::BEFORE THE DISTRICT CONSUMER DISPUTES  REDRESSAL COMMISSION AT BIDAR::

                                                                    C.C. No.37/2022.

                                                                                                                                 Date of filing: 01.04.2022

                                                              Date of disposal: 03.06.2023.

P R E S E N Ts:-    

                                (1) Shri. Mabu Saheb H.Chabbi,                                                                                                               B.Com.,LL.B.,(Spl.),

                                                                               President.,  

                                (2) Kum. Kavita,

                                                               M.A.,LL.B.,(Spl.),  

                                                                         Member.

                                  (3) Shri.Thriyambakeshwara,

                                                                                   B.A.,LL.B.,(Spl.), 

                                                                                           Member.

COMPLAINANT/S                    Jyoti W/o Late Kishankumar Biradar, 

                                                      Age: 34 years, Occ: Household,
                                                      R/o Jai Bhavani Nivas Mailoor Road,
                                                      Bidar-585403.                                                                                                   

                                                 (By Sri.G.D.Srimale.,Advocate.)                         

                 V/s

OPPONENT/S                            1.  The Manager,  

                                                      Care Health Insurance Co. Ltd.,

                                                      Site No.8, 80 Feet Road, S.T. Bed area,

                                                      2^nd Floor, 4^th Block near Maharaj Hotel
                                                      Koramangala, Bangalure-560034 (K.S.).

                                                      2.         The Manager,

                                                      SREI Equipment Finance Ltd.,

                                                      Corporate Office,

                                                      Olisa House, 4 Govt. place (North),

                                                      7^th floor, Kolkata-700001 (W.B).                                                  

                                                     (By OP No.1 Sri. S.Wilson and OP No.2 Ex-parte.)

::  J U D G M E N T  ::

By. Sri. Mabu Saheb H.Chabbi,. President.

The complainant has filed the complaint under section 35 of the Consumer Protection Act, 2019, against the opponents for the deficiency of service caused by not settling the claim amount of the insurance policy of the deceased Sri.Kishankumar Biradar the husband of the complainant.  Hence upon conclusion of the trial, the following judgment is passed. 

Brief facts of the complaint.

The brief facts of the complaint in nut-shell are as follows: -

1.         The complainant is the W/o Sri Late Kishankumar Biradar, who has availed loan of Rs.52,00,000/- from OP No.2 for purchasing Hyundai R210 Smart Excavator Machine on 05.10.2018, under contract No.SEFL/168419/NG63404, and agreed to repay the said loan amount in 46 monthly installments with an EMI of Rs.1,35,858.12/- per month.  The deceased regularly paid the EMI’s for 22 installments till 05.08.2020.  The OP No.2 insisted the deceased to purchase the Group Health Insurance Policy, from OP No.1 and accordingly the husband of the complainant Sri.Kishankumar Biradar, by paying an amount of Rs.49,532/-got insured with OP No.1 bearing group health insurance Policy No.11763125 and the certificate insurance No.12886765 which covers the risk from 16.08.2018 to 15.08.2022, the sum assured under the said insurance is for Rs.48,36,000/- and complainant Smt.Jyoti Biradar is the nominee for the said Health Insurance.  The deceased Sri.Kishankumar Biradar died on 07.09.2020 at BRIMS Hospital, Bidar.  After the death of complainant’s husband the OP No.2 took the possession of the said Hyundai R210 Smart Excavator Machine.  The deceased died during the existence of insurance policy and   the complainant is entitled for the assured amount from OP No.1.  Complainant informed the death of her husband to the OP No.1 and 2 and requested to settle the claim.  But, OPs did not take steps to settle the claim of the complainant, and they did not surrender the possession of above said machine to the complainant.  Thereby the OPs have caused harassment and the complainant sustained loss, on account of deficiency of service by the OPs.  Hence this complaint got filed against OPs.

Gist of Written Version.

2.         The OP No.1 appeared before this commission after due service of notice from this commission and submitted his written version.  The OP No.2 has not appeared and has failed to file its written version even after service of notice to OP No.2.  Hence, OP No.2 is placed ex-parte.  The gist of the written version of OP No.1 is as below.    

            The OP.No.1submitted that, the Group Health Insurance Policy, issued to the deceased Sri Kishankumar Biradar, and covered for the benefits under critical illness with effect from 16.08.2018 till 15.08.2022, with the Plan Name of Group Credit Protection Plan for sum insured of Rs.48,36,000/- subject to policy terms and conditions.  As listed in the policy.  The complainant filed the claim before OP No.1 and claimed with respect to hospitalization of the insured at Bidar institute of Medical Science, teaching Hospital, Bidar from 04.09.2020 till 07.09.2020.  As per the hospital records.  The insured was diagnosed with SARI (Sever Acute Respiratory Infection SARS CoV), respiratory failure, uncontrolled diabetes mellitus.  The death of the insured was also caused by the above mentioned illness and the SARS which does not come under the benefits of critical illness and hence, OP No.1 denied the claim by issuing the letter dated 04.05.2021, for the reason of “No coverage of benefits”?  As the health condition of the insured did not fall under the criteria of Critical illness.  The OP No.1 denied the purchase of policy at the instance of OP No.2 by the deceased.  The OP No.1 has issued the policy to the husband of the complainant for any loss due to health condition and accordingly health policy was issued.  The policy in question was health policy which terminated upon the death of the husband of the complainant and the risk covered was in respect of critical illness.  The diagnosis of the illness of the deceased did not fall under critical illness benefit Criteria.  There is no such cause of action arose to the complainant to file this complaint  and is liable to dismiss.

Evidence of complainant.

3.         The complainant herself examined as P.W.1 by filing evidence affidavit and got marked 12 documents as per Ex.P.1 to Ex.P.12 those are as follows.

1.   Ex.P.1-Copy of certificate of insurance.

2. Ex.P.2-Copy of death certificate pertaining to Kishankumar Biradar.
3. Ex.P.3-Copy of death summery report issued by BRIMS Hospital Bidar.
4. Ex.P.4-Copy of reply to legal notice dt:05.04.2022.
5. Ex.P.5-Copy of tax invoice issued by Hyundai Construction equipment India.
6. Ex.P.6-Copy of loan instalment payment statement.
7. Ex.P.7-Copy of legal notice issued by complainant to the Ops dt:03.03.2022.
8. Ex.P.8&8(1)-Postal receipts.
9. Ex.P.9-Copy of postal track report.
10. Ex.P.10&10(1)-Postal acknoiwledgements.
11. Ex.P.11-Copy of Aadhar Card pertaining to Kishankumar Biradar.
12. Ex.P.12-Copy of Aadhar Card pertaining to complainant.

Evidence of OP.

4.         One Sri.Ravi Boolchandani, Manager Legal of OP No.1 company got examined as R.W.1 by filing evidence affidavit on behalf of OP No.1 and no documents were marked on behalf of OP No.1.

Points/Issues.

5.         The complainant Advocate is heard in part but, he  did not argue in further despite of giving sufficient opportunity hence his further argument is taken as nil and OP No.1 argued his case.  Based on the pleadings and documents produced by the parties, the points that arose for consideration before this Commission are as below. 

1. Whether the complainant proves that, she is consumer to Ops and further proves the deficiency of service from the Ops? 

2. Whether the OP No.1 proves that the repudiation of claim of the complainant is in accordance with law?

3. Whether the complainant proves any entitlement of claim and compensation from OPs and if yes what order?

6.         Our answers to the points raised above are as follows: -

1. In the negative.
2. In the affirmative.
3. In the negative and as per the final order.

7.         In order to decide the said issues, since the points/issues No.1 to 3 are inter related, all the 3 points are discussed together as follows.  

8.         The complainant and OPNo.1 filed their evidence affidavit as P.W.1 and R.W.1 respectively and reiterated the facts of their respective pleadings and complainant produced 12 documents to prove her case.  The OP No.1 has not produced and got marked any document on his side.  The OP No.2 is already placed ex-parte on 09.05.2022.  The case of the complainant is that, her husband had purchased the health insurance policy from OP No.1 for an assured amount of Rs.48,36,000/- with an yearly premium of Rs.49,532/- commencing from 16.08.2018 to 15.08.2022.  The husband of the complainant died on 07.09.2020 at BRIMS Hospital Bidar, and the complainant sought for settlement for claim from the OPs for the assured amount of Rs.48,36,000/-.  But, the OP No.1 has denied the same stating that, the said insurance policy has been issued to the deceased Kishankumar Biradar covering the risk of critical illness condition.  The OP No.1 has stated in his W.V. that, the insurance policy Ex.P.1 covers only 20 critical illness as stated in the policy terms and conditions and the said policy issued by OP No.1 as health policy got terminated upon the death of the husband of the complainant and the risk covered was in respect of critical illness but the deceased was diagnosed with SARI (Sever Acute Respiratory Infection SARS CoV) respiratory failure, uncontrolled diabetes mellitus and the death of insured on account of above said illness does not come under the benefits of critical illness and accordingly issued a letter of repudiation dt:04.05.2021 and in view of the said fact the claim of the complainant was denied to the complainant.

9.         On going through the certificate of policy which has been marked as per Ex.P.1, it does not disclose that, in the event of death of the insured the policy made availabe to pay the assured amount to the complainant.  On going through the document Ex.P.1 it does not cover the claim of the complainant.  The policy does not disclose that, the complainant could claim the assured amount in the event of death of the insured.  The policy was only regarding health insurance.  The complainant has produced Ex.P.3 death summary report of Sri.Kishankumar and in the said report the cause of death is shown as “SARI Respiratory fail Covid positive /DM” from the contents of this document which was produced by the complainant herself, it clearly goes to show that, the deceased died on account of the ailments which were not shown in the critical illness criteria shown in Ex.P.1 policy terms and conditions.  In view of the said Ex.P.3 document also the policy does not cover or support the facts of the complainants case.

10.       The documents which were produced by the complainant regarding tax invoice as per Ex.P.5  and loan repayment statement as per Ex.P.6 are only the document regarding the loan and its repayment statement.  The OP No.1 has given a reply notice to the complainant and to her Advocate on 05.04.2022 as per Ex.P.4 and in the said reply notice also the OP No.1 has denied the claim of the complainant that, the cause of death of the deceased was due to any critical illness but the insurance issued as health insurance policy to deceased.  The complainant has not produced any vouchers or bills regarding the expenses incurred for the critical health of the deceased Sri.Kishankumar Biradar pertaining prior to the date of death of Kishankumar.  From the above said discussion we are of the considered opinion that, the case of the complainant is not maintainable against the OPs and hence, we answer point No.1 and 3 in the negative as against complainant and point No.2 in the affirmative in favor of OP No.1, and proceed to pass following,

::ORDER::

        The complaint u/s 35 of CP Act 2019, filed by the complainant against Ops is hereby dismissed no order as to cost.

            Intimate the parties accordingly.                         

 (Typed to our dictation then corrected, signed by us and then pronounced in the open Commission on this   03^rd day of June-2023).

Documents produced by the complainant.

1. Ex.P.1-Copy of certificate of insurance.
2. Ex.P.2-Copy of death certificate pertaining to Kishankumar Biradar.
3. Ex.P.3-Copy of death summery report issued by BRIMS Hospital Bidar.
4. Ex.P.4-Copy of reply to legal notice dt:05.04.2022.
5. Ex.P.5-Copy of tax invoice issued by Hyundai Construction equipment India.
6. Ex.P.6-Copy of loan instalment payment statement.
7. Ex.P.7-Copy of legal notice issued by complainant to the Ops dt:03.03.2022.
8. Ex.P.8&8(1)-Postal receipts.
9. Ex.P.9-Copy of postal track report.
10. Ex.P.10&10(1)-Postal acknoiwledgements.
11. Ex.P.11-Copy of Aadhar Card pertaining to Kishankumar Biradar.
12. Ex.P.12-Copy of Aadhar Card pertaining to complainant.

Document produced by the Opponent.

-Nil-

Witness examined.

Complainant.

1. P.W.1- Jyoti W/o Late Kishankumar Biradar,                          (complainant).   

Opponent.

2. R.W.1- Sri.Ravi Boolchandani,