that, the very intent of the policy in to protect the house by paying up the loan, in case of any personal incident as well as critical illness, which was clear from the Group Credit Secure Plus Policy's brochure that has been provided to her husband. The Opposite Party, being a company with high reputation they were under the bonafide belief that their right and interest would be well protected, but the 1^st Opposite Party has misled her husband and engaged in an unfair practice by denying her claim. She had been subjected to undue financial loss and hardship due to such act of the Opposite Party. Due to such denial and delay by the 1^st Opposite Party, the interest on the home loan has been accumulated and this has also caused her serious mental agony. Her repeated attempts to approach the 1^st Opposite Party and get the claim approved have ended in vain and the 1^st Opposite Panty has remained evasive, callous and indifferent. Hence, left with no other alternative, she had caused a legal notice dated 08.09.2021 to the Opposite Parties and the same has been duly delivered to the Opposite Parties, but nothing has forth come from the Opposite Parties despite the same. Hence the complaint.

3. Written Version filed by the Opposite Parties 1 and 2 in brief is as follows:-

 The submissions of the Opposite Parties 1 and 2 were that the opposite parties 3 and 4, financial institution involved in the business of extending housing loan, had availed Group Credit Secure Plus insurance for their customers. Coverage under the said policy was subject to risks stipulated therein subject to terms and conditions which constitute the contract between the parties. The Policy contemplates Critical Illness, Personal Accident and various Additional Covers subject to payment of necessary premium but the choice of the nature and extent of coverage including the tenure is of the customers at the time of enrolment in the Group Policy. The choice of the customer is reflected in the individual Certificate of Insurance specifying the nature of coverage obtained. Every customer availing the benefit of the group insurance is entitled to coverage as per the terms of the policy and cannot claim any benefit beyond the same. The Complainant who was the borrower of housing loan from the Opposite Parties 3 & 4 had enrolled in the Group Policy covering her husband Mr.K.Gowthaman for Personal Accident cover alone without opting for Critical Illness cover as is reflected by the Certificate of Insurance filed by the Complainant herself. The coverage was obtained for tenure of 5 years from 13.07.2018, the total sum insured was equivalent to the loan amount of Rs.38,50,000/-, the Certificate specifically stipulates the respective Sum Insured for each cover. The Complainant never disputed the nature of insurance that had been availed by her without Critical Illness Coverage, nor denied any knowledge of the terms and conditions of the insurance before the claim or at any relevant point of time. Though the Complainant has referred to the brochure for the insurance explaining the nature of coverages, the Complainant has not filed even the same before this Hon'ble Commission, obviously to mislead and create confusion by self-serving arguments. The Complainant's husband/Insured had died on 23.05.2019. On examination of the records submitted it was found that the death was due to illness and was not accidental death as covered under the Certificate of Insurance availed by the Complainant. Since the Complainant's husband had died due to illness and not due to accident, they had justifiably declined liability for the claim. Their decision was in accordance with the terms and conditions of the policy which cannot be construed as deficiency in service. The Complainant is bound by the Certificate of Insurance read with the relevant terms and conditions of the Group Policy and cannot claim for death which has not occured due to accident. The additional covers of the policy also do not apply in the present case. The Complainant cannot introduce new explanations of purpose to sustain an otherwise inadmissible claim. The reference to "home protection" is misleading and frivolous.  She admits that death of her husband was due to illness. Hence they declined liability since the Policy availed by Complainant covered only death due to  accident. Action by the Opposite Parties 3 & 4 cannot be the basis of claim under the Policy without reference to the actual terms and conditions. The allegations that the 2^nd Opposite Party trying to knock off the house of Complainant is meaningless as also the allegation that the Policy would protect the house. They can only entertain and settle claims within the terms and conditions of the Policy irrespective of Complainant's misfortunes. The Complainant cannot attempt to distort and expand the nature of coverage by pleading to have limited knowledge of insurance. The allegations of Group Credit Secure Plus Policy having cover for death from Critical Illness as well as Personal Accident is misleading, would also show that the Complainant's knowledge of the Policy terms and conditions, the fact remains that the Complainant had chosen only to avail Personal Accident covers and not Critical Illness cover evidently perceiving no risk of Critical Illness.The Group Policy refers to all the benefits available generally, each involving higher premium. The choice of the covers based on the appropriate premium is decided at the time of insurance by the customer and the Complainant opted for PA cover alone when enrolling for the Group insurance. If Critical Illness cover had been opted, they would have the benefit of higher premium, which they have foregone due to the choice of PA cover alone by the Complainant. The reference to certain exclusion only shows that the Complainant has fully knowledge of all terms and conditions of the Policy. Further quoting some clause of Exclusion out of context cannot create a coverage for Critical Illness benefit under the Policy which would be evident if the entire Policy terms and conditions placed before this Hon'ble Commission. The Complainant was called upon to produce the entire terms and not to suppress the same. The plea of bona fide belief is vehemently denied and self-serving. By such untenable pleading the Complainant cannot create a new contract or stretch the benefits of the actual insurance obtained by her. The "home protection benefit" is a caption which cannot be understood without looking at the terms. A perusal of the terms of the said benefit would reveal that it covers contents of premises during travel by the Insured and has no relevance to the Complainant's claim. The various reliefs sought are unsustainable. They are not liable for insured sum of Rs.38,50,000/- since the Complainant's husband had not died due to accident as specifically covered under the Group Policy evidenced by the Certificate of Insurance of the Complainant. The home protection benefit of Rs.3,85,000/- is also not payable as there is no loss of contents of home during travel and no such claim as per the coverage was ever made. Hence prayed to dismiss the complaint.   

4.The Complainant submitted his Proof Affidavit and Written Arguments. On the side of the Complainant, documents were marked as  Ex.A-1 to Ex.A-7. The 1^st and 2^nd Opposite Parties submitted their Proof Affidavit and Written Arguments. On the side of 1^st and 2^nd Opposite Parties documents were marked as Ex.B-1 to Ex.B-2.

5.  The 3^rd and 4^th Opposite Parties did not appear before this Commission even after sufficient notice was served on them and remained absent. Hence the 3^rd and 4^th Opposite Parties set exparte on 05.05.2022.

Points for Consideration:-

1. Whether there is deficiency in service on the part of the Opposite Parties?

2. Whether the Complainant is entitled for reliefs claimed?

3. To what other reliefs the Complainant is entitled to?

Point No.1:

        It is an undisputed fact that the Complainant’s husband deceased Mr.Gowthaman.K, had availed a housing loan from the 3^rd Opposite Party in securing the said housing loan, the Complainant’s husband had availed a Group Credit Secure Plus Insurance bearing policy No.0235987720 for a period of five years from 13.07.2018 to 12.07.2023 from the 1^st and 2^nd Opposite Parties.  It is also not in dispute that the sum assured in the said policy was Rs.38,50,000/-.  It is also not in dispute that the Complainant’s husband, the insured, died on 27.05.2019 due to sickness.

        The disputed fact of the Complainant is that she had submitted a claim form to the 1^st and 2^nd opposite parties under claim No.082162287A claiming the death benefits under the above said insurance policy availed from the 1^st and 2^nd opposite parties and by letter dated 01.11.2019 the claim made by the Complainant was rejected stating that as the insured had died due to sickness and since he had opted for critical illness benefit under the policy,  the 1^st and 2^nd opposite parties were not liable for the claim. The Complainant and her husband with bonafide belief and impression that accidental death would mean sudden death opted for the policy and as per brochure even under Section 4 of the exclusion clause of the policy, under general exclusions only pre-existing disease, critical illness or covered disease/illness/sickness of which the signs or symptoms first occurred within 90 days and the critical illness resulting from a physical condition which existed prior to first risk inception date which was not disclosed were exempted and the policy provides for critical illness as well as personal accident cover.  Further the very availment of the policy itself is to protect their property from housing loan in case of any untoward incident happens in case of any personal accident as well as critical illness, but the 1^st Opposite Party had misled and engaged in unfair trade practice without protecting their rights and interests.  Further contended that after the death of her husband the interest could not be paid, the 3^rd & 4^th opposite parties had declared the loan account as Non Performing Assets and had proceeded as per SARFAESI Act and had initiated arbitral proceedings and had obtained an Award.

        The contention of the 1^st and 2^nd opposite parties are that the base cover under the policy availed by the Complainant’s husband was for personal accidents and permanent disability and the sum assured was Rs.38,50,000/- towards the same and as additional cover of Home Protection Benefit.  The Complainant herself had admitted about the coverage of policy was towards personal accident and the policy document filed by the Complainant would also clearly speaks about the same.  Further contended that the bonafide belief and impression that any sudden death is an accidental death and as the Complainant’s husband died because of illness which is covered under the policy were absolutely denied, as the Complainant and her husband had clear knowledge about the policy coverage as well as the terms and conditions of the policy.  Further contended that the home protection benefit was given as additional cover does not mean far paying/clearing the outstanding loan and would only apply and covers the contents of premises during travel by the insured.           

         On discussion made above and on considering the facts and circumstances of the case, it is clear from Ex.A-1 Group Credit Secure Plus certificate of insurance  bearing Master Policy No.0235987720 covering from 13.07.2018 to 12.07.2023 and the coverage is for accidental death, permanent disability with an additional cover of home protection benefit to the sum assured of Rs.38,50,000/- and does not cover Critical Illness. From Ex.A-7  Policy Wordings under standard definitions Accident means a sudden unforeseen and in voluntary event caused by external visible and violent means and under Clause 2.2: Personal Accident, P-1  Accidental Death: defined as “ If an insured person suffers an accident during the policy period and this in the proximate cause of his death within 365 days from the date of accident, then we will pay the base sum assured”.  P2- Permanent Total Disability: “we will pay the base sum insured shown in the policy schedule/certificate of insurance if injury to you results in you suffering Permanent Total Disability.  The injury may occur within the policy period as mentioned in the policy schedule certificate of insurance and the disability should continue for 365 days from the date of accident which caused the injury.  This waiting period of 365 days is not applicable for severance or  amputation cases. And under clause D of the terms and conditions of the said policy, under Free Look period, it was mentioned that “you have a period of 15 days from the date of receipt of the Policy document to review the terms and conditions of this Policy. If you have any objections to any of the terms and conditions, you have the option of cancelling the Policy stating the reasons for cancellation and you will be refunded the premium paid by you after adjusting the amounts spent on any medical check-up, stamp duty charges and proportionate risk premium. You can cancel Your Policy only if you have not made any claims under the Policy. All your rights under this Policy will immediately stand extinguished on the free look cancellation of the Policy. Free look provision is not applicable and available at the time of renewal of the Policy”.

         From Ex.B-2 in page No.39 Group Credit Secure Plans Additional covers terms under E7(E) Home Protection Benefit, 1. What we cover, When the entire cost of the passenger fare(s) of a trip are charged to your payment card or paid otherwise while the insurance is effective, we will cover the damage, disappearance or destruction of the following terms due to burglary at your residence during your trip travel time:

1.your furniture, clothes, applicances

2.Your money and cheque(s)

     Hence, from Ex.A1 Insurance Policy availed by Complainant’s husband as well as Ex.A-7, Ex.B-1 and Ex.B-2 being the policy wordings and terms and conditions of the policy, the repudiation/rejection made on 01.11.2019, Ex.A-3 by the 1^st and 2^nd opposite parties is legally sustainable, as the Complainant had not produced any authenticated evidence to establish the cause of the death of her husband, namely Late Gowthaman,covered under the said policy and to disprove the repudiation/rejection made as per Ex.A-3. Therefore this Commission is of the considered view that there is no deficiency of service on the part of 1^st and 2^nd opposite parties.  As there is no cause of action and as no relief sought for against Opposite Parties 3 and 4, the complaint against Opposite Parties 3 and 4 is dismissed as not maintainable.  Accordingly Point No.1 is answered. 

Point Nos.2 and 3. 

       As discussed and decided Point No.1 against the Complainant, the Complainant is not entitled for the reliefs claimed in the complaint and also not entitled for any other reliefs.  Accordingly Point Nos.2 and 3 are answered. 

          In the result the complaint is dismissed. No costs.

Dictated to Steno-Typist, transcribed and typed by her, corrected and pronounced by us in the Open Commission, on 28^th of March 2023.

 

 

S. NANDAGOPALAN               T.R. SIVAKUMHAR                 B.JIJAA

         MEMBER II                       MEMBER I                        PRESIDENT

 List of documents filed on the side of the Complainant:-

Ex.A1	13.07.2018	Copy of Certificate of Insurance
Ex.A2	01.07.2019	Copy of Death certificate of Mr.Gowthaman
Ex.A3	01.11.2019	Copy of Rejection of claim
Ex.A4	15.09.2020	Copy of Arbitral Award
Ex.A5	04.08.2021	Copy of Possession Notice
Ex.A6	08.09.2021	Copy of Legal Notice with acknowledgement
Ex.A7	-	Copy of Group Credit Security Plus Policy Wordings

List of documents filed on the side of the 1^st & 2^nd Opposite Parties:-

Ex.B1		Group Credit Secure Plus Terms
Ex.B2		Group Credit Secure Plus Additional covers terms

 

List of documents filed on the side of the 3^rd & 4^th Opposite Parties:-

 

NIL

S. NANDAGOPALAN               T.R. SIVAKUMHAR                    B.JIJAA

         MEMBER II                       MEMBER I                         PRESIDENT