RESERVED

 STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

                              UTTAR PRADESH, LUCKNOW

                               COMPLAINT NO. 117 OF 2020     

01.Smt. Suman Verma

W/o Late Shri Sanjeev Kumar Verma

R/o 17-B Amar Bagh, Dayalbagh

Agra-282005

                                                                                         ...Complainant

                                                     Vs.

Tata AIG General Insurance Company Limited

1. A-501, 5^th Floor, Building No.4

Infinity IT Park, Dinoshi

Malad (E) 400097, Maharashtra

(2)Unit No. H-1 3^rd Floor

Padam Business Park Plot No.INS 1

Sector 12, Avas Vikas Colony,Sikandra

Agra-282007 (U.P.

                                                                                       ...Opposite Parties

BEFORE:

HON'BLE MR. JUSTICE ASHOK KUMAR, PRESIDENT

For the Complainant        :  Sri V S Bisaria, Advocate.

For the Opposite Party     :  Sri T J S Makker, Advocate.

Dated :  28-12-2022

                                            JUDGMENT

           MR. JUSTICE ASHOK KUMAR, PRESIDENT

Heard Sri V S Bisaria, learned Counsel for the complainant and Sri T J S Makker, learned Counsel for the opposite parties.

The instant complaint has been filed under Section 35 of the Consumer Protection Act, 2019 by the wife of the deceased late Sanjeev Kumar Verma with the following prayer:-

“It is, therefore, prayed that this Hon’ble District Council may kindly be pleased to pass an order for payment of Rs.33,33,523/- alongwith 18% interest thereon till the amount is paid to the complainant.

Cost of the complaint be also paid to the complainant which the Hon’ble Forum may deem fit and proper in the circumstances of the case.”

Facts of the case stated in brief are that the deceased Sanjeev Kumar Verma was insured by the opposite party under Home Guard Plus

:2:

Policy No. 0235324883. The policy was valid for the period 19-01-2017 to 18-01-2020. On 03-05-2019 unfortunately the deceased for the first time had suffered from massive heart attack and immediately his sons and relatives took him to G.G. Medical Institute and Research Centre, Agra where he was attended by their doctor and was declared to have been died/brought dead.

It is submitted by the learned Counsel for the complainant that the complainant immediately forwarded the claim for insurance amount as per policy of the opposite party but it repudiated the claim of the complainant on 16-10-2019 on the ground that while the deceased had expired on 03-05-2019 and the certificate issued by the G. G. Medical Institute and Research Centre, Agra is dated 21-06-2019.

The extract of the repudiation letter is as follows:-

“16 October 2019

To,

Mrs. Suman Verma

Wife of Mr. Sanjeev Kumar Verma

R/o 17-B, Amar Bagh, Dayal Bagh

Agra-282005

Uttar Pradesh

Tel: 9837351280

Sub : Death Claim of Mr Sanjeev Kumar Verma/Home Guard 0235324883/ Claim No. 0821609824A

This has reference to the above mentioned claim. We are extremely sorry to learn about the sad demise of Mr. Sanjeev Kumar Verma and pray for his soul to rest in peace.

We observe the following from the documents pertaining to the claim.

1. On 03-05-2019 51 yrs old insured was brought dead to G G Medical Institute and Research Centre, Agra.
2. We also note the certificate issued by G G Medical Institute and Research Centre is post date of loss dated 21 Jun 2019.

No other documents or information has been provided to

:3:

 substantiate the circumstances or cause of death and therefore, we are unable to determine any coverage under the policy which provides for such events.

As none of the submitted documents substantiate occurrence of any of the name Critical Illnesses under the policy, we regret out inability to assume any liability for the claim made under the above captioned policy.

Please note that the forgoing declination of the insurer’s liability is issued on the facts presently known. We reserve the right to extent and modify the declination should additional facts and circumstances become known to us.

For Tata AIG General Insurance Company Ltd.

                Sd/-

  AVP-Claims Department (A & T)”    

The deceased was just 51 years of age and, therefore, his relatives were shocked and his death gave a serious blow to the family and, therefore, since he was admitted in the aforesaid Medical Institute, the certificate was issued later.

It is further submitted by the learned Counsel for the complainant that the cause of repudiation by the opposite party is illegal, arbitrary and against humanity. No document can naturally be there to substantiate the circumstances or cause of death as for the first time he became ill and unfortunately expired because of severe cardiac arrest then and there and, therefore, the repudiation made by the Insurance Company is absolutely illegal and the complainant is entitled to the insured amount of Rs.33,33,523/- alongwith 18% interest thereon. The aforesaid facts constitute sufficient cause of action to file the complaint within the jurisdiction of this Commission and this Commission has right to entertain the complaint as the claim is of Rs.33,33,523/-.

In support of her complaint the complainant has filed the following document.

1. Affidavit of Smt. Suman Verma the complainant.
2. Home Guard Plus Policy Schedule.
3. Death Certificate issued by Sub-Registrar (Birth & Death),

Nagar Nigam, Agra.

4. Certificate of Medical Officer of G.G. Medical Institute & Research Centre, Agra.
5. Claim Forum.
6. Repudiation letter dated 16-10-2019 issued by the Insurance Company.

The opposite party Insurance Company thereby filing the written statement did not deny the factum of the death of the deceased Sri Sanjeev Kumar Verma. The submission of the claim before the opposite party by the complainant has also not been denied. The opposite party Insurance Company has denied the allegations made by the complainant.

It is submitted by the learned Counsel for the opposite party, Insurance Company that the deceased was insured for a sum of Rs.33,33,523/- and any claim under the policy is payable subject to it’s coverage as well as terms and conditions. As per records/documents/information made available to the answering opposite party, the insured died on 03-05-2019. The complainant lodged a claim with the opposite party on 02-08-2019 under the coverage of Accidental Death of the subject policy. When a callback was arranged with the family member to get the claim details, it was informed that the insured met with an accident at home and died on the way to the hospital.

It is further submitted by learned Counsel for the opposite party that as per the certificate dated 21-06-2019 issued by G. G. Medical Institute & Research Centre as provided by the complainant, it is stated that Mr. Sanjeev Kumar Verma was brought dead to the hospital. There is no mention of cause of death in the certificate. The complainant failed to provide any medical records, documents or information to substantiate that death of the insured resulted from accident, as intimated. The complainant also failed to provide any medical record or document to the answering opposite party to substantiate occurrence of any of the critical illnesses covered under the policy as such the opposite party was left with no alternative except to regret its inability to assume any liability under the policy. The relevant extract of policy wordings with respect to coverage is as follows:-

:5:

Learned Counsel for the opposite party has also mentioned the relevant portion of the policy with respect to the details of critical illnesses as covered under the policy are as under:-

Covered Critical Illness : A “Critical Illness” shall mean any one of the following critical illness and it is subject to fulfilment of all conditions as defined above of this benefit and as applicable particularly to each Critical Illness as defined below

C1 – Cancer of specified severity

C2 – Kidney Failure Requiring Regular Dialysis

C3 – Multiple Sclerosis with persisting symptoms

C4 – Major Organ/Bone Marrow Transplant

C5 – OpenHeart Replacement or Repair of Heart Valves

C6 – Open Chest CABG

C7 – Stroke resulting in Permanent Symptoms

C8 – Permanent Paralysis of Limbs

C9 – First Heart Attack – of specified severity

The complainant apparenty relied upon the claim under C9 which has been clarified through policy wording as under:-

C9 – 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

:6:

supply to the relevant area. The diagnosis for this will be evidenced by all of the following criteria:

1. History of typical clinical symptoms consistent with the diagnosis sof Acute Myocardial Infarction (for e.g.typical chest pain)
2. New characteristic electrocardiogram changes
3. Elevation of infarction specific enzymes, Troponins or other specific biochemical markers.

The following are excluded : 1. Non-ST-segment elevation myocardial infarction (NSTEMI) with elevation of Troponin I or T; 2. Other acute Coronary Syndromes 3. Any type of angina pectoris.

That mode of diagnosis for the critical illnesses as mentuioned in the poicy wording is as under:-

14.Diagnosis – means the definitive diagnosis made by a Physician as herein below defined, based upon such specific evidence, as referred to herein below in the definition of the particular Critical Illness concerned, or, in the absence of such specific evidence, based upon radiological, clinical, histological or laboratory evidence acceptable to the Company.

It is submitted by the learned Counsel for the opposite party that moreover the certificate dated 21-06-2019 was issued after about 50 days from the date of death and did not bear any reference number nor mentioned any cause of death of the insured as such was found to be not reliable for the purposes of claim under the policy.

It is submitted by learned Counsel for the opposite party that since the death of insured did not result from any of the perils covered under the policy, hence the claim of the complainant was denied vide letter dated 16-10-2019 and in the given set of circumstances, the present complaint is liable to be dismissed. No cause of action accrued to the complainant for filing of complaint. Also the Hon’ble Commission does not have jurisdiction to try and entertain present complaint.

It is further submitted by the learned Counsel for the opposite party that the policy of insurance is a contract between the insurer and insured and the claim, if any, is payable only under the terms of the policy for the

:7:

risks covered, subject to complaine of statutory provisions and exclusion clauses. When the claim was lodged by the complainant, the claim was duly processed but it transpired that the cause of death of the insured was beyond the scope of policy obtained since the policy coverd death only or under specified diseases and not under all medical conditions. Since the insured suffered natural death without contracting any of the specified illnesses, the claim was rightly repudiated being beyond the scope and coverage obtained under policy. Since the insured died of causes/illnesses other than specified in the policy, the claim was rightly repudiated. There is absolutely no deficiency in services rendered by the opposite party and as such the instant claim before this Hon’ble Commission is not maintainable. Even otherwise, in the circumstances of the case, this Hon’ble Commission has no jurisdiction to try and adjudicate this complaint and the complainant may agitate his grievance before appropriate authority if so advised. The complaint filed by the complainant is liable to be dismissed with special cost.

In support of the written statement the opposite party has filed the following documents:-

1. The copy of policy with terms and conditions.
2. The copy of the claim form submitted by the complainant.
3. The copy of the certificate dated 21-06-2019 issued by G G Medical Institute & Research Centre.

 I have heard learned Counsel for the parties and perused the documents which are referred by the learned Counsel for the respective parties.

Learned Counsel for the complainant has argued that the opposite party has insured the deceased under Home Guard Plus Policy No. 0235324883. The policy was valid for the period 19-01-2017 to 18-01-2020. On 03-05-2019 unfortunately the deceased for the first time had suffered from massive heart attack and he was taken to G.G. Medical Institute and Research Centre, Agra immediately where he was attended by the doctor and was declared to have been died/brought dead.

Learned Counsel for the complainant has further argued that the claim form was submitted to the opposite party for payment of insured

:8:

amount as per terms and conditions of the policy but the opposite party repudiated the claim of the complainant on 16-10-2019 on the ground that while the deceased had expired on 03-05-2019 and the certificate issued by the G. G. Medical Institute and Research Centre, Agra is dated 21-06-2019. The deceased was just 51 years of age and, therefore, his relatives were shocked and his death gave a serious blow to the family and, therefore, since he was admitted in the aforesaid Medical Institute, the certificate was issued later.

It is argued by the learned Counsel for the complainant that the cause of repudiation by the opposite party is illegal and arbitrary and against humanity. No document can naturally be there to substantiate the circumstances or cause of death as for the first time he became ill and unfortunately expired because of severe cardiac arrest then and there and, therefore, the repudiation made by the Insurance Company is absolutely illegal and the complainant is entitled to the insured amount of Rs.33,33,523/- alongwith 18% interest thereon. The aforesaid facts constitute sufficient cause of action to file the complaint within the jurisdiction of this Commission and this Commission has right to entertain the complaint as the claim is of Rs.33,33,523/-.

Learned Counsel for the opposite party, Insurance Company has argued that the deceased was insured with the opposite party and any claim under the policy is payable subject to it’s coverage as well as terms and conditions of the policy. As per records/documents/information made available to the opposite party, the insured died on 03-05-2019 and the claim was lodged with the opposite party on 02-08-2019 under the coverage of Accidental Death of the subject policy. When a callback was arranged with the family member to get the claim details, it was informed that the insured met with an accident at home and died on the way to the hospital.

It is further argued by learned Counsel for the opposite party that as per the certificate dated 21-06-2019 issued by G. G. Medical Institute & Research Centre as provided by the complainant, it is stated that Mr. Sanjeev Kumar Verma was brought dead to the hospital. No cause of death has been mentioned in the certificate. The complainant failed to

:9:

provide any medical records, documents or information to substantiate that death of the insured was caused due to accident.

Learned Counsel for the opposite party has argued that the complainant also failed to provide any medical record or document to the opposite party to substantiate occurrence of any of the critical illnesses covered under the policy as such the opposite party was left with no alternative except to regret its inability to assume any liability under the policy.

It is further argued by the learned Counsel for the opposite party that moreover the certificate dated 21-06-2019 was issued after about 50 days from the date of death and did not bear any reference number nor mentioned any cause of death of the insured as such was found to be not reliable for the purposes of claim under the policy.

It is submitted by learned Counsel for the opposite party that since the death of insured did not result from any of the perils covered under the policy, hence the claim of the complainant was denied vide letter dated 16-10-2019 and in the given set of circumstances, the present complaint is liable to be dismissed. No cause of action accrued to the complainant for filing of complaint. Also the Hon’ble Commission does not have jurisdiction to try and entertain present complaint.

It is further argued by the learned Counsel for the opposite party that the policy of insurance is a contract between the insurer and insured and the claim, if any,is payable only under the terms of the policy for the risks covered, subject to complaine of statutory provisions and exclusion clauses.

When the claim was lodged by the complainant, the claim was duly processed but it transpired that the cause of deathy of the insured was beyond the scope of policy obtained since the policy coverd death only or under specified diseases and not under all medical conditions. Since the insured suffered natural death without contracting any of the specified illnesses, the claim was rightly repudiated being beyond the scope and coverage obtained under policy. Since the insured died of causes/illnesses other than specified in the policy, the claim was rightly repudiated. There is absolutely no deficiency in services rendered by the opposite party and

:10:

as such the instant claim before this Hon’ble Commission is not maintainable. Even otherwise, in the circumstances of the case, this Hon’ble Commission has no jurisdiction to try and adjudicate this complaint and the complainant may agitate his grievance before appropriate authority if so advised. The complaint filed by the complainant is liable to be dismissed with special cost.

Learned Counsel for the opposite party has argued that the complainant is not entitled to any relief as no deficiency is being caused by the opposite party at any point of time. The instant complaint is abuse and misuse of process of law. The complaint of the complainant may kindly be dismissed with cost.

Having heard the arguments of learned Counsel for both the parties and after considering the facts and circumstances of the case I am of the positive opinion that the submission of learned Counsel for the complainant appeares to be justified and the ground alleged by the opposite party for repudiation of claim is not justified and the complainant was entitled to recover the claim under the insurance policy.

In view of the aforesaid, I am of the positive opinion that the argument of the learned Counsel for the complainant has force and the complaint of the complainant is liable to be allowed. The opposite parties are liable to pay the amount of Rs.33,33,523/- (Rupees Thirty Three Lacs Thirty Three Thousand Five Hundred Twenty Three only) towards the sum insured under the policy of insurance issued by the opposite parties  and since the repudiation was unwarranted she will also get interest. The opposite parties are liable to pay interest at the rate of 06% per annum with effect from the date of claim lodged by the complainant with the opposite party till the actual payment of insurance amount is paid to the complainant. Apart from that I also direct the opposite parties to pay sum of Rs.20,000/- (Rupees Twenty Thousand Only) towards the cost of the case. The aforesaid amount is directed to be paid by the opposite parties to the complainants within a period of 60 days from the date of the delivery of the judgment.

                                     ORDER 

The complaint is allowed. The opposite parties are directed to pay

:11:

the amount of Rs.33,33,523/- (Rupees Thirty Three Lacs Thirty Three Thousand Five Hundred Twenty Three only) towards the sum insured under the policy of insurance issued by the opposite parties. The opposite parties are further directed to pay interest at the rate of 06% per annum with effect from the date of claim lodged by the complainant with the opposite party till the actual payment of insurance amount is paid to the complainant. Apart from that I also direct the opposite parties to pay sum of Rs.20,000/- (Rupees Twenty Thousand Only) towards the cost of the case. The aforesaid amount is directed to be paid by the opposite parties to the complainants within a period of 60 days from the date of the delivery of the judgment.

Let copy of this order be made available to the parties as per rules.

The Stenographer is requested to upload this order on the website of this Commission today itself.    

                                                      ( JUSTICE ASHOK KUMAR )

                                                                     PRESIDENT

           Pnt.