Haryana

Ambala

CC/70/2018

Mr. Parmanand Dua - Complainant(s)

Versus

The Manager HDFC ERGO Gen Inss - Opp.Party(s)

12 Mar 2019

ORDER

 

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AMBALA

 

                                                                      Complaint case no.        : 70 of 2018

                                                          Date of Institution         : 27.02.2018

                                                          Date of decision    : 12.03.2019  

 

 

 Mr. Parmanand Dua son of Shri Purshotam lal Dua resident of 42/667, Baldev Nagar, Ambala City.

    ……. Complainant.

 

 

1.  The Manager Claims, HDFC EGRO General Insurance Company Ltd. 6^th Floor, Leela Business park, Andheri kurla Road, Andheri East, Mumbai-400059.

 

2.  HDFC Egro General Insurance Company Nicholson road, Near Geeta Gopal Chowk, Ambala Cantt.

 

 .…. Opposite Parties.

 

Before:        Ms. Neena Sandhu,  President.

                   Ms. Ruby Sharma, Member,

Sh. Vinod Kumar Sharma, Member

                  

 

Present:        Sh. Pardeep Batra, counsel for complainant.

 Sh. Mohinder Bindal,  counsel for OPs.

 

 

Order:         Smt, NeenaSandhu, President

Complainant has filed this compliant under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the Opposite Parties(hereinafter referred to as ‘Ops’.

                   In nutshell, brief facts of the present complaint are that the father of the complainant late Shri Purshotam Lal Dua was insured with the Ops under the plan HDFC ERGO SARVE SURAKSHA PLUS, bearing policy No.2950201483203000000 having coverage for loss of job(three EMI), accidental death, permanent disability, accidental hospitalization and  critical illness. All of a sudden, insured Purshotam Lal Dua died on 18.10.2016, due to severe heart attack and his death was sudden and not due to any critical illness. The complainant submitted claim form along with all necessary documents including death and post mortem report as required by OPs, the Ops repudiated the claim of the complainant on the ground that since the insured died due to critical illness within 90 days from the date of commencement of the policy, therefore, as per exclusion clause, no claim is payable under Section 1, “critical illness”. By repudiating the genuine claim of the complainant, the OPs have committed deficiency in service. It is prayed that the complaint may be allowed and OPs be directed to review the repudiation letter and make the payment of insured amount. Ops may also be directed to pay compensation for mental agony and physical harassment suffered by him.   

2.               Upon notice, OP Nos. 1 & 2 appeared through counsel and tendered version statement, raising preliminary objections qua complaint is not maintainable, not come with clean hands,  no locus standi, no cause of action, no jurisdiction and false and frivolous facts. On merits, OPs stated that the claim of the insured, late Sh. Purshotam lal Dua was duly entertained in due course, on being presented by his son, Mr. Parmanand Dua, being nominee and the entire case with all set of papers was gone through by the concerned team of the answering Op. The insured late Sh. Purshotam Lal Dua had taken the insurance policy on 29.08.2016. The deceased insured suffered a stroke on 18.10.2016 and expired on the same day i.e after 50 days from the commencement of the insurance policy. Section 1 of the policy terms, being part of the said policy which deals with critical illness coverage, of the insurance policy clearly and specifically says that no payment will be made by the company for any claim directly or indirectly caused due to any critical illness diagnosed within first 90 days of the date of commencement of the policy. Since, the insured died within 90 days from the date of commencement of the policy, therefore, as per terms and conditions of the policy, the insurance company has rightly repudiated the claim. Thus, there is no deficiency in service on the part of the Ops and prayed for dismissal of the present complaint.

3.                To prove his version counsel for the complainant tendered his affidavit as Annexure C-A along with documents as annexure C-1 and C-23 and closed his evidence. On the other hand, Counsel for the OPs tendered affidavit as Annexure R-A alongwith documents as Annexure R-1 to R-5 and closed their evidence.

4.                We have heard both the counsel of the parties and carefully gone through the case file.

5.                Admittedly, Late Sh. Purshotam Lal Dua(hereinafter referred to as DLA) was duly insured with the OPs, for the period from 29.08.2016 to 28.08.2021 vide policy certificate, Annexure C-9. As per medical certificate Annexure C-10 DLA died on 18.10.2016. The plea of the complainant is that the DLA died due to accident but the OPs have wrongly repudiated the claim by treating his case under the category “critical illness”. As per term no.4 of the terms and conditions of the policy, Annexure R-2, Accident Means a sudden/unforeseen and involuntary caused by external, visible and violent means.  It may be stated here that in the medical certificate Annexure C-10 and post mortem report Annexure C-11, cause of death has not been mentioned. No documents has been placed on record by the complainant to establish that there was any external violent and visible means to cause  any accident, thus it cannot  be said  to be an accident, as define in term No.4 of the  insurance policy.  As such the complainant has failed to prove that DLA died due to accident. Complainant in his complaint has contended that DLA died due to severe heart attack. Thus, as per the contention of the complainant, his case falls under the Section 1. ‘Critical Illness’ of terms and conditions of the policy which reads as under:-

CRITICAL ILLNESS COVERAGE

1. First Heart Attack-of specified severity:

The first occurrence of myocardial infarction which means the death of a portion of the heart muscle as a result of inadequate blood supply to the relevant area. The Diagnosis for this will be evidenced by all of the following criteria.

• A history of typical clinical symptoms consistent with the diagnosis of Acute Myocardia Infarction(for e.g. typical chest pain)
• New characteristic electrocardiogram changes
• Elevation of infarction specific enzymes, Troponins or other biochemical markers.

The following are excluded.

• Non-ST-segment elevation myocardial infaction (NSTEMI) with only elevation of Troponin I or T.
• Other acute Coronary Syndromes
• Any type of angina pectoris

6.                From the record it is borne out that the DLA died within 90 days  from of commencement of the policy. Therefore, as per exclusion clause no.2 :- “Any critical  illness  diagnosed within the first 90 days  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” of specific exclusions applicable to Section 1, the insurance company is not liable to pay any claim to the complainant. As such the insurance company cannot be said to be deficient in providing services to the complainant. The complaint filed by the complainant is devoid of merits, consequently, we dismiss the same with no order as to cost. Copy of this order be supplied to both the parties free of cost. File be indexed and consigned to record room after due compliance.

Announced on :12.03.2019

 

 

                    

                                             

          (Vinod Kumar Sharma)            (Ruby Sharma)    (Neena Sandhu)

                      Member                  Member              President