Agreeing with the concurrent findings recorded by the district forum and the state commission, the national consumer disputes redressal commission (NCDRC) directed HDFC ERGO General Insurance Company Ltd to pay Rs14.45 lakh death claim on home loan insurance and Rs22,000 as compensation towards mental agony and litigation expenses. The borrower or deceased life assured (DLA) died due to a stroke; however, the death claim was rejected by the insurer, saying that it does not fall under the nine major medical illnesses and procedures covered under the home loan insurance policy.
In an
order last month, the NCDRC bench of Dr Inder Jit Singh (presiding member) says, "We have carefully gone through the policy coverage clauses, exclusions and other relevant contents. The description of covered conditions narrated is not easy to understand for any normal individual who gets such an insurance policy. Only a medical expert in the field can exactly understand the detailed implications of such coverage and exclusion clauses."
"Normally, an insured will look at a broad description of coverage while taking such a policy. The policy schedule states nine major medical illnesses and procedures as listed therein are covered. The listing of such nine major items is in broad terms. It is difficult for an insurer to understand whether any specific health condition he may face under such broad heads will get covered or not. Hence, we find that there is some ambiguity in the coverage clauses and the insured was justified in interpreting the coverage clauses to assume that the diseases for which he has undergone treatment will get covered," the order says.
On 26 August 2015, Kandoola, Raigarh district from Chhattisgarh-based Ashok Patel, obtained a home loan of Rs14.45 lakh from HDFC Bank Ltd. To secure the loan, HDFC Bank obtained a five-year life insurance policy in the name of Ashok Patel from HDFC ERGO General Insurance. On 20 September 2017, during the policy period, Mr Patel was admitted to Sanjivini Nursing Home in Raigarh. Due to his serious condition, the next day, he was shifted to OP Jindal Hospital.
On 21 September 2017, while undergoing treatment, Mr Patel died due to a cardiac arrest. His mother, Rupkuwar Patel, filed the insurance claim which was rejected. The mother then sent a legal notice to HDFC ERGO General Insurance and HDFC Bank. While the insurer did not reply to the legal notice, the lender informed her that the insurance claim had already been repudiated on the ground that the death of Mr Patel, the DLA, was due to acute respiratory distress syndrome (ARDS), acute respiratory failure and sickle cell crisis which are not covered under the policy.
Ms Patel then filed a complaint before the Raigarh district consumer disputes redressal forum. On 21 May 2018, the district forum directed HDFC ERGO General Insurance to pay Rs14.45 lakh to Ms Patel within one month. The forum also asked the insurer to pay Rs20,000 as compensation for mental agony and Rs2,000 as litigation costs.
Aggrieved by the order, HDFC ERGO General Insurance filed an appeal before the Chhattisgarh state consumer disputes redressal commission. On 26 September 2019, the state commission dismissed the appeal, observing that HDFC ERGO General Insurance did not produce documents and had only refuted the claim in the written statement, whereas Ms Patel proved her complaint, letter and documents on evidence by way of affidavit.
HDFC ERGO General Insurance then approached NCDRC with its revision petition. It contended that the order passed by the state commission is bad both in law as well as on facts and ought to be set aside. "The state commission failed to appreciate the settled law that the onus is on the insured to prove that the claim falls under the purview of the policy. As per the claim form, Ms Patel had lodged a claim for 'stroke' but failed to establish that the insured had suffered or died due to a stroke. Therefore, the order is liable to be set aside on this sole ground itself."
The counsel for Ms Patel contended that the state commission held that if there was any error in the insurance proposal or in the insurance condition of the insurance policy and if the disease was out of the cover of the policy, then HDFC ERGO General Insurance should have produced the copy of that proposal with regard to those conditions of the policy.
Dr Singh from NCDRC observed that the counsel for the insurance company fairly agrees that even if at least one of these nine diseases is the cause of death, death due to multiple reasons will stand covered under the policy. On the other hand, the counsel for Ms Patel contended that the deceased died due to bradycardia with hypothyroidism, a type of cardiac arrest or stroke which is covered under serial number 7 of the list of nine diseases covered.
After reviewing some medical literature, the bench noted that bradycardia is a slow or irregular heart rhythm, usually fewer than 60 beats per minute. "At this rate, the heart is able to pump enough oxygen-rich blood to pump enough oxygen-rich blood to the body during normal activity or exercise. Hypotension refers to low blood pressure. Bradycardia with hypotension means a person has both a slow heart rate and low blood pressure. A stroke is a medical emergency that occurs when the blood supply to a part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients. While bradycardia itself is not a type of stroke, but it can related to stroke risk factors. Although bradycardia and stroke are two distinct medical conditions, bradycardia may affect blood flow to brain, potentially increasing the risk of ischemic events."
"After giving a thoughtful consideration to the entire facts and circumstances of the case, various pleas raised by the parties, we find that there is no illegality or material irregularity or jurisdictional error in the order of the state commission, hence the same is upheld. Accordingly, revision petition is dismissed," NCDRC says in the order.
(Revision Petition No2459 of 2019 Date: 16 October 2024)
They should have asked to pay all claims with 18 percent interest as charged by credit cards for delayed payment.