HDFC ERGO GENERAL IN... v. Ms. S.Krishnaveni T

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insurance premium of the complainant Ms.S.Krishnaveni.T for the period from 27.09.2019 to 26.09.2024. The complainant and her husband stood as nominees for each other's insurance premium policy. The said policy covers the claim under different factors under which "Major Medical Ill-ness" and "Procedures" was one of the factors. The said insurance policies were taken to protect the family of the complainant during the difficult times. The husband of the complainant died on 31.05.2021 due to cardio pulmonary arrest, post Covid mucormycosis, lateral rhinostomy with right partial maxillectomy, viral fever, acute respiratory distress syndrome secondary to viral infection with covid positive status. After the death of her husband, the complainant was looking after two young girl children and the parents of her deceased husband, who were dependent on her. After the death of her husband, the complainant approached the office of the opposite parties for claim of policy under the head "Major Medical Ill-ness" and "Procedures"

as she is the nominee of the policy. The complainant submitted her claim form dated 19.07.2021 to the opposite parties. The same was received by the opposite parties on the same date, but the opposite parties rejected the claim stating that the said ailments were not covered under critical illness, as enlisted in Sec.3 and informed vide letter dated 14.08.2021.

b) The complainant further submitted that the Insurance Policy holder Late Sri Ramanjaneya Reddy Kunduru, died of cardio pulmonary arrest i.e. Heart Stroke due to Covid-19 and black fungus. In the letter given by the opposite parties, they had clearly mentioned that the stroke was covered under the said insurance

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policy. Her husband died due to cardio pulmonary arrest i.e. Heart Stroke due to Covid-19 and black fungus. Though Covid-19, came into effect after availing the insurance policy, it has become a critical and major serious illness from 2019. The opposite parties failed to recognize the fact that when once virus has become a threat to the lives of the people around the world and it has been declared as major critical ill-ness and serious disease, simply rejecting the claim by giving vague reasons that the said virus was not mentioned in the list of critical major illness was improper. The policy holder died due to Covid-19, Black Fungus and cardio pulmonary arrest i.e. heart stroke. The main purpose of the above said insurance policy was to provide assistance and benefit to the claimants, when the insured person was affected with major critical and serious ill-ness. The opposite parties failed to understand and rejected the claim with baseless and vague reasons. Aggrieved by the said rejection, the complainant preferred the complaint.

4. The Opposite Parties No.1 to 3 filed written version admitting issuance of Home Credit Assure Policy to the Complainant's late husband Sri Ramanjaneya Reddy Kunduru, but contended that the subject policy was not absolute in nature and their liability under the said policy was subject to the terms, conditions and limitations thereof. The said policy provides multiple coverage and eligibility under the said benefits have to meet certain criteria to avail them. They contended that the Complainant was not a consumer as defined U/s.2 (d) of the Consumer Protection Act, 2019 and the complaint filed by the Complainant would not come

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under the purview of the Consumer Dispute as envisaged in Section-2(e) of the Act. The Consumer Forum has no jurisdiction to entertain the complaint. The contract of Insurance does not fall under the purview of the Sale of Goods Act as defined under Section 2(i). They further submitted that on 21.07.2021, the Complainant approached them with a claim form for reimbursement of home loan as mentioned under the critical illness benefit of the policy. After verifying the records, it came to their attention that the subject claim was inadmissible as cause of death as per death summary was Covid-19 induced cardiac arrest which does not attract the criteria for availing benefits under the critical illness of the policy. As the subject claim was made for death caused due to Covid induced cardiac arrest, the claim was inadmissible. Fundamental difference between cardiac arrest and myocardial infarction was physiological function of the heart. During cardiac arrest heart muscles become arrested due to the abrupt loss of heart function, breathing and consciousness. On the other hand, in heart attack or its technical term myocardial infarction, the blockage prevents the oxygen rich blood from getting to the heart. The said two ailments were totally different, causes for their origin also differ. Both were not considered as same under the category of critical illness in the policy. As such they repudiated the claim by sending a repudiation letter dated 14.08.2021. The repudiation could not be termed as illegal, inadvertent and high-handed action. There was no deficiency of service or negligence or unfair trade practice on the part of the Opposite Parties. Neither party can travel beyond the terms and conditions of the policy. The Opposite Parties could not settle the

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claim in contravention of the terms and conditions of the policy. If the claim was not within the ambit of terms and conditions of the policy, the same could not be settled. They were not liable to pay any compensation as claimed by the Complainant. The complaint was not maintainable and prayed to dismiss the complaint.

5. The Opposite Party No.4 was shown as not necessary party and they filed written version contending that they were not into the home loan business and Insurance business and prayed to dismiss the complaint against them.

6. The Complainant filed her evidence affidavit as PW1 and got marked Ex.A1 to A10 on her behalf. The Opposite Parties No.1 to 3 got examined their Manager, legal as DW1 and got marked Ex.B1 to B4. The Branch Manager of the Opposite Party No.4 was examined as DW2.

7. Considering the oral and written submissions filed by the Complainant as well as the arguments of the Opposite Parties No.1 to 4, the District Commission observed that both cardiac arrest and stroke were inter-related and come under major medical illness that causes instant death. There was nexus between the stroke and cardiac arrest. The terms and conditions mentioned in the policy cover the risk to substantiate the claim made by the Complainant and allowed the complaint in part directing the Opposite Parties No.1 to 3 to pay the amounts as stated supra.

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8. Aggrieved by the said order passed by the District Commission, the Opposite Parties No.1 to 3 preferred this appeal contending that:

 The District Commission ought to have seen that the claim was made under major medical illnesses which covers only 9 types of major medical illness and procedures. However, in the present case, the death of the Insured was due to Covid-19 induced cardiac arrest, therefore, the same was inadmissible.

 The District Commission ought to have seen that there was a fundamental difference between the cardiac arrest and myocardial infarction. The two ailments were totally different. The causes for their origin also differ. Both cannot be considered as same under the category of critical illness in the policy. Since the claim does not come under the conditions mentioned under the policy under critical illness, the claim was repudiated vide letter dated 14.08.2021.  The District Commission ought to have seen that the subject policy was not a Covid tailored policy and death of the deceased does not fall under the purview in connection with policy benefits.

 The District Commission ought to have seen that the insurance was a contract and the terms and conditions have to be given strict meaning. The Commission could not substitute its own opinion for awarding compensation.  The District Commission ought to have followed the well- considered principles laid down in decided cases and ought to have dismissed the complaint in the interest of justice

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and prayed to allow the appeal by setting aside the order passed by the District Consumer Disputes Redressal Commission-II, Hyderabad.

9. Heard the learned counsel for the Appellants/Opposite Parties No.1 to 3, represented by Sri Gangadhar Rao Deshpande and the learned counsel for the Respondent No.1/Complainant, Smt.Ch.Laxmi Chaya. Respondent No.2 was shown as a proforma party. Both the counsel for Appellants and Respondent No.1 filed written arguments.

10. Now the points for consideration in this appeal are:-

(i) Whether the order passed by the District Commission is in accordance with the law and facts on record and whether the District Commission committed any error in passing the above judgment and whether the same is liable to be set aside, rectified or interfered with in any manner?

(ii) To what result?

11. Point No.1:-

As seen from the pleadings and the written arguments filed by both the parties, there is no dispute with regard to the Complainant and her deceased husband availing home loan facility from HDFC Bank Ltd., Hyderabad branch for an amount of Rs.29,70,000/- and obtaining insurance policy from HDFC ERGO General Insurance Company Limited and both the husband and wife stood as nominees for each other. It was also not disputed that the husband of the Complainant died on 31.05.2021 during the second wave of Covid-19 (Delta Variant) and the cause of death was recorded as Cardio Pulmonary arrest, Post Covid

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Mucormycosis and that the Complainant had submitted the claim form on 19.07.2021 and the said claim was repudiated by the Appellants/Opposite Parties No.1 to 3 vide their letter dated 14.08.2021 stating that the said ailment was not covered under medical illness enlisted in Section-3, major illness and procedures of the policy terms and conditions.

12. As such it was necessary to look into the terms and conditions of the policy. Ex.B1 is the policy. It is not a general insurance policy but it is Home Credit Assure Policy linked to the specific home loan taken by the policy holders i.e., the Complainant and her husband. The sum insured is fixed and covers only specified incidents like (i) Fire and allied perils, earthquake and terrorism (ii) Burglary, house breaking theft (iii) Major medical illness and procedures (iv) Personal accident (v) Loss of job. Each and every event is defined. The main purpose of this policy is to protect the loan but not to protect the family of the Insured. It was specifically designed to repay the outstanding home loan if the borrower dies during the loan tenure and protects the lender bank or financial institution. The premium collected is also a fixed amount. As per the Complainant they paid a one-time premium of Rs.45,101/- for Sri Ramanjaneya Reddy Kunduru and Rs.33,645/- for the Complainant for the period from 27.09.2019 to

26.09.2024.

13. Section-3 of the policy covers major illness and procedures. The policy specifies that under Major Medical Illness & Procedures, it covers only 9 events like:

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(1) Cancer

(2) End stage renal failure

(3) Multiple Sclerosis

(4) Major organ transplantation

(5) Heart valve replacement

(6) Coronary artery bypass graft

(7) Stroke

(8) Paralysis

(9) Myocardial infarction. It also specifies that in the certificate wordings, under the list of major medical illnesses and procedures enlisted under Section-III it has 18 illnesses/procedures. However, the coverage provided under the certificate of insurance was restricted only to the above mentioned major nine medical illnesses and procedures. Under Section-III (c) it covers stroke and myocardial infarction. Stroke is defined as any cerebro vascular incident producing permanent neurological sequelae. This includes infarction of brain tissue, thrombosis in an intra-cranial vessel, haemorrhage and embolisation from an extracranial source. The diagnosis has to be confirmed by a specialist medical and evidenced by typical clinical symptoms as well as typical findings in CT Scan or MRI of the brain. Evidence of permanent neurological deficit lasting for at least 3 months has to be produced.

14. As seen from Ex.A5, the husband of the Complainant Sri Ramanjaneya Reddy Kunduru died on 31.05.2021. As per the claim form submitted under Ex.B2, the Complainant claimed under the head Section-3 pertaining to major medical illness and procedures. As per Ex.A5, the copy of the death certificate issued by Osmania General Hospital, the cause of death of the deceased

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K.Ramanjaneyulu on 31.05.2021 was recorded as sudden cardio pulmonary arrest. The antecedent cause was shown as K/C/O Post Covid Mucormycosis, SIP (right lateral rhinotomy ć ® partial maxillectomy). As such the cause of death is cardio pulmonary arrest secondary to covid related complications but not due to stroke or myocardial infarction. The definition of stroke as per the policy terms and conditions should include infarction of brain tissue, thrombosis in an intracranial vessel, hemorrhage or embolization from an extracranial source with diagnosis for CT/MRI and evidence of permanent neurological deficit lasting for atleast 3 months. But no CT/MRI documented brain infarction/hemorrhage/embolism or 3 months neurological deficit was filed by the Complainant or recorded in Ex.B3.

15. Insurance liability arises only when the insured event falls squarely within the contractual definition. Mucormycosis is a fungal sinus infection but not stroke. It primarily effects paranasal sinuses, orbit, facial bones and occasionally brain. Mere severe infection or surgery (lateral rhinotomy/maxillectomy) does not amount to cerebral infarction, intracranial thrombosis or hemorrhagic stroke unless specifically demonstrated by neuro imaging. Cardiopulmonary arrest is the terminal mechanism of death. It occurs in all deaths and is not equivalent to cerebro vascular accident. The Complainant cannot equate cardiac arrest or systemic deterioration with stroke.

16. The burden of proof lies on the Complainant to establish occurrence of insured event. Mere assertion of stroke is

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insufficient. Medical evidence must strictly satisfy policy definition. In the absence of CT/MRI confirmation, the claim fails. For stroke coverage, the Complainant must prove brain infarction or intracranial thrombosis or hemorrhage, confirmed by CT/MRI. In the absence of imaging confirmation, no insured event occurred. There is no CT/MRI confirming infarction and no opinion of the Neurologist was placed by the Complainant diagnosing cerebrovascular infarction. The discharge summary was not mentioning as acute stroke except as post covid mucormycosis. The hospital records filed by the Complainant was showing only sinus/orbital mucormycosis for which a lateral rhinotomy and partial maxillectomy were conducted. The MRI report dated 26.05.2021 prior to his death does not disclose any cerebral involvement, infarct, thrombosis or intracranial extension. It shows the findings of brain as:

 Multiple small periventricular and subcortical hyperintense foci in bilateral frontal and parietal white matter.  Partial empty sella configuration.

 Cerebellum, 4^th ventricle, brain stem, CP angle regions, 7^th & 8^th nerve complexes, internal auditory canals, cavernous sinuses and flow voids of all the major intracranial vessels are within normal limits.

 Suprasellar & parasellar areas are normal.  The extracerebral spaces and supratentorial ventricular system are normal.

 Rest of cerebral parenchyma shows normal grey white matter differentiation, signal intensity values and sulcal/gyral pattern.

 Midline structures and corpus callosum are normal.  No haemorrhagic pathology/extraaxial collection seen.

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Thus MR image morphology showed only impression of symptoms of right sino-orbital fungal disease.

17. The Complainant had not examined any expert/doctor to prove that the cause of death of the deceased falls under either stroke or myocardial infarction. The Home Credit Assure Policy issued by the Appellants/Opposite Parties No.1 to 3 is a pre- defined critical illness cover issued in 2019 long before Covid-19 complications were widely known. Section-3 was drafted to cover only 9 specific major illnesses/procedures. The District Commission's approach treats Covid induced complications as if it was a 10^thcritical illness, contrary to policy structure. The Hon'ble Apex Court in several cases disapproved judicial addition of new heads of coverage in insurance contracts, emphasizing that sympathy for the insured cannot override the plain language of the contract.

18. The learned counsel for the Appellants/Opposite Parties No.1 to 3 relied upon the judgments of the Hon'ble Apex Court in -

a) General Assurance Society Ltd., Vs. Chandumull Jain, AIR 1966 SC 1644 wherein it was held that: "Insurance policy must be construed on its own terms; courts cannot make a new contract by adding to or deleting from the policy wording."

b) He further relied upon the judgment of Hon'ble Apex Court in Oriental Insurance Co.Ltd., Vs. Sony Cherian, (1999)

6 SCC 451 wherein it was held that: "Extent of insurer's liability is strictly as per policy; insured cannot claim anything more than what is covered; equitable considerations cannot expand the risk."

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c) He further placed reliance upon the judgment of the Hon'ble Apex Court in Export Credit Guarantee Corporation of India Ltd., Vs. Garg Sons International, (2014) 1 SCC 686

wherein it was held that: "Commercial insurance contracts are to be interpreted as commercial documents on their plain language; contra-proferentem applies only when there is real ambiguity."

d) He further placed reliance upon the judgment of the Hon'ble Apex Court in Vikram Greentech (India) Ltd., Vs. New India Assurance Co.Ltd., (2000) 3 SCC 673 wherein it was held that: "Where the policy clearly limits risk to specified contingencies, courts must give effect to such limitation and cannot extend cover to risks not so agreed."

e) He further placed reliance upon the judgment of the Hon'ble Apex Court in Manmohan Nanda Vs. United India Insurance Co.Ltd., (2013) 2 SCC 479, wherein it was held that:

"The insured cannot claim anything beyond what is covered; in Mediclaim/health policies listing specific covered events, the claim must fall strictly within those events."

19. The learned counsel for the Respondent/Complainant relied upon the judgments of the High Court of Madras in Writ Petition No.22234/2016 in Jasmine Ebenezer Arthur Vs. HDFC ERGO General Insurance Company Limited, wherein the Court obtained a report from the expert cardiologist who opined that

"Acute Coronary Syndrome (ACS) includes Myo-Cardial Infarction (MI). The cause of death is MI due to Ventricular Fibrillation (VF)." From the above, it was clear and evident that the cause of death of

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the Insured was well within the defined medical events prescribed in the policy.

20. But the facts of this case are different. There was no expert evidence showing that the deceased died due to Myocardial Infarction or stroke. The antecedent cause of death is shown as

"Post covid mucormycosis" which was not covered under the medical events prescribed in the policy.

21. The learned counsel for the Respondent further placed reliance upon the judgment of Tripura State Consumer Disputes Redressal Commission, Agartala in The Manager, Birla Sun Life Insurance Company Ltd., Vs.Sri Biplab Deb wherein the issue is whether the Coronary Artery Bypass Grafting (CABG) can be considered as heart attack and whether the Petitioner was entitled to get the medical illness benefit and observed that the ailment suffered by the Respondent was serious and life threatening. The Respondent suffered a serious heart ailment and an artery was found blocked and a stent was placed and as such it comes within the policy terms and conditions.

22. She further relied upon the judgments of the High Court of Madras in Writ Petition No.26233/2022 dated 29.04.2024 and of the judgment of the Consumer Disputes Redressal Commission, Gujarat in FA.No.236/2023 dated 31.05.2023. She also placed reliance upon the judgment of the Hon'ble Apex Court in Gurmel Singh Vs. Branch Manager, National Insurance Co.Ltd., in Civil Appeal No.4071/2022 which is completely different with the fact situations of the present case. It only holds that while settling

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the claims, the Insurance Company should not be too technical and ask for documents which insured cannot produce due to circumstances beyond his control. It was a case of truck being stolen and the Insurance Company refusing to settle the claim for non-submission of duplicate a certified copy of Certificate of Registration which is no way connected with the fact situation of the present case.

23. She further placed reliance upon the judgment of the Delhi Disputes Consumer Disputes Redressal Commission in Chander Prakash Vs. M/s.Care Health Insurance Limited in CC.No.371/2022. She further relied upon the judgment of the Hon'ble Apex Court in Mahakali Sujatha Vs. The Branch Manager, Future Generali India Life Insurance Company Limited & another in Civil Appeal No.3821 of 2024 which is a case of repudiating the claim of the Appellant on the ground of suppression of material information. The Hon'ble Apex Court also stated in the said case that the principles necessitating disclosure by the assured would apply having regard to the nature of policy and to consider as to what is necessary to be disclosed would depend upon the nature and extent of coverage of risk under a particular type of policy.

24. This case is also not applicable to the factual situation of the present case. Thus the judgments relied by the learned counsel for the Respondent/Complainant are fact specific or based upon different policy wordings but do not lay down any binding rule that a contractual definition of stroke must be ignored. As the policy contains clear and exhaustive definition, general medical

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descriptions cannot override the contractual language as made clear by the Hon'ble Apex Court in the decisions relied by the learned counsel for the Appellant.

25. Cardio pulmonary arrest due to Covid-19 complications is not a covered critical illness as per the policy. As such we consider that the repudiation made by the Appellants/Opposite Parties No.1 to 3 is well within the terms and conditions of the policy and is based upon the relevant records. As the order of the District Commission appears to be allowed on sympathetic grounds ignoring mandatory policy conditions and the findings are based on assumptions rather than evidence equating cardiopulmonary arrest with stroke, the order is liable to be set aside. In predefined policies, sympathy cannot override the terms and conditions of the policy. Stroke definition is conjunctive and mandatory. Confirmation by CT/MRI was an essential condition. The District Commission cannot rewrite contract. As such we consider that the findings are perverse and contrary to evidence.

26. Point No.2:

In the result, we consider it fit to set aside the order dated 28.03.2023 in CC.No.712/2021 by the District Consumer Disputes Redressal Commission-II, Hyderabad and dismiss the complaint filed by the Respondent No.1/Complainant holding that the claim was not covered under Section-3 of the Home Credit Assure Policy. However, considering the circumstances that the Respondent/Complainant was a widow having two young children and also looking after the parents of her deceased husband, we consider it fit not to impose any costs.

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The Appellants/Opposite Parties No.1 to 3 are permitted to withdraw the statutory deposit along with accrued interest, after the appeal time.

Dictated to the Stenographer and transcribed by her on the System; corrected by me and pronounced by us in the Open Court on this the 19^thday of February' 2026.

Sd/- Sd/- PRESIDENT MEMBER-NJ

Dated : 19.02.2026 *UC