DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION ERNAKULAM
Dated this 9th day of August, 2024
.
Filed On: 08/09/2021
PRESENT
Shri.D.B.Binu President
Shri.V.Ramachandran Member Smt.Sreevidhia.T.N Member
CC No. 311/2021
COMPLAINANT
Vishnu Raj, Thekkemadathilparambil, Chemmanathukara P.O, Vaikom, Kottayam-686606
V/s
Opposite party
Health Claims Department, Navi General Insurance Limited, 1st Floor, Salarpuria Business Centre, 4th B Cross Road, 5th Block, Koramangala, Bengaluru, Karnataka, Pin-560095.
(Rep. by Adv. George A. Cherian, George Cherian Associates, St. Benedict 1st Cross Road, Ernakulam North, Kochi)
F I N A L O R D E R
V. Ramachandran, Member:
- A brief statement of facts of this complaint is as stated below:
The complainant filed a complaint under Section 35 of the Consumer Protection Act, 2019. The complainant met with a tragic bus accident on January 1, 2020, at Paravoor in Ernakulam district, which resulted in the total traumatic amputation of his left upper limb. He was admitted to Medical Trust Hospital, where he underwent multiple debridement procedures and a stump closure for his left arm. Due to the severity of his injury, the complainant lost his job as he was rendered incapable of performing daily activities, including his professional duties. The complainant was 31 years old when the bus accident occurred.
The complainant had taken a home loan from DHFL Bank, which was subsequently transferred to ICICI Bank. Along with the loan, the complainant was provided a Standard Fire & Special Perils Policy and a Group Critical Illness Insurance Policy by DHFL Bank, with coverage spanning from December 30, 2017, to December 29, 2022.
Following the accident and the resultant loss of his left hand, the complainant applied for compensation under the Group Critical Illness Insurance Policy, specifically under Section B-ii, which covers loss of job. Despite the severity of his condition and the evident loss of livelihood, the opposite party insurer failed to provide any response to his claim application.
This lack of response and the refusal to honour the insurance claim has led the complainant to approach the Consumer commission for redressal. He seeks compensation for the outstanding loan amount, damages for the deficiency in service, and relief from the financial burden imposed by the unpaid instalments. The case is brought against the opposite party, the insurance company, for their failure to fulfil the obligations under the insurance policy, thereby causing significant financial and emotional distress to the complainant.
2. NOTICE:
The Commission issued a notice to the opposite party, who subsequently filed their version.
3. THE VERSION OF THE OPPOSITE PARTY:
The opposite party, the insurance company, asserts that the complainant obtained a Group Critical Illness Insurance Policy and a Standard Fire & Special Perils Policy for his loan account No. 00010857, covering the period from December 30, 2017, to December 29, 2022. The Group Critical Illness Insurance Policy is designed to provide indemnity to the policyholder if any of the illnesses specified in the policy occur during the policy period.
The insurance company contends that the policy clearly defines the categories of critical illnesses covered and does not extend coverage to accidents or injuries resulting from road accidents. According to the opposite party, the complainant's injuries, which were sustained in a motor accident on January 1, 2020, and led to the loss of his left hand, are not covered under the scope of the Group Critical Illness Insurance Policy. They argue that the complainant should seek remedy for his accident-related injuries under the Motor Vehicles Act (M.V. Act).
The opposite party further clarifies that under the policy, a loss of job is covered only if it results from a critical illness as defined in the policy. Clause 2.2.4 of the policy specifically covers loss of employment due to critical illness, and Clause 2.1.1 defines the covered critical illnesses. The loss of an upper limb is not categorized as a critical illness under the policy, and therefore, the complainant’s claim is deemed to be outside the scope of coverage.
The insurance company also asserts that the complainant did not approach their grievance redressal cell before filing a complaint with the Insurance Ombudsman. They stated that they carefully scrutinized the claim and rightfully repudiated it on July 7, 2021, as it was outside the policy's coverage. The opposite party maintains that there is no deficiency in service or unfair trade practice on their part and requests that the commission dismiss the complaint with costs.
4. Evidence:
The complainant submitted a proof affidavit along with eight documents. The documents in the complaint are marked as Exhibits A1 to A8:
- Exhibit A1: Discharge Summary (Medical discharge summary detailing the treatment and condition of the complainant following the accident.)
- Exhibit A2: The copy of the Order of the insurance Ombudsman’s. (The official order issued by the Insurance Ombudsman concerning the dispute between the complainant and the insurance company.)
- Exhibit A3: The copy of the Letter from the Opposite Party
- Exhibit A4: Certificate of Disability. (Official document certifying the complainant's disability resulting from the accident.)
- Exhibit A5 Series: Insurance Policy Documents. (Copies of the insurance policy issued by the opposite party, including terms, conditions, and coverage details)
- Exhibit A6: Bank Passbook
- Exhibit A7: Repudiation Letter from Insurance Company
- Exhibit A8: Email Communications. (Copies of email correspondence between the complainant and the opposite party regarding the insurance claim and dispute.)
The Opposite Party submitted a proof affidavit along with one document, which is marked as Exhibit B1:
- The terms and conditions along with the schedule of the policy.
5. ARGUMENT NOTES FILED BY THE COMPLAINANT
The complainant was involved in a severe motor accident that led to the amputation of his left arm. The amputation was not merely a consequence of the initial injury but was necessitated due to a deep cut that resulted in a severe infection. The medical professionals informed the complainant that, without the amputation, there was a significant risk of systemic complications, including potential kidney damage, which could have led to a life-threatening situation.
Given the grave nature of the injury and the subsequent medical intervention, it is evident that the complainant has suffered a substantial physical and emotional toll. This has also directly impacted his ability to work, resulting in the loss of livelihood and the mounting burden of an outstanding loan.
In light of these facts, it is just and proper that the complainant be entitled to the insurance amount as per the policy. The commission is requested to direct the opposite party to provide the insurance benefit due to the complainant, along with compensation for the physical and financial hardships endured.
It is further prayed that the commission ensure that the insurance company fulfills its obligation under the policy, and that the complainant be compensated for the deficiency in service and the unfair trade practice exhibited by the opposite party.
6. Summary of the Argument Note Filed by the Counsel for the Opposite Party
Repudiation of Insurance Claim:
The complainant approached the court challenging the repudiation of an insurance claim under the "Loss of Job" clause (2.2.4). The respondent company rejected the claim based on the terms of the policy, which only covers job loss due to critical illness, not motor accidents.
Concurrent Legal Proceedings:
The complainant has also filed OP(MV) 1189/2020 before the Motor Accident Claims Tribunal (MACT), Ernakulam, seeking remedy for injuries sustained in a motor accident on 01/01/2020. The opposite party argues that since MACT has jurisdiction over the matter, the complainant cannot seek relief from multiple forums for the same incident.
Policy Coverage Limitations: The policy in question specifies various illnesses (clauses 2.1.1 to 2.1.1.41), but motor accidents are not included under critical illness. Thus, the losses suffered in the motor accident are not covered by the policy.
Ombudsman’s Award:
The Insurance Ombudsman passed an award on 29/03/21, directing the insurer to settle the claim of loss of job under the specified policy terms. The opposite party reiterates that the policy only applies to critical illness, not motor accidents, and the complainant has already received remedies for the accident under MACT.
Admission by Complainant:
The complainant admitted in the claim petition that the injury resulted from a road accident, which further supports the repudiation, as the policy does not cover such incidents. The repudiation was communicated to the complainant on 07/07/2021.
Jurisdictional Challenge:
If dissatisfied with the Ombudsman’s award, the complainant should challenge it in the High Court of Kerala, not in this commission.
Lack of Evidence:
The complainant’s claim for Rs. 1,38,037 as three EMI dues and Rs. 10,24,749 as the outstanding loan amount is unsupported by bank statements or records, rendering the case dismissible for insufficient documentation.
Case Laws Cited:
Oriental Insurance Co Vs Sony Cherian (1999 SCC 451): The terms of agreement must be strictly construed to determine the insurer's liability.
Export Credit Guarantee Corp of India Ltd Vs Garg Sons International (2014 SCC 686): Insured cannot claim more than what is covered by the policy.
Supreme Court Decision (2010 10 SCC 567): The terms of a contract of insurance must be given paramount importance.
Conclusion:
The opposite party concludes that they are not liable to pay any claims since the insurance policy only covers critical illness and not motor accidents. The complainant is, therefore, not eligible for any claim based on the policy and case laws.
7. Points for Consideration:
The main points to be analyzed in this case are as follows:
i) Whether there is any deficiency in service or unfair trade practice from the side of the opposite party to the complainant?
ii) If so, whether the complainant is entitled to get any relief from the side of the opposite party?
iii) Costs of the proceedings, if any?
The issues mentioned above are considered together and are answered as follows:
We have meticulously considered the detailed submissions of both parties, as well as thoroughly reviewed the entire record of evidence, including the argument notes.
8 . Background and Facts:
The complainant suffered a tragic motor accident on January 1, 2020, which resulted in the total amputation of his left upper limb. Following this incident, the complainant was unable to continue his professional duties, leading to a significant loss of income. The complainant had obtained a Group Critical Illness Insurance Policy through DHFL Bank, which was transferred to ICICI Bank. The policy was intended to cover critical illnesses and loss of job under specific conditions. Despite the severity of his condition and the resultant loss of livelihood, the insurance company repudiated his claim, leading the complainant to seek redressal through this Commission.
In the Revision Petition No. 2513 of 2019 reviewed by the Hon’ble National Consumer Disputes Redressal Commission, referenced a decision by the Hon’ble Supreme Court from the case Canara Bank vs. United India Insurance Co. Ltd. & Ors. [(2020) 3 SCC 455]. Held that:
“9. It was held by the Hon’ble Supreme Court in Canara Bank vs. United India Insurance Co. Ltd. & Ors. (2020) 3 SCC 455 that Insurance Policy must be read holistically so as to give effect to reasonable expectations of all parties, including the insured, coverage clauses to be read broadly, and ambiguity, if any, to be resolved in favour of the Insured, exclusions to be read narrowly. Hence, we do not find any reason to interfere with the order of the State Commission.”
In this cited Supreme Court case, it was held that an insurance policy should be interpreted as a whole to fulfil the reasonable expectations of all parties involved, particularly the insured. This interpretation means that coverage clauses should be construed broadly, while any ambiguities should be resolved in favour of the insured, and exclusion clauses should be interpreted narrowly.
In light of this precedent, the National Consumer Disputes Redressal Commission found no grounds to interfere with the decision of the State Commission of Rajasthan, effectively upholding the earlier ruling.
A. Deficiency in Service and Negligence:
The primary issue at hand is whether the opposite party acted negligently and displayed a deficiency in service by repudiating the complainant's claim. The opposite party argued that the policy did not cover injuries resulting from motor accidents and that the loss of job coverage was applicable only in cases of critical illness. However, the complainant has presented evidence, including a discharge summary, disability certificate, and communication records, to substantiate his claim that the loss of his left hand and subsequent loss of employment resulted from the accident.
Upon reviewing the terms and conditions of the Group Critical Illness Insurance Policy, it is evident that the policy defines certain illnesses under specific clauses. However, it is crucial to interpret the insurance contract holistically. The Hon’ble Supreme Court in Canara Bank vs. United India Insurance Co. Ltd. & Ors. [(2020) 3 SCC 455] emphasized that insurance policies should be read as a whole to fulfil the reasonable expectations of all parties involved, particularly the insured. Coverage clauses should be interpreted broadly, and any ambiguities should be resolved in favour of the insured.
In this context, the complainant's loss of job is a direct consequence of the severe injury sustained in the motor accident, which necessitated the amputation of his limb. The Commission observes that the opposite party’s narrow interpretation of the policy's terms to exclude coverage for such a significant loss is unjust and contrary to the principles laid out by the Hon’ble Supreme Court.
B. Liability of the Opposite Party:
Given the legal precedents and the facts of the case, it is evident that the opposite party failed to honour its obligations under the insurance policy by repudiating the complainant's claim without proper justification. The opposite party’s actions constitute a deficiency in service and negligence, causing significant financial and emotional distress to the complainant.
In considering the plight of the complainant, it is impossible to overlook the profound impact this tragic accident has had on a young life full of promise. At just 31 years old dedicated welder by profession, faced a life-altering event that not only took away his ability to work but also cast a shadow over his future prospects. The amputation of his left arm was not merely a physical loss but a devastating blow to his livelihood, which depended entirely on his skill and physical capability. As a welder, his hands were his tools, his means of earning a living, and securing a future for himself and his family. This sudden and severe setback has placed an overwhelming burden on him, both emotionally and financially.
Moreover, the complainant insured is eligible for compensation for loss of job, which is three EMIs or Rs.2,00,000/- whichever is lesser. The opposite party had not even considered the claims of loss of job as envisaged under relevant clause of Group Critical Illness Policy and hence this Commission is of the opinion that the repudiation of the claim of the complainant is without proper consideration and therefore the following orders are issued
Hence, the prayer is allowed as follows:
The Commission finds that the complainant is entitled to the insurance amount under the Group Critical Illness Insurance Policy.
The opposite party is directed to settle the complainant's claim for loss of job in compliance with the terms and conditions of the Group Critical Illness Policy for which the complainant is entitled to get. Complainant shall provide documents if any asked for by the opposite party which is essential to settle the claim on demand by the opposite party and the opposite party shall comply with the orders within 45 days from the date of receipt of such documents failing which the insurance company (opposite party) shall be liable to pay the amount due to the complainant by way of Group Critical Illness Policy (which shall be worked out by the opposite party) as per Policy with 9% interest from 08/09/2021 to the date of full realization of amount.
Pronounced in the open Commission on this the 9th day of August, 2024
Sd/-
V. Ramachandran, Member
Sd/-
D.B.Binu, President
Sd/-
Sreevidhia.T.N, Member
Forwarded/By Order
Assistant Registrar
Appendix
Complainant’s Evidence
Exhibit A1: Discharge Summary (Medical discharge summary detailing the treatment and condition of the complainant following the accident.)
Exhibit A2: The copy of the Order of the insurance Ombudsman’s. (The official order issued by the Insurance Ombudsman concerning the dispute between the complainant and the insurance company.)
Exhibit A3: The copy of the Letter from the Opposite Party
Exhibit A4: Certificate of Disability. (Official document certifying the complainant's disability resulting from the accident.)
Exhibit A5 Series: Insurance Policy Documents. (Copies of the insurance policy issued by the opposite party, including terms, conditions, and coverage details)
Exhibit A6: Bank Passbook
Exhibit A7: Repudiation Letter from Insurance Company
Exhibit A8: Email Communications. (Copies of email correspondence between the complainant and the opposite party regarding the insurance claim and dispute.)
Opposite party’s Exhibits
Exbt. B1: The terms and conditions along with the schedule of the policy
Despatch date:
By hand: By post
kp/
CC No. 311/2021
Order Date: 09/08/2024
