Karnataka

Chitradurga

CC/49/2017

Smt. Premalatha, R. W/o - Complainant(s)

Versus

The Manager, HDFC ERGO, general Insurance - Opp.Party(s)

Sri. G.P. Prakash

15 Mar 2018

ORDER

COMPLAINT FILED ON:26/05/2017

DISPOSED      ON:15/03/2018

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHITRADURGA.

 

CC.NO: 49/2017

 

DATED: 15^th MARCH 2018

PRESENT: - SRI. T.N. SREENIVASAIAH  : PRESIDENT                                   B.A., LL.B.,

                   SRI.N. THIPPESWAMY        : MEMBER

                          B.A., LL.B., PGDCLP   

……COMPLAINANT/S	Smt. Premalatha.R, W/o Late Parashurama.T, Age:30 Years, Kallappa Beedi,\Nehru Nagara, Makka Maszid Road, Chitradurga Town.   (Rep by Sri.G.B.Prakash, Advocate)
V/S
…..OPPOSITE PARTIES	1. The Manager, HDFC ERGO Life Insurance Company Limited, 6th Floor, Leela Business Park Anderi-Kurla Road, Anderi East, Mumbai.   2. The Manager, HDFC ERGO Life Insurance Company Limited, No.25/1, II Stage, Building No.2, Shankaranarayana Building, M.G. Road, Bangalore-01.   (Rep by Sri.K.E. Mallikarjuna, Advocate)

ORDER

SRI. T.N. SREENIVASAIAH:   PRESIDENT

The above complaint has been filed by the complainant u/Sec.12 of the C.P. Act, 1986 for the relief to direct the OPs to pay a sum of Rs.2.00,000/- along with interest at the rate of 12% p.a from the date of complaint till realization, Rs.25,000/- towards costs and such other reliefs.

2.      The brief facts of the case of the above complainant are that, one Sri. T. Parashuram, the husband of complainant was working as a lineman in Chitradurga BESCOM.  While working, he obtained two Sarva Suraksha Policies from the OPs each for Rs.1,00,000/-.  The first policy bearing No.2950201273136900000 was valid from 21.12.2015 21.12.2019 and another policy bearing No.41408274 was valid from 27.09.2013 to 26.09.2016.  The said Parashuram was died on 24.06.2016 at General Hospital, Chitradurga due to illness.  The death of her husband was intimated to the OPs for settlement of the claim under the above said policies but, the OPs failed to settle the claim made by her.  The complainant approached OPs personally for so many times requesting to settle the claim.  But, the OPs neglected and refused to settle the claim.  On 03.03.2017, the complainant has send legal notice though his counsel.  After receipt of the notice, the OPs repudiated to settle the claim which is a deficiency in service.  The cause of action for this complaint arose at Chitradurga which is within the jurisdiction of this Forum and therefore, the complainant has respectfully prayed before this Forum to allow his complaint with cost. 

3.      On service of notice, OPs appeared through Sri. K.E. Mallikarjuna, Advocate and filed version.  According to the version filed by the OPs, it is true that, the husband of the complainant obtained two Sarva Suraksha Insurance Policies each for Rs.1,00,000/- from the OPs and there is no dispute with regard to obtaining of insurance policies.  Further it is true that, after the death of her husband, the complainant has applied for settlement of the claim. It is submitted that, the claim made by the complainant is not covered under the terms and conditions of both the said policies.  Hence, the OPs have repudiated the claim. It is submitted that, as per the policy terms and conditions, only following critical illness are covered i.e., 1) First Heart Attack of specified severity, 2) Open Chest CABG, 3) Stroke resulting in Permanent Symptoms, 4) Cancer of Specified Severity, 5) Kidney Failure Requiring Regular Dialysis, 6) Major organ/Bone Marrow Transplant 7) Multiple Sclerosis with Persistent Symptoms 8) Surgery of Aorta 9) Primary Pulmonary Arterial Hypertension and 10) Permanent Paralysis of Limbs other than the above illness, if the policy holder dies for any other reasons coverage under the policy is not available.  It is further submitted that, as per medical records, the deceased died due to massive upper GI bleed-peptic ulcer Disease/vertical bleed, secondary to anticoagulation, hypolemic/septic shock, RVD-CD4-902, left leg Dvt. Gluteal Abscess, Chronic Pancreatitis, Pancreatic DM and AKI and the said ailments are not covered under the aforesaid policies and hence, the OPs have rightly repudiated the claim of the complainant and there is no deficiency of service on their part.  It is further submitted that, the complainant has sent legal notice to the OPs but, they have repudiated the claim made by her on 03.03.2017 itself.  Therefore, the complaint filed by the complainant is not maintainable either in law or on facts and prayed for dismissal of the complaint.

         4.       Complainant has examined as PW-1 by filing affidavit evidence and the documents Ex.A-1 to A-6 were got marked. On behalf of OPs, one Sri. S. Sanjay Kumar, Assistant Manager(claims), has examined as DW-1 by filing the affidavit evidence and Ex.B-1 to B-4 documents have been got marked.  

 

5.      Arguments of both sides heard.

6.      Now the points that arise for our consideration for decision of above complaints are that;

 

(1)  Whether the complainant proves that the OPs have committed deficiency of service for non-settling the claim made by her under the said policies obtained by her husband while he was working in BESCOM and entitled for the reliefs as prayed for in the above complaint?

              (2) What order?

          7.      Our findings on the above points are as follows:-

          Point No.1:- Partly in Affirmative.

          Point No.2:- As per final order.

REASONS

8.      It is not in dispute that, complainant is wife of deceased T.Parashuram who died on 24.06.2016.  He was working as a line man in BESCOM.  While working he has obtained two Sarva Surksha Insurance policies bearing Nos. No.2950201273136900000 was valid from 21.12.2015 21.12.2019 and another policy bearing No.41408274 was valid from 27.09.2013 to 26.09.2016.  After the death of her husband, complainant approached OPs for settling the claim under the above said policies which were obtained by her husband.  But, the OPs repudiated the claim made by the complainant stating that, the reasons for death of her husband is not comes under the terms and conditions of the policy.  As per the exhibits produced by the OPs i.e., Ex.B-4, the critical illness is also covered under the policy.  In this case, the husband of the complainant was died due to acute kidney failure as per the medical certificate issued by the Manipal Hospital.  The same has been marked as Ex.A-6.  The OPs have taken a contention in its arguments that, whatever the illness stated in the medical certificate of T. Parashuram, those illness are not comes under the policy. 

9.   We have gone through the entire documents filed by both the parties and the evidence given by both sides.  As per the documents produced by the complainant i.e., Ex.A-1 to A-6 which clearly shows that, the husband of the complainant died due to acute kidney failure.  This point is also covered under the policy ie., point No.5 of the documents produced by the OPs itself.  When the documents produced by the OPs ie., Ex.B-4 and the document produced by the complainant Ex.A-1, the point No.5 kidney failure requires regular dialysis.  In this case also, the husband of the complainant died due to acute kidney failure/injury.  So, this disease is also comes under the critical illness.  Hence, OPs have their bounden duty to settle the claim made by the complainant under the above policies.  Accordingly, this Point No.1 is held as partly affirmative to the complainant.          

            10.     Point No.2:- As discussed on the above point and for the reasons stated therein we pass the following:-

ORDER

The complaint filed by the complainant U/s 12 of C.P Act 1986 is partly allowed.

It is ordered that, the OPs are hereby directed to pay a sum of Rs.1,00,000/- under policy No.2950201273136900000 and Rs.1,00,000/- under policy No.41408274, in all a sum of Rs.2,00,000/- to the complainant along with interest at the rate of 9% p.a from the date of complaint till realization.   

It is further ordered that, the OPs are hereby directed to pay Rs.10,000/- towards mental agony and Rs.5,000/- towards costs of this proceeding.  

It is further ordered that, the OPs are hereby directed to comply the above order within 30 days from the date of this order.

 (This order is made with the consent of Member after the correction of the draft on 15/03/2018 and it is pronounced in the open Court after our signatures)         

 

 

                                     

 MEMBER                                                   PRESIDENT

-:ANNEXURES:-

Witnesses examined on behalf of Complainant:

PW-1:  Complainant by way of affidavit evidence.

Witnesses examined on behalf of OPs:

DW-1:  Sri. S. Sanjay Kumar, Manager (Claims) of OPs by way of affidavit evidence. 

Documents marked on behalf of Complainant:

01	Ex-A-1:-	Letter of claim repudiation
02	Ex-A-2:-	Copy of policy No.2950301273136900000
03	Ex-A-3:-	Copy of policy No.41408274
04	Ex-A-4:-	Copy of claim Form
05	Ex.A-5:-	Copy of death intimation
06	Ex.A-6:-	Discharge summary

 

Documents marked on behalf of OPs:

01	Ex-B-1:-	Copy of policy No.2950301273136900000
02	Ex-B-2:-	Discharge summary
03	Ex-B-3:-	Letter of claim repudiation

 

 

 

 

MEMBER                                                            PRESIDENT

Rhr**