State Consumer Disputes Redressal Commission
M/S Hdfc Ergo General Insurance Co. Ltd vs M/S Sarita Goyal on 10 March, 2026
FA/325/2023 D.O.D.: 10.03.2026
HDFC ERGO GENERAL INSURANCE CO. LTD. VS. MS. SARITA GOYAL
IN THE DELHI STATE CONSUMER DISPUTES
REDRESSAL COMMISSION
Date of Institution: 19.07.2023
Date of hearing: 02.02.2026
Date of Decision: 10.03.2026
FIRST APPEAL NO.- 325/2023
IN THE MATTER OF:
M/S HDFC ERGO GENERAL INSURANCE
CO. INDIA PVT. LTD.,
OFFICE AT: 5TH FLOOR, TOWER-1,
STELLAR IT PARK, C-25, SECTOR- 62,
NOIDA - 201301.
(Through: SS Law Partners)
.... Appellant
VERSUS
MS. SARITA GOYAL,
W/O LATE MR. MAHENDER GOYAL,
R/O H. NO. 174, GALI NO. 6,
FRIENDS ENCLAVE, SP ROAD
SULTANPURI, BLOCK DELHI - 110086.
NEW DELHI - 110026.
(Through: Mr. Aditya Aggarwal & Ankit Mutreja, Advocates)
....Respondent
DISMISSED PAGE 1 OF 10
FA/325/2023 D.O.D.: 10.03.2026
HDFC ERGO GENERAL INSURANCE CO. LTD. VS. MS. SARITA GOYAL
CORAM:
HON'BLE JUSTICE SANGITA DHINGRA SEHGAL
(PRESIDENT)
HON'BLE MS. BIMLA KUMARI, MEMBER (FEMALE)
Present: Ms. Shruti Mishra and Mr. Suman Tripathy, Counsel for the
appellant appeared through VC Respondent in person.
Ms. Pooja Roy, Counsel for the Respondent (Enrl. No.D/
6938/2020, Email: [email protected])
PER: HON'BLE JUSTICE SANGITA DHINGRA SEHGAL,
PRESIDENT
JUDGMENT
1. The facts of the case necessary as per the District Commission record are:
"The present complaint has been filed by Ms. Sarita Goyal, widow of Late Sh. Mahender Goyal and the nominee of the insurance policy purchased by her deceased husband with the allegations of deficiency in services against Apollo Munich Health Insurance Company Ltd. (OP).
1. Facts necessary for the disposal of the present complaint are that, Late Sh. Mahender Goyal, the husband of the complainant got an Individual Personal Accident Standard insurance policy bearing no. 110800/21001/2000093745-OS from OP, with accidental death benefit of Rs. 10,00,000/- plus Cumulative Bonus, for a cover period from 29/09/2018 to 28/09/2019. The cumulative bonus as explained in the policy as on policy issuance date i.e 27/09/2018 is Rs.2,50,000/-. However, in the said policy it has also been explained the said cumulative bonus is provisional and the final cumulative bonus shall be calculated on the expiry date.
2. On 13/06/2019, Sh.Mahender Goyal, the husband of the complainant, hereinafter referred as Deceased Life Assured ("DLA") went for a morning walk around 6.00 am where he met with a Train accident and succumbed to injuries. The inquiry was conducted by the police officials and as per the DISMISSED PAGE 2 OF 10 FA/325/2023 D.O.D.: 10.03.2026 HDFC ERGO GENERAL INSURANCE CO. LTD. VS. MS. SARITA GOYAL inquest report the "DLA" was brought dead to the hospital with the cause of death stated to be accidental death. As per post-mortem report dated 08.08.019(sic) though it is 16/06/2019, it was stated that the deceased had sustained injuries in a train incident and found dead on spot between KM Pole No.16/7 to 16/1 near Nangloi Raiway Station. The cause of death as mentioned in post-mortem report is "Cranio-Cerebral damage, consequent upon blunt force trauma to head. All injuries are ante-mortem in nature, fresh in duration prior to death, caused by blunt force/surfaced impact and are possible in train accident."
3. Claim was registered with OP by the complainant, which was rejected by the OP and the same was informed to the complainant vide email dated 24/09/2019 on the ground:
As per submitted document and evaluation death due to suicide attempted by insured hence claim is repudiated under GENERAL EXCLUSIONS APPLICABLE TO ALL BENEFITS (B) 'intentional self-injury, suicide or attempted suicide while sane or insane.
4. The complainant has alleged that despite recording her statement, the request for reconsideration was also rejected. The complainant has further stated that there is no evidence to suggest that the "DLA" had committed suicide. Under some other insurance cover issued by Paytm, insurance claim of the husband of the complainant of free accident insurance cover upto Rs.2,00,000/- has already passed. The complainant has alleged that the repudiation of the claim by OP on unjustified ground has not only caused hardship and distress but also making it difficult for her to maintain and take care two children.
5. The complainant has prayed for directions to OP to release the claim benefits under the insurance policy taken by the husband of the complainant along with interest @18% p.a. with effect from the date of maturity of the claim i.e. 16/06/2019 till realisation; compensation on account of DISMISSED PAGE 3 OF 10 FA/325/2023 D.O.D.: 10.03.2026 HDFC ERGO GENERAL INSURANCE CO. LTD. VS. MS. SARITA GOYAL mental agony, pain and trauma to the tune of Rs.1,00,000/- and litigation expenses of Rs.65,000/-.
6. The complainant has annexed the copy of Aadhar card as Annexure A, copy of insurance policy as Annexure B, copy of inquest report as Annexure C, copy of post-mortem report as Annexure-D, copy of email dated 24/09/2019 rejecting the claim as Annexure-E, copy of statement of the complainant recorded at Apollo Munich Health Insurance Co. Ltd. Central Processing Centre, Gurgaon as Annexure -F, copy of email sent by OP as Annexure-G, Insurance papers from Paytm in which the claim benefit have already been released as Annexure-H, copy of the Aadhar Card of the children of the complainant as Annexure-l and copy of the Legal notice along with courier receipt along with tracking report as Annexure-J.
7. Notice of the present complaint was issued to OP. Written statement was filed on their behalf where they have submitted that as the HousingDevelopment Finance Corporation Ltd. (HDFC Ltd.) had acquired the majority stake of Apollo Munich Health Insurance Company Ltd. with effect from 09/01/2020, thus now Apollo Munich Health Insurance Company Ltd is HDFC Ergo Health Insurance Company Ltd. They have taken preliminary objections such as the claim had been repudiated as per terms & conditions mentioned under the:
GENERAL EXCLUSIONS APPLICABLE TO ALL BENEFITS (B) intentional self-injury, suicide or attempted suicide while sane or insane'
8. The insured had committed suicide as per the memo issued by the Station Master to GRP. It has been submitted as per the Investigator appointed by OP, the driver of the train also confirmed that the husband of the complainant had jumped in front of the train thus the claim had been rightly repudiated as suicide is not covered for the payment of benefit of the policy. It has been denied that there was deficiency in the services.
9. It has been submitted that the proposal form was submitted for issuance of insurance policy and based on for the proposal DISMISSED PAGE 4 OF 10 FA/325/2023 D.O.D.: 10.03.2026 HDFC ERGO GENERAL INSURANCE CO. LTD. VS. MS. SARITA GOYAL form, policy cover dated 26/09/2013 for a sum of Rs.10,00,000/- was issued. Rest of the contents of the complaint have been denied, with the prayer for dismissing complaint as it is baseless, incorrect and unwarranted along with cost and legal expenses in favour of the OP.
10. The certificate of incorporation dated 08/01/2020 as Annexure- R1, Power of Attorney dated 02/02/2021 authorising Sh.Manoj Kumar Prajapati as Annexure-R2, the copy of the statement of the driver of the train (illegible) Annexure-R3 and email repudiating the claim as Annexure-R4 have been filed with the written statement. Though in the written statement they have mentioned the insurance policy as Annexure-R-5, however the same has not been annexed with the written statement..."
2. The District Commission after taking into consideration the material available on record passed the order dated 19.05.2023, whereby it held as under:
"15. We have heard the argument of the Ld. Counsel for the complainant and Id. Counsel OP and have perused the material placed on record. The case of the complainant is that her husband died in train accident whereas OP has repudiated the claim on the ground that the "DLA" had committed suicide which was not payable under General Exclusions Applicable to All Benefits (B) "intentional self- injury, suicide or attempted suicide while sane or insane'. The issuance of policy is not in dispute, if we look at policy document Ex.CW1/1, first policy inception date is 26/09/2013. Perusal of the final inquest report (Ex.CW1/2) which has been filed by the investigating officer, Sh.Rattan Singh, ASI, shows that it appears to be a train accident. Similarly, the post- mortem examination report dated 16/06/2019(Ex.CW1/4) also supports the case of the complainant, the doctor conducting the post-mortem has mentioned under the head:
OPINION DISMISSED PAGE 5 OF 10 FA/325/2023 D.O.D.: 10.03.2026 HDFC ERGO GENERAL INSURANCE CO. LTD. VS. MS. SARITA GOYAL Cause of death is cranio-cerebral damage, consequent upon blunt force trauma to head. All injuries are ante- mortem in nature, fresh in duration prior to death, caused by blunt force/surface impact and are possible in train accident.
So, even as per the post-mortem report the cause of death can be train accident. This post-mortem report has been prepared by a government doctor, which cannot be doubted. Even the Final Inquest Report under Section 174, the Code of Criminal Procedure, 1973 is not disputed. On the other hand OP, apart from the copy of the statement of the driver of the train, which is illegible, has placed nothing on record in support of their contention that the "DLA" had committed suicide. Thus, the repudiation of the claim ofn the complainant on the flimsy ground without any cogent reason amounts to deficiency in services.
16.As a result while rejecting the repudiation by the insurance policy, we are of the opinion that the complainant herein is entitled to receive the sum assured of Rs.10,00,000/- and the cumulative bonus so earned by the insured which is not less than Rs.2,50,000/- as indicated in the policy schedule. It is to be pointed out here that the policy schedule indicate that as on the date of policy i.e. 27/09/2018, the cumulative bonus on the policy was Rs.2,50,000/-and it has also been explained in the policy that the said bonus is provisional and the final cumulative bonus would be calculated on the date of expiry of complainant. As the provisional cumulative bonus was Rs.2,50,000/- on the date of policy issuance, in our opinion, in terms of the policy wordings, the actual cumulative bonus must be more than Rs.2,50,000/- on the date of death of the insured i.e. 16/06/2019.
Therefore, in the facts and circumstances of the present complaint and in the interest of justice, we direct OP:
i. To pay Rs. 10,00,000/- being the benefits assured under accidental death along with interest @9 % per annum from the date of filing of complaint(24/02/2020) till realisation;
DISMISSED PAGE 6 OF 10 FA/325/2023 D.O.D.: 10.03.2026
HDFC ERGO GENERAL INSURANCE CO. LTD. VS. MS. SARITA GOYAL ii. Cumulative bonus as per policy schedule, which should not be less than Rs. 2,50,000/- along with interest @ 9% per annum from the date of filing of complaint(24/02/2020) till realisation;
iii. Compensation of Rs.20,000/- on account of mental agony and harassment.
iv. Litigation expenses of Rs. 15,000/-.
v. This order be complied with in 30 days from the receipt of this order, in case of failure to comply with in stipulated period, OP shall be liable to pay interest @ 12% per annum on the entire amount payable as directed above in clauses (i),
(ii), (iii) and (iv)/-."
3. Aggrieved by the aforesaid order, the Appellant has preferred the present appeal on the grounds that the District Commission erred in not considering the primary evidence produced by the Appellant, as the Appellant had filed the memo issued by the Station Master which clearly established the fact that the death of the insured occurred due to suicide. The Counsel for the Appellant further contended that the District Commission failed to appreciate the fact that the locomotive pilot/driver was an eye-witness to the said incident and confirmed to the investigating agency that the deceased policy holder had committed suicide. The Counsel further submitted that the District Commission failed to appreciate that it erroneously relied upon the inquest report and post-mortem report, wherein it is nowhere mentioned that the case was not a suicide but an accident. He also submitted that the District Commission wrongly observed that the memo filed by the Appellant was illegible in nature; therefore, could not be considered. Lastly, he contended that there is no deficiency in service on the part of the Appellant, as the Appellant rightly repudiated the claim of the Respondent as per the DISMISSED PAGE 7 OF 10 FA/325/2023 D.O.D.: 10.03.2026 HDFC ERGO GENERAL INSURANCE CO. LTD. VS. MS. SARITA GOYAL terms and conditions of the policy. Pressing the aforesaid grounds, the Appellant prayed that the aforesaid order be set aside.
4. The Respondent has filed reply to the present Appeal and denied all the contentions of the Appellant. Moreover, the Respondent submitted that there is no error in the impugned order as the entire material available on record was properly scrutinized before passing the said order.
5. The Appellant has filed the written arguments and reiterated the submission made in the appeal.
6. The Respondent, on the other hand, has also filed the written arguments and denied the submission of the Appellant.
7. We have perused the material before us.
8. The question that falls for our consideration is whether the District Commission erred in holding the Appellant deficient in service with respect to the repudiation of claim of the Respondent.
9. The counsel for the Appellant submitted that the Appellant rightly repudiated the claim of the Respondent as per the terms and condition of the said policy.
10. It is not disputed that Late Mr. Mahender Goyal husband of the Respondent had obtained an Individual Personal Accident insurance policy no. 110800/21001/2000093745 from the Appellant with accidental death cover of Rs.10,00,000/- along with cumulative bonus of Rs. 2,50,000/-. It is also not disputed that the insured died on 13.06.2019 in a train incident near Nangloi Railway Station.
11. Thereafter, the Appellant vide email dated 24.09.2019, repudiated the claim of the Deceased Life Assured (DLA) on the ground that the death of the DLA occurred due to an alleged suicide attempt.
DISMISSED PAGE 8 OF 10 FA/325/2023 D.O.D.: 10.03.2026
HDFC ERGO GENERAL INSURANCE CO. LTD. VS. MS. SARITA GOYAL Therefore, the case of the DLA falls under the General Exclusions Applicable to All Benefits (B) of the policy, which provides that the insured persons are not entitled to any claim in cases of intentional self-injury, suicide, or attempted suicide, whether while sane or insane.
12. On perusal of record, it is clear from the record that the Final Inquest Report prepared by the investigating officer indicates that the death appears to have occurred due to a train accident. Similarly, it is clear from the post-mortem that the cause of death was cranio-cerebral damage resulting from blunt force trauma, which is possible in a train accident.
13. On the other hand, the Appellant has mainly relied upon the alleged statement of the locomotive pilot/driver and the memo issued by the Station Master. However, no cogent evidence has been placed on record by the Appellant to show that the death of the insured person occurred due to suicide. Moreover, the statement of the locomotive pilot/driver merely states that a person had committed suicide and that the dead body was lying on the track but no supporting material has been placed on record to corroborate the said statement.
14. Furthermore, we are in agreement with the District Commission that the Appellant has not produced any material on record to establish that the death of the insured person was due to suicide apart from the aforesaid statement. It is a settled principle that the burden to prove suicide lies upon the insurer and the same cannot be discharged on mere assumptions. As a result, we are of the view that the repudiation of the claim of the Respondent by the Appellant under DISMISSED PAGE 9 OF 10 FA/325/2023 D.O.D.: 10.03.2026 HDFC ERGO GENERAL INSURANCE CO. LTD. VS. MS. SARITA GOYAL the General Exclusions Applicable to All Benefits (B) of the policy was unjustified.
15. In light of the aforesaid discussion, we find no reason to interfere with the order dated 19.05.2023 passed by the District Consumer Disputes Redressal Commission- I (North District), Govt. of NCT of Delhi, Ground floor, Tis Hazari Court Complex, Delhi - 110054.
16. Consequently, the present Appeal stands dismissed with no order as to costs.
17. Application(s) pending, if any, stand disposed of in terms of the aforesaid judgment.
18. A copy of this judgment be provided to all the parties free of cost as mandated by the Consumer Protection Act, 1986. The judgment be uploaded forthwith on https://e-jagriti.gov.in for perusal of the parties.
19. File be consigned to record room along with a copy of this Judgment.
(JUSTICE SANGITA DHINGRA SEHGAL) PRESIDENT (BIMLA KUMARI) MEMBER (FEMALE) Pronounced On:
10.03.2026 LR-ZA DISMISSED PAGE 10 OF 10