IN THE HIGH COURT OF JUDICATURE AT MADRAS
PUSHPA SATHYANARAYANA, J.
Jasmine Ebenezer Arthur – Appellant
Versus
HDFC ERGO General Insurance Company Limited – Respondent
W.P.No.22234 of 2016 and W.M.P.Nos.18968 of 2016 and 26265 of 2018
Decided on : 06-06-2019
Constitution of India, 1950 - Article 12 - Contract of insurance - Home Loan Agreement - Petition has been instituted by petitioner of Mandamus directing first respondent herein to honour her claim in respect of Health Insurance Policy availed by her husband in Policy without insisting for any further documentations or particulars - Petitioner as has been culled out from affidavit and typed set of papers runs infra - Petitioner and her husband applied for Home Loan with second respondent for property located at Plot An offer letter was issued in favour of petitioners husband whereby sum of was sanctioned to them which has to be repaid in Equated Monthly Installments each - Home Loan Agreement was also entered into between parties – Held, Insurance companies should focus on educating their customers about their financial backing - Such propagation and education should not only be in form of issuing pamphlets booklets etc. to customers but also providing them with audio and visual forms such as informative slides conversational videos educating about Frequently Asked Questions etc which could be given either via CDs or e-mails in bilingual - Reason being even educated professionals of large portion of population are unaware of various insurance plans and risk involved in insurance companies cannot wash their hands by merely contending that every minute information has been given in offer documents and insured accepted those conditions by affixing their signature in documents as those information were never noticed by insured - Companies should concentrate on factors like right mix of flexibility risk and return which will suit customer – Petition closed
ORDER :
This writ petition has been instituted by the petitioner seeking a Writ of Mandamus directing the first respondent herein to honour her claim of Rs.36,45,813/- in respect of Health Insurance Policy availed by her husband in Policy No.2918200650184900000 dated 31.12.2013 without insisting for any further documentations or particulars.
2. The case of the petitioner, as has been culled out from the affidavit and the typed set of papers, runs infra :
2.1. The petitioner and her husband applied for a Home Loan with the second respondent for the property located at Plot No.19, Survey No.371/6A2, Srikrishna Nagar, S.Kolathur, Chennai. An offer letter dated 31.07.2013 bearing File No.609270480/DE107 was issued in favour of the petitioner's husband, whereby, a sum of Rs.35,00,000/- was sanctioned to them, which has to be repaid in 120 Equated Monthly Installments of Rs.47,522/- each. Home Loan Agreement dated 16.12.2013 was also entered into between the parties.
2.2. The petitioner stated that her husband was advised to avail insurance coverage for the Home Loan called Home Suraksha Plus stating that the said insurance policy, inter alia, covers Critical Illness Diagnosis as well. Section 3(c) of the Policy also provides coverage for “Myocardial Infarction”. He took the policy bearing No.2918200650184900000 dated 31.12.2013, by paying a premium of Rs.1,45,812/- covering the period upto 30.12.2018.
2.3. The couple were residing in Abu Dhabi. On the fateful day, when the petitioner's husband was proceeding to his office by driving the car, he suffered massive cardiac arrest and was rushed to Mafraq Hospital. It was diagnosed that he suffered from cardiac arrest and he went through ventricular fibrillation. However, he breathed last on 06.04.2015 in Abu Dhabi, where, no post-mortem could be conducted.
2.4. The petitioner filed a claim petition on 20.04.2015, which was assigned No.C291815000056. Since there was inaction on the part of the first respondent, she lodged a complaint with the grievance cell, thereupon, she was told on 13.10.2015 that the document with respect to the “cause of Ventricular Fibrillation and Cardiac Arrest from treating Doctor” was required. She received the same on 22.11.2015 from Mafraq Hospital and submitted it with the first respondent on 24.11.2015, which was received by them on the very next day, i.e., on 25.11.2015. As per the report, the cause of the death of her husband was “acute coronary artery syndrome”.
2.5. The petitioner was informed during January, 2016, that her claim had been repudiated on the ground that the cause of death of her husband was not covered under 'Major Medical Illness”. Aggrieved by such repudiation, the petitioner lodged a complaint with the grievance cell on 03.03.2016, which did not yield any positive response. Hence, she filed a complaint with the Insurance Ombudsman, Chennai, on 15.04.2016, which was dismissed vide Award dated 15.05.2016.
2.6. In such a backdrop, the petitioner is before this Court with the aforesaid prayer.
3. The first respondent filed a counter-affidavit dated 07.01.2019 refuting the allegations. It is claimed that the first respondent is not a “State” within the meaning of Article 12 of the Constitution and hence, by merely impleading the third respondent as a party, the writ petition seeking Mandamus against the first respondent is not maintainable in law. Since the petitioner and the first respondent only have a contractual relationship, she cannot maintain this writ petition and she should have approached appropriate forum to ventilate her grievance, by placing reliance on oral and documentary evidence. The cardiac arrest suffered by the petitioner's husband is not Myocardial Infarction and thus, not covered under the policy and hence, she cannot stretch the policy to include the uninsured risks or derive any extraordinary benefits and they have not denied any lawful right covered under the policy. To substantiate this claim, it is stated that they have r
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