| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA C.C. No. 246 of 14-09-2018 Decided on : 14-09-2022 Rajinder Singh aged about 37 years S/o Tara Singh S/o Rona Singh, R/o H. No. 283, Patti Sran, Raiya urf Hardaspura, Tehsil Phul and Distt. Bathinda. ........Complainant Versus HDFC Bank Limited, branch office at Guru Kashi Marg, Bathinda, through its Branch Manger/Authorized person. HDFC ERGO General Insurance Company Limited, having its registered office at 1st floor, 165-166, backbay Reclamation H.T Parekh Marg. Church Gate Mumbai 400 020 through its authorized person. HDFC ERGO General Insurance Company Limited, having its office at 6th Floor, Leela Business Park, Andheri Kurla Road (E), Mumbai Pin 400059. HDFC Bank Branch Tapa Mandi, Tehsil Tapa, Distt. Barnala through its Branch Manager.
.......Opposite parties
Complaint under Section 12 of the Consumer Protection Act, 1986 QUORUM Sh.Kanwar Sandeep Singh, President Sh. Shivdev Singh, Member. Present For the complainant : Sh. Amandeep Singh Mann, Advocate. For opposite parties : Sh. Sanjay Goyal for OP No. 1. Sh.Varun Gupta for OP Nos. 2 & 3. Opposite party No.4 ex-parte. ORDER Kanwar Sandeep Singh, President The complainant Rajinder Singh (here-in-after referred to as complainant) has filed this complaint U/s 12 of Consumer Protection Act, 1986 (Now C.P. Act, 2019, here-in after referred to as 'Act') before this Forum (Now Commission) against HDFC Bank Limited and others (here-in-after referred to as opposite parties). Briefly stated, the case of the complainant is that deceased Tara Singh was his father and Tara Singh was having a loan account bearing No.29427139 with HDFC Bank Ltd. Branch Tapa. He was offered the insurance policy by the bank. As such, he was issued the insurance policy bearing No.2950200845340200000 for Rs.5,00,000/- known as Sarv Suraksha Policy. This insurance policy was one time insurance policy and its premium was paid by the deceased Tara Singh at the time of availing this policy. It is alleged that the terms and conditions of the insurance policy were not issued to deceased Tara Singh or any of his family members, rather it was conveyed that same will be handed over lateron. All of sudden, Tara Singh suffered from chest pain and felt discomfort. He was taken to Daya Nand Medical College & Hospital, Ludhiana and there he died on 6.4.2018. In the insurance policy, the complainant was the nominee of Tara Singh and it is duly mentioned in the insurance policy. It is alleged that after death of Tara Singh, the complainant submitted claim bearing No.RR-CI18-10557115 and submitted all the documents as required by the opposite parties. As per the insurance policy, the complainant is entitled to receive amount of insurance policy i.e Rs.5,00,000/- alongwith other benefits, but opposite parties have rejected the claim with the remarks "no claim" vide their letter/e-mail dated 24.7.2018 on the ground that as per the case summary received, late Mr.Tara Singh was diagnosed to he suffering from coronary artery disease with triple vessel disease. These ailments are not covered under the policy, hence the claim is repudiated. It is further alleged that as per the conditions mentioned in the same letter dated 24.7.2018, it is clearly mentioned in Condition No.1 that first heart attack of specified severity, open chest CABG are covered under the policy. Deceased Tara Singh has also suffered from the first heart attack and he was duly covered under the policy, but opposite parties have illegally and against facts rejected the claim of the complainant on false grounds and without any sufficient cause or reason. It is also alleged that the complainant several times approached opposite parties and requested them to pay amount of life insurance alongwith other benefits, but they have illegally and against facts refused to admit his claim. As such, there is deficiency in service on the part of opposite parties On this backdrop of facts, the complainant has prayed for directions to opposite parties to pay insurance claim amounting to Rs.5,00,000/- alongwith other benefits and pay Rs.2 lakhs as damages on account of harassment and Rs.11000/- as costs litigation expenses. Upon notice the opposite party Nos.1 to 3 put in appearance through counsel and contested the complaint by filing written version. Despite notice none appeared behalf on behalf of opposite party No.4, so opposite party No.4 was proceeded against ex-parte. Opposite party No.1 filed separate written version and raised legal objections that this complaint is not maintainable qua it as neither any insurance policy was purchased from it nor any claim can be paid by it. This complaint is bad for mis-joinder of opposite party No.1. On merits, also all the averments of the complainant are denied by opposite party No.1 and prayer is made for dismissal of complaint. Opposite party No.3 filed written version and later on, counsel for opposite party No.3 suffered statement to the effect that written version filed by opposite party No.2 be read as written version of opposite party No.3. In their written version, opposite party Nos.2 and 3 pleaded that this complaint is not maintainable in its present form and complainant has no cause-of-action to file the complaint. The complainant has not come with clean hand and he has suppressed the material facts from this Forum. As such, he is not entitled to any claim of any amount from the parties. The intricate questions of law and facts are involved in this case and parties have to examine the witnesses who are to be cross-examined by the other party. As such, the matter involved cannot be determined in summary procedure before this Forum. The complainant, if so advised, should have to approach the civil court. The complaint is false, frivolous and vexatious in nature and it has been filed in order to cause undue harassment and botheration to opposite party Nos.2 and 3. Opposite party Nos.2 and 3 float the insurance scheme for the public in general after prior approval of the Insurance Regulatory & Development Authority and all the terms and conditions of the respective insurance policies are set by the IRDA Act, 1999 and Insurance Act, 1938. Thereafter opposite party Nos.2 and 3 have raised preliminary objections that the complainant has alleged that policy terms and conditions were not provided by them. The policy was issued to the insured and therefore the insured was the right person to raise the objection. The policy covers in itself mentions that 'The policy wording attached herewith includes all the standard coverage offered by the company to its customers. Your entitlement for coverage/benefits shall be restricted to the coverage/benefits as mentioned in this policy Schedule issued to you. Please read the Policy Wording in conjunction with the policy schedule. For clarification please call our toll free number'. As such, the contention of the complainant that no terms and conditions were provided comes to an end. Had the insured would had not been provided with the policy wording, he would had called or informed opposite party Nos.2 and 3 about non- receiving of the policy wordings, but nothing was received from his side about non-receiving of the terms and conditions till the filing of the complainant. Further preliminary objections are that the complaint has been filed without any cause-of-action. The complainant has tried to manipulate the facts for imposing this false and frivolous complaint. The claim of the deceased/insured Mr.Tara Singh was duly entertained in due course on being presented and entire case with all set of papers was gone through by opposite party Nos.2 and 3. During processing, it was observed, established and even presented that the insured Late Mr.Tara Singh died due to Acute Coronary Syndrome with Left Ventricular Function. As per documents submitted by the complainant, the insured died due to Acute Coronary Syndrome with Left Ventricular Function. However, aliment suffered by the insured is excluded from the section of Critical illness of the policy. Since the losses claimed under Critical illness were excluded as per the policy wording, the insurance company treated the claim as 'No Claim' and conveyed the same to the complainant vide letter dated 24.7.2018. It is further admitted that Tara Singh purchased Sarv Suraksha policy having policy bearing No.2950 2008 4534 0200 000 valid from 4.9.2014 to 3.9.2019. The policy was not a life insurance policy and further opposite party Nos.2 and 3 run their business under general insurance in India. As per policy purchased by the complainant, the policy covered risks, which were only related with of coverage as provided under coverage details which is described as under: Coverage | Premium | Sum Insured | Coverage | Premium | Sum Insured | 1. Loss of Job (3 EMI) | 473 | 1,00,000/- | 5. Critical Illness | 1276 | 1,00,000/- | 2. Accidental Death | 547 | 5,00,000/- | 6. Credit Shield Insurance | 912 | 5,00,000/- | 3. Permanent Total Disability | 729 | 5,00,000/- | 7. Garbage Cash | 821 | 3,500/- | 4. Accidental Hospital-ization | 365 | 1,00,000/- | 8. House-holders coverage | 607 | 1,50,000/- |
As per the coverage provided in the policy schedule, the complainant is entitled for only those risks that have been mentioned in the policy schedule and elaborated in the policy terms and conditions. The policy issued to the insurer is a survival benefit policy and not a compensation policy that is issued covering the death unlike Life Insurance Policy. It is further pleaded that claim was lodged by the complainant alleging that insured was admitted in Dayanand Medical College and Hospital, Ludhiana with complaint of chest pain since 8-10 days and died on 6.4.2018. The complainant by this complaint is claiming the sum insured against the Credit Shield Coverage. In this case, death of the insured happened due to the Acute Coronary Syndrome with Left Ventricular Function. As such, benefits are not attracted due to the policy terms and conditions. Opposite party Nos.2 and 3 are not liable to pay the balance loan amount. As per the definition of Accidental mentioned the Personal Accident coverage states that 'Accident' or 'Accidental means' a sudden, unintended and fortuitous external and visible event. In order to bring any claim under the preview of the Accident, one has to prove that the death happened due to the external and visible means. But in this case, the death happened due Acute Coronary Syndrome with Left Ventricular Function and not the due to any external or visible means. As such, the death of the insured cannot be called as a accidental death. Thus, the benefit under the coverage of credit shield is not payable. On merits, opposite party Nos.2 and 3 have reiterated their stand as taken in the preliminary objections as detailed above and denied all other averments of the complainant and prayed for dismissal of complaint. In support of his complaint, the complainant has tendered into evidence his affidavit dated 14/09/2018 (Ex. C-8) and other photocopies of documents (Ex. C-1 to Ex. C-7) and closed the evidence. In order to rebut the evidence of complainant, the opposite party No.1 has not led any evidence. Opposite party Nos.2 and 3 tendered into evidence affidavit of Sh.Pankaj Kumar dated 22-11-2018 (Ex.OP-2/14) and other photocopies of documents (Ex.OP-2/1 to Ex.OP-2/13) and closed evidence. We have heard learned counsel for the parties and gone through the record. Learned counsel for parties have reiterated their stand as taken in their respective pleadings and detailed above. We have given careful consideration to these submissions. In this case, admitted facts are that policy was issued in the name of deceased Tara Singh by the opposite parties No. 2 & 3 and complainant is nominee of insured. It is also admitted that on death of Tara Singh claim was submitted with the opposite parties No. 2 & 3 and the same was repudiated. Ex. OP-2/2 is the claim repudiation letter dated 24-07-2018 and the claim has been repudiated on the ground that critical illness does not meet the requirement for its eligibility as per the policy terms and conditions. So, the claim is not admissible and the losses are not payable and opposite parties No. 2 and 3 close the claim as “No Claim” in their record. Further it has been mentioned in this letter that “As per the case summary received, Late Mr. Tara Singh was diagnosed to be suffered from Coronary Artery Disease with Triple vessel disease. The said aliments are not covered under policy, Hence, claim is repudiated. It is further referred that disease covered under section 1; Critical Illness – 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. 10. Permanent Paralysis of Limbs Since the under Critical Illness are not covered as per above policy wording, we treat the claim as “No Claim”. Perusal of the claim form Ex. OP-2/3 reveals that the claim was filed by complainant in respect of critical illness and credit shield. Heart Attack (Myocardial Infarction) is mentioned as critical illness. Ex. OP-2/13 are the terms and conditions of policy. As per Section 1 CRITICAL ILLNESS: If the Insured person named in the schedule is diagnosed as suffering from a Critical Illness which first occurs or manifests itself during the Policy Period and the Insured survives for a minimum of 30 days from the date of diagnosis, the company shall pay the Critical Illness benefits as shown in the schedule :- 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:- (i) A history of typical clinical symptoms consistent with the diagnosis of Acute Myocardial Infarction (for e.g. typical chest pain) (ii) New characteristic electrocardiogram changes (iii) Elevation of infarction specific enzymes, Troponins or other biochemical markers. The following are excluded: (i) Non ST-segment elevation myocardial infarction (NSTEM) with only elevation of Troponin I or T (ii) Other acute Coronary Syndromes (iii) Any type of angina pectoris. Perusal of the document Ex. OP-2/1 i.e. death summary reveals that insured was admitted in Dayanand Medical College & Hospital on 06-04-2018 and he died on the same day. Further perusal of this document reveals that insured was also treated by the said hospital on 30-08-2016 for CAD - Triple Vessel Disease. Document Ex. OP-2/4 further reveals that insured Tara Singh remained admitted from 25-08-2016 to 06-09-2016. We are of the view that as per Section 1 Critical Illness, if the Insured person named in the schedule is diagnosed as suffering from a Critical Illness which first occurs or manifests itself during the Policy Period and the Insured survives for a minimum of 30 days from the date of diagnosis and only in case of first heart attack of specified severity, the company shall pay the Critical Illness benefits as shown in the schedule. As per this condition of the policy, the insured was entitled to get benefit of the policy if insured would have survived minimum of 30 days of diagnosis but in this case insured died on the same day when he got admitted in the hospital. Further perusal of hospital record reveals that insured was also remained admitted in hospital in the year 2016 for Heart Disease which proves that present Heart Attack is not First Heart Attack. So far as the contention of complainant qua Credit Shield Coverage under this policy is concerned, as per section 5 of the policy, it was to be applicable only in the event of accidental death or Permanent Total Disability of insured person during the policy period. So, as discussed above, we are the view of that complainant is failed to prove any deficiency in service or unfair trade practice on the part of opposite parties. Resultantly, this complaint fails and is hereby dismissed with no order as to costs. The complaint could not be decided within the statutory period due to heavy pendency of cases. Copy of order be sent to the parties concerned free of cost and file be consigned to the record room. Announced : 14-09-2022 (Kanwar Sandeep Singh) President (Shivdev Singh) Member
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