Mr. Shantnu Aggarwal, Advocate v. M/S HDFC ERGO GENERAL INSURANCE COMPANY LIMITED, THRUGH ITS DIRECTOR ORS

W.P.(C) 168/2024 1 $~28 * IN THE HIGH COURT OF DELHI AT NEW DELHI + W.P.(C) 168/2024 SMT. SUSHMA TYAGI .....Petitioner Through: Mr. Shantnu Aggarwal, Advocate. versus M/S HDFC ERGO GENERAL INSURANCE COMPANY LIMITED, THRUGH ITS DIRECTOR & ORS. .....Respondent Through: Ms. Suman Bagga, Advocate for R-1. Mr. Abhishek Nanda, Ms. Falguni Bajpai, Advocates for R-2/IRDAI. CORAM: HON'BLE MR. JUSTICE MANOJ JAIN O R D E R % 07.03.2025 CM APPL. 13919/2025 (seeking early hearing) 1. Present application, filed by the petitioner, seeks early hearing. 2. The petitioner is aggrieved by the rejection of her claim. 3. Her husband had availed home loan facility of Rs.50,00,000/- from HDFC Ltd. for purchasing a property and, simultaneously, he also purchased an Insurance Policy under the name “Home Credit Assure” to secure the abovesaid home loan. The policy was taken to provide insurance coverage to the home loan taken by her husband in the event of any mis-happening, either to the person insured or, for that matter, to the property. 4. The policy was taken in the year 2018 and the premium was paid regularly by petitioner till the year 2021. 5. After such unfortunate death of her husband in the year 2021, petitioner raised her claim under the abovesaid policy. 6. As per the death summary, the cause of death was cardiac arrest but This is a digitally signed order. The authenticity of the order can be re-verified from Delhi High Court Order Portal by scanning the QR code shown above. The Order is downloaded from the DHC Server on 01/07/2025 at 22:50:07 W.P.(C) 168/2024 2 the abovesaid claim has been rejected by the Insurance Company contending that it was not covered under „Major Medical Illness‟. 7. According to petitioner, she is facing acute hardship and inconvenience in making the payment of EMIs to HDFC Ltd. with respect to the abovesaid home loan and, to make the things worse, her claim has been arbitrarily rejected. 8. She wonders as to how the death in question, which is on account of cardiac arrest, does not stand covered within the category of critical illness. 9. During the course of the hearing, this Court has, however, noticed one more peculiar aspect of the case. After the rejection of the claim by the concerned Insurance Company i.e. HDFC Ergo General Insurance Company Limited, the matter was escalated by the petitioner to the Insurance Ombudsman. 10. The decision of the Insurance Ombudsman is dated 26.09.2023 and the observations and conclusions given by learned Ombudsman are as under:- “Case called and parties of the case were present. The Complainant stated that her husband alongwith Mr. Naresh Kumar Tyagi took the loan from the Bank and policy from the current insurer. Her husband died due to cardiac arrest with respiratory failure with B/L Pneumonitis. As per policy 50% of sum insured was supposed to be paid to her but insurer rejected the claim. The insurer stated that the coverage was of 09 illnesses and death due to cardiac arrest with respiratory failure with B/L Pneumonitis does not falls in any of the peril insured. However Myocardial Infarction is near to cardiac arrest and a conciliation developed between parties of the case that complainant would approach to the treating doctor to take certificate whether cardiac arrest is due to Myocardial Infarction. Insurer also agreed to reconsider the case. A form of mediation was given to the complainant to fill up the same and return but the accompanied person did not allow to fill up the form. Complainant refused to fill-up and sign the form. Hence no conciliation was arrived at between the parties of the case.” This is a digitally signed order. The authenticity of the order can be re-verified from Delhi High Court Order Portal by scanning the QR code shown above. The Order is downloaded from the DHC Server on 01/07/2025 at 22:50:07 W.P.(C) 168/2024 3 11. Learned counsel for petitioner submits that he never objected to seek settlement through mediation but the copy of the form which was given to the petitioner for the purposes of his signature, tells a different story altogether. Such format of mediation/conciliation agreement/refund is attached herewith as Annexure P-16. 12. The question of somebody signing to the settlement agreement would only come if such party is agreeable to such terms. 13. Nobody, whether the complainant or, for that matter, the Insurance Company, can be forced to sign on a blank form in anticipation of any settlement. The Ombudsman can only seek consent for participation in mediation but cannot force settlement on parties. 14. In view of the above, the Insurance Ombudsman should not have shown exit door to petitioner, merely, on the basis that petitioner had refused to sign the requisite form. 15. Moreover, in case, there is no settlement by conciliation or mediation, it rather becomes obligatory for Insurance Ombudsman to reach a final conclusion of the matter on merits, either way. Even as per the scheme of Insurance Ombudsman Rules 2016, in case, there is no settlement through mediation, the Ombudsman is under statutory duty to pass an award based on pleadings and evidence adduced by the parties. 16. Viewed thus, the Insurance Ombudsman should not have closed the proceedings merely on the premise that the form of settlement was not signed by petitioner. 17. The abovesaid aspect would also be duly explained by the respondent No.2 herein i.e. Insurance Regulatory and Development Authority of India. It would also apprise as to what kind of form is, generally, provided by the This is a digitally signed order. The authenticity of the order can be re-verified from Delhi High Court Order Portal by scanning the QR code shown above. The Order is downloaded from the DHC Server on 01/07/2025 at 22:50:07 W.P.(C) 168/2024 4 office of the Insurance Ombudsman to the parties and a copy of such form would also be placed on record by respondent No.2 after contacting the office of Insurance Ombudsman. 18. Keeping in mind the reasons assigned, the date is pre-poned and the matter shall now be taken up on 17.03.2025. 19. Be shown in Supplementary List. MANOJ JAIN, J MARCH 7, 2025/ss/SS