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2021 Supreme(Online)(NCDRC) 279
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION
MRS. JUSTICE DEEPA SHARMA, PRESIDING MEMBER, MR. SUBHASH CHANDRA, MEMBER
HDFC ERGP GENERAL INSURANCE CO. LTD. – Appellant
Versus
PRIYA SINGH – Respondent
FIRST APPEAL NO. 267 OF 2021
For the Appellants/Petitioners: Ms. Suman Bagga
For the Respondents: Mr. Jitesh Vikram Srivastava
The court upheld that the insurance claim for End Stage Liver Disease was valid, confirming the lower court's ruling on coverage despite the insurer's rejection.
Headnote:(A) Consumer Protection Act, 1986 - Section 19 - Appeal against the order of the State Commission directing payment of Rs.33,27,346/- for deficiency in service due to wrongful rejection of insurance claim - Coverage of End Stage Liver Disease contested by the insurance provider. (Paras 1, 3, 5, 11, 13)
(B) The insured’s illness and cause of death were well-documented, displaying End Stage Liver Disease - The court upheld the State Commission’s findings that the claim was covered and refusal to honor it constituted a deficiency in service. (Paras 5, 12)
Facts of the case:
The insured had been admitted to a hospital, where he later died due to End Stage Liver Disease related complications, leading to a dispute over an insurance claim, which the Insurance Company had denied citing insufficient coverage under the policy terms.
Findings of Court:
The court established that sufficient evidence linked the insured’s death from chronic liver disease to the insurance policy, thus supporting the Complainant's claim.
Issues: Whether the disease leading to the death of the insured was covered by the insurance policy - The court confirmed it was.
Ratio Decidendi: The court found no fault in the lower commission’s ruling, confirming that the End Stage Liver Disease terms applied and the coverage included the circumstances of death.
Result: Appeal dismissed.
| Table of Content |
|---|
| 1. details on the insurance claim and its rejection. (Para 1) |
| 2. validity of the claim under insurance policy (Para 2 , 5 , 6) |
| 3. cause of death linking to insured condition (Para 3 , 4) |
| 4. overview of the lower court proceedings and arguments. (Para 7) |
| 5. assessment of coverage definitions and medical evidence (Para 8 , 9 , 10) |
| 6. final determination on insurer's obligations (Para 11 , 12 , 13) |
ORDER (ORAL)
The present Appeal, under Section 19 of the Consumer Protection Act , 1986 (for short “the Act”) has been filed by the Appellant (hereinafter be referred as “the Insurance Company”) against the order dated 09.02.2021 of the State Consumer Disputes Redressal Commission, Uttar Pradesh (for short “the State Commission”) in Complaint No.27 of 2020. Vide the impugned order, while allowing the Complaint of the Complainant, the State Commission has directed as under:
ORDER
“The complaint is allowed with cost partially. The opposite parties no 2 and 3 are directed to settle the claim of the complainant and pay her Rs.33,27,346/- at a rate of 10% simple interest per annum from the date of filing of this complaint within 30 days and if they fail to do so a higher rate of interest at the rate of 15% will be charged after 30 days till the date of payment. The opposite parties are also directed to pay Rs.2 lakh compensation for mental agony and, Rs.50,000 cost of the suit. If it is not paid within 30 days the complainant will be free to recover it through the court on the cost of opposite parties no. 2 & 3. Till then no recovery letter/notice/demand shall be issued and no interest shall be payable on loan amount by the complainant from the date of filing of the complaint till the payment of decreetal amount.”
2. The Insurance Company has challenged the impugned order solely on the ground that the disease which caused the death of the insured was not covered under the insurance policy and therefore, the impugned order suffers with illegality and infirmity and is liable to be set aside. It is argued that End Stage Liver Disease means, as per Clause of the Policy, end stage liver disease resulting in cirrhosis and evidenced by all of the following criteria; a) permanent jaundice, b) ascites, c) encephalopathy, d) portal hypertension. In present case, the cause of the death of the insured was not due to these reasons. The argument of learned Counsel for the Appellant is that the Death Summary itself shows that the immediate cause of death was sepsis with septic shock with multiorgan dysfunction syndrome which shows that the death of the insured was not due to End Stage Liver Disease.
3. Learned Counsel for the Complainant has argued that the Death Certificate which contains the illness history clearly shows that the insured had died of End Stage Liver Disease and it also elaborately mentions the reasons, illness and the symptoms with which the patient was suffering and for which he was treated in the Hospital but despite medical attention given to the patient, the Doctors could not save him and this fact clearly shows that he was suffering with End Stage Liver Disease. It is argued that had he not been suffering with the End Stage Liver Disease, the Doctors would have been able to save his life by providing the medical treatment.
4. We have heard the arguments at length and have given thoughtful consideration to the arguments as well as perused the documents on record.
5. The admitted facts of the case are that the diseases were covered by the insurance policy issued by the Insurance Company to the insured and one of the diseases, which was covered, was End Stage Liver Disease. The insured Abhishek Vikram Singh, who was the husband of the Complainant, was admitted in the Medanta Hospital on 21.06.2019 due to some serious illness where he died on 24.06.2019. The Death Certificate was issued on 01.07.2019. The Complainant submitted a claim of ₹33,27,346/- with the Insurance Company and other Respondents on 30.08.2019. The clai
