BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.458 of 2017
Date of Instt. 01.12.2017
Date of Decision: 19.02.2020
Charanjit son of Sh. Dass Ram, resident of V.P.O. Boparai Kalan, Tehsil Nakodar, District Jalandhar.
..........Complainant
Versus
1. The Manager, HDFC Bank Ltd., Plot No.911, First Floor, Near Narinder Cinema, G. T. Road, Jalandhar.
2. The Manager, HDFC ERGO General Insurance Co. Ltd., 1st Floor, HDFC House, 165-166, Backbay Reclamation, H. T. Parekh Marg, Church Gate, Mumbai-400020.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Smt. Jyotsna (Member)
Present: Sh. H. D. Sampla, Adv. Counsel for the Complainant.
Sh. Sushil Mehta, Adv. Counsel for the OP No.1.
Sh. R. K. Sharma, Adv. Counsel for the OP No.2.
Order
Karnail Singh (President)
1. The instant complaint has been filed by the complainant, wherein alleged that the complainant is the father of the deceased Mr. Ravi Pal (insured), who has died on 16.04.2017 and the complainant being nominee of Ravi Pal is going to file the present complaint. The deceased Ravi Pal was working in Police Department and lastly posted at Police Station Mehatpur, Tehsil Nakodar, District Jalandhar. That deceased Ravi Pal has purchased an insurance policy “Sarv Suraksha Policy” bearing No.2950200882309300000 from the OP No.1 and 2 valid for the period from 20.10.2014 to 19.10.2017 covering critical illness. One time premium of Rs.2453/- was paid to the respondents No.1 and 2 from the salary account of the deceased insured Ravi Pal. So that the loan installment which was obtained by Ravi Pal, was deducted from the account of the deceased Ravi Pal. Deceased Ravi Pal also received a welcome letter dated 20.10.2014 which describes HDFC ERGO SARV Suraksha PRO is a comprehensive plan that covers his personal loan from HDFC Bank. OP No.1 has received all installments and credited to the personal loan of Ravi Pal deceased regularly. The OP No.1 is the agent of the OP No.2 who had told the deceased Ravi Pal that all critical illness are included in the coverage of this policy and his personal loan which has been taken from OP No.1 is also covered under this policy. This fact was also told by deceased, Ravi Pal to the complainant during his lifetime, being his nominee.
2. That unfortunately, Mr. Ravi Pal died due to critical illness on 16.04.2017 during his treatment at PGI, Chandigarh. The complainant informed the OP No.1 and OP No.2 about the death of insured Ravi Pal son of the complainant and lodged a claim on 21.05.2017 against policy No.2950200882309300000 to OP No.2 in consultation with OP No.1. As per said policy the amount of claim was to be credited in the personal loan of Ravi Pal deceased to the extent of amount which was to be paid by the deceased Ravi Pal at the time of his death to the OP No.1. But the OP No.2 has wrongly and illegally repudiated/rejected the claim of the complainant, vide intimation No.C295017001786 on the ground that “The said ailments are not covered under the policy”, whereas critical illness were not explained to the insured/deceased Ravi Pal at the time of purchase of the policy by the OP No.1. By rejecting the claim of the complainant, the OPs have committed deficiency in service and unfair trade practice on their part and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay Rs.1,55,000/- which was payable towards personal loan standing in the name of deceased Ravi Pal at the time of his death alongwith interest and installments already paid to the OP No.1 and further, OPs be directed to pay compensation for causing mental tension and harassment to the complainant to the tune of Rs.10,000/- and also be directed to pay litigation expenses.
3. Notice of the complaint was given to the OPs and accordingly, OP No.1 appeared through its counsel and filed a written reply and contested the complaint by taking preliminary objections that the instant complaint is not maintainable qua answering OP No.1 because the OP No.1 approached to the answering OP for grant of personal loan/financial assistance and also gave assurance to the OP No.1 that he will abide by the terms and conditions on which loan may be granted by the bank. The OP No.1 in the year 2016 based on the aforesaid assurance given by Ravi Pal deceased and accordingly, personal loan was sanctioned to the tune of Rs.2,38,000/-, which was to be paid by way of 36 equated monthly installments of Rs.8221/- and further submitted that the OP No.1 has not issued policy to the borrower i.e. deceased Ravi Pal. None was involved in the insurance transaction. The OP No.1 was merely a facilitator in the insurance transaction, so to allow or to disallow the claim was discretion of the OP No.2 and OP No.1 has no role to play in the insurance claim and there is no deficiency in service or unfair trade practice on the part of the OP No.1 and lastly prayed that the complaint of the complainant qua replying OP No.1 may be dismissed with cost.
4. OP No.2 filed its separate reply and contested the complaint by taking preliminary objections that the complaint of the complainant is without any cause of action, thus, the same is liable to be dismissed and further averred that the policy in question was issued to the complainant by the answering OP subject to terms and conditions of the insurance policy, which was never disputed by the complainant and the insurance claim of the deceased insured Ravi Pal was submitted and after going through the claim form and documents submitted by the complainant it was found that as per the medical certificate of cause of death, the ailment suffered by the insured/deceased was not listed under the ailments mentioned under the list of critical illness, therefore, the claim was found not payable and accordingly, the same was rightly repudiated. It is further averred that there are 10 categories mentioned under the list of critical illness. The claim was lodged claiming benefit under coverage 1 i.e. critical illness respectively. As per policy terms and conditions, the ailment of the complainant does not cover under the category of critical illness, therefore the claim of the complainant has been rightly rejected and further submitted that the complainant is claiming the benefit under coverage of credit shield. However, it is stated the claim of the complainant under the coverage credit shield is not payable. As the benefits under the credit shield is given only, when the death of the insured is due to accident. But in the present case, the death of the insured was not due to any accident which is an admitted fact by the complainant in present complaint under Para No.5. Thus, the complainant is not entitled for any benefits under the coverage of credit shield as per terms and conditions. On merits, it is admitted that the insurance policy was issued to the deceased Ravi Pal, son of the complainant and after the death of insured, his father i.e. complainant filed insurance claim, which was rightly rejected as per terms and conditions and the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
5. In order to prove his case, the complainant himself tendered into evidence his own affidavit Ex.CA alongwith some documents Ex.CA-1 to Ex.CA-9 and closed the evidence.
6. Similarly, counsel for the OP No.1 tendered into evidence affidavit Ex.OP1/A and closed the evidence.
7. Similarly, counsel for the OP No.2 tendered into evidence affidavit of Pankaj Kumar as Ex.OP2/A alongwith some documents Ex.O-1 to Ex.O-3 and closed the evidence.
8. We have heard the arguments of learned counsel for the respective parties and also gone through the case file very minutely.
9. In nutshell, we find that the case of the complainant qua purchasing of insurance policy under the heading “Sarv Suraksha Policy”, by the deceased son of the complainant for a period 20.10.2014 to 20.10.2017 after paying a premium of Rs.2453/- is not in dispute, rather these facts have been admitted by the OP No.2/Insurance Company. Further, it is also not in dispute that the insured deceased Ravi Pal has expired on 16.04.2017 and after his death, the father of the insured filed an insurance claim and the same was rejected vide letter dated 11.05.2017. Upto this extent, there is no dispute between OP No.1 and OP No.2.
10. The role of the OP No.1 is only in this complaint is to provide a loan to the son of the complainant and also facilitate to provide insurance policy from OP No.2 and as such, we find there is no direct or indirect liability of OP No.1 in this case and the complaint of the complainant qua OP No.1 is not maintainable rather OP No.1, we find a formal party in this case.
11. Coming to the main aspect, where-from we can ascertain the reason why the insurance claim of the complainant was repudiated by the OP that can be adjudged from repudiation letter Ex.CA-6 dated 31.05.2017, wherein the reason for repudiation of letter is mentioned as under:-
“As per the case summary received, Late Mr.Ravi Pal died due to Raised Intracranial Pressure, Chronic Meningoencephalitis, Tuberculoma. The said ailments are not covered under policy, Hence claim is rejected. Because the deceased of the insured is not covered in the critical illness section of policy.” Before proceeding further, we firstly glance only insurance policy, photostat copy of the same is available on the file Ex.CA-3, wherein the insurance coverage are (a). Critical Illness, (b) Accidental Death, (c) Permanent Total Disability/Permanent Partial Disability, (d) Credit Shield Insurance, (e) Accidental Hospitalization, the above said are the coverage of the insurance policy of the deceased Ravi Pal and for each coverage the insured amount is different one and insurance premium of each category as stated above had been also paid by the deceased insured which is mentioned against the each coverage and total premium paid by the deceased was Rs.2453/-. For critical illness, the premium paid Rs.893/- and for credit shield insurance premium Rs.420/-. Similarly for other is also mentioned in the said insurance policy Ex.CA-3. It is no where mentioned in the insurance policy Ex.CA-3 that the coverage for only one i.e. critical illness, because the OP No.2 has charged premium for each category as mentioned above and therefore, the OPs are required to consider the case of the complainant for all category without waiting for a request from the complainant, but in the instant case, the OP has considered only one factor that the ailment to the deceased insured was not covered under the critical illness as per terms and conditions of the policy. First of all, we will discuss whether the case of the complainant is not covered under the definition of critical illness, for that purpose, we have gone through the copy of terms and conditions placed on the file by the OPs, alongwith the insurance policy Ex.O-1 and its forth page, under the heading of critical illness coverage, Para No.4 ‘Cancer of specified severity’:-
“A malignant tumour characterized by the uncontrolled growth & spread of malignant cells with invasion & destruction of normal tissues. This diagnosis must be supported by histological evidence of malignancy & confirmed by a pathologist. The term cancer includes leukemia, lymphoma and sarcoma.”
Now, we have to analyze whether the disease suffered by the deceased insured is covered under the critical illness or not, for that purpose, we have to take into consideration above Para No.4 of the terms and conditions, which itself speaks that the ailment to the deceased Ravi Pal is apparently covered because as per certificate issued by the treating doctor Ex.CA-4, wherein categorically mentioned that “as per MRI brain showed left frontal lobe brain tumor and deceased was operated twicely, brain tumor biopsy revealed tuberculoma, he did not show improvement. He was referred to PGI, Chandigarh on 06.04.2017 for further management. His disease comes under critical illness as it was a brain tumor which did not respond to medical and surgical treatment.” If the opinion of the doctor is to corelate with Para No.4 of the terms and conditions, then we can say without any hesitation that the illness suffered by deceased has been apparently covered under the critical illness and as such, we are of the opinion that the OP No.2 has wrongly and illegally repudiated the claim of the complainant.
12. Further, we find that the case of the complainant is more covered under the heading of ‘Credit Shield Insurance’, but the said coverage has not been considered by the OP No.2 rather took a plea in the written statement in Para No.8 on preliminary objections that the stated claim of the complainant under the coverage of ‘Credit Shield Insurance’ is not payable, as the benefit under the ‘Credit Shield Insurance’ is given only, when the death of the insured is due to accident, but in the present case the death of the insured was not due to any accidental, which is an admitted fact by the complainant in the present complaint and therefore, the complainant is not entitled for the insurance claim under the coverage of ‘Credit Shield Insurance’.
13. We have considered the plea taken by the OP No.2 qua ‘Credit Shield Insurance’ coverage and find that the OP has took a wrong plea that the death of the complainant was not due to accident rather if we go through the terms and conditions, wherein the word accident or accidental, both the words as per our opinion having different meanings, accident means whenever any incident happened by way of accident, but the meaning of accidental is somehow different from the meaning of word accident. Accidental means when anything happened all of sudden it is not always external or visible. So, accordingly, if we take the case of the deceased insured Ravi Pal and all of sudden tumor was developed in his brain and due to that disease, accidentally he was died and accordingly, we find that the case of the complainant is also covered under the ‘Credit Shield Insurance’ as well as also covered under critical illness coverage but the OP No.2 without considering the case of the complainant under these headings, wrongly and illegally without applying its mind has repudiated, which is liable to be set-aside and accordingly, ordered and further find that the complainant is entitled for the relief i.e. the loan amount which was remained due towards the deceased Ravi Pal at the time of his death alongwith interest, compensation and litigation expenses.
14. In view of the above detailed discussion, the complaint of the complainant is partly accepted qua OP No.2 and accordingly, OP No.2 is directed to pay the loan amount which was remained due i.e. Rs.1,55,000/-, to the complainant because the complainant has already paid the said loan amount to OP No.1/Bank as loan installment with interest @ 12% per annum from the date of death of the deceased insured i.e. 16.04.2017 till realization and further, OP No.2 is directed to pay compensation for causing mental tension and harassment to the complainant, to the tune of Rs.7000/- and litigation expenses Rs.3000/-. The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
15. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jyotsna Karnail Singh
19.02.2020 Member President
