IMPORTANT POINT
Insurance Policy – Ambiguity in coverage clauses of disease – Repudiation of claim not justified.

ORDER

The present Revision Petition (RP) has been filed by the Petitioner against Respondents as detailed above, under section 21(b) of Consumer Protection Act, 1986 against the order dated 26.09.2019 of the State Consumer Disputes Redressal Commission, Chhattisgarh (hereinafter referred to as the ‘State Commission’), in First Appeal (FA) No. 18/645 in which order dated 21.05.2018 of District Consumer Disputes Redressal Forum, Raigarh (hereinafter referred to as District Forum) in Consumer Complaint (CC) No. 31/2018 was challenged, inter alia praying for setting aside the order dated 26.092019 passed by the State Commission and for dismissing the Complaint filed by Respondent-1/complainant before the District Forum.

2. While the Revision Petitioner (hereinafter also referred to as OP-3/Insurance Company) was Appellant before the State Commission and OP-3 before the District Forum and the Respondent-1 (hereinafter also referred to as Complainant) was Respondent-1 before the State Commission and Complainant before the District Forum and Respondent-2/HDFC Ltd. (hereinafter referred to as Bank) were Respondent-2 before the State Commission in FA/18/645 and OPs- 1 & 2 before the District Forum in Complaint No. 31/2018.

3. Notice was issued to the Respondents on 04.12.2019. Parties filed Written Arguments on 23.02.2024 (Petitioner), 17.11.2020 & on dated nil (Respondent-1) and 10.11.2023 (Respondent-2) respectively.

4. Brief facts of the case, as emerged from the RP, Order of the State Commission, Order of the District Commission and other case records are that: -

Respondent-1/Complainant’s son (deceased) had taken home loan of Rs.14,45,000/- from Respondent-2 Bank/OPs- 1 & 2 on 26.08.2015 for purchasing a Flat No. 307, Third Floor in Chandra Paradise, Raigarh. Bank had obtained Life insurance policy from OP-3/Petitioner herein in the name of Ashok Patel to secure the loan account. The policy was valid from 30.09.2015 to 29.09.2020. In the said period of Insurance, on 20.09.2017 assured was admitted to Sanjivini Nursing Home, Raigarh. The condition being serious, on 21.09.2017 the assured was shifted to O.P. Jindal Hospital, Raigarh. During the treatment assured died due to cardiac arrest on 21.09.2017. The complainant, the mother of the assured, filled claim form for the payment/adjustment of said home loan of Rs.14,45,000/-, but OP-3 did not settle the claim. The Complainant sent a legal notice dated 12.01.2018 to OP-3, but the OP did not settle the claim and did not give reply to the legal notice. Bank vide reply dated 19.01.2018 informed the complainant that claim has already been repudiated vide letter dated 15.11.2017 on the ground that death of assured was due to Acute Respiratory Distress Syndrome (ARDS), Acute Respiratory Failure, Sickle Cell Crisis. The said ailments are not covered under policy. Hence, the complainant filed complaint.

5. Vide Order dated 21.05.2018, in the CC No. 31/2018, the District Forum allowed the complaint and passed the following order directing the OP-3:

“a) The respondent No.3 will pay Rs.14,45,000/-(Rupees fourteen lakh, forty five thousand only) to the applicant within a period of one month.

b) The respondent No. 3 will pay Rs.20,000/- (Rupees twenty thousand only) as compensation towards mental agony and Rs.2,000/- (Rupees two thousand only) towards litigation expenses to the applicant within period of one month.

c) The respondent No. 3 should pay the decretal amount within a period of one month, in default will be liable to pay interest @ 9 per cent per annum from the date of filing the complaint on dated 26.02.2018 till realisation.”

6. Aggrieved by the said Order dated 21.05.2018 of District Forum, Petitioner/Insurance Company appealed in State Commission and the State Commission vide order dated 26.09.2019 in FA No. 18/645 dismissed the Appeal and affirmed the order passed by the District Forum.

7. Petitioner have challenged the said Order dated 26.09.2019 of the State Commission m