SRI BASANTA KUMAR MALLICK, MEMBER

The dispute arises out of the complaint filed by the complainant alleging deficiency of service  & unfair trade practice.

The facts disclosed in the complaint are to the effect that the complainant is the widow of Late Indramani Kandara who died due to a vehicular accident occurred on dt. 18.06.2013 while travelling in a private transport vehicle from his village to Ghatagan along with his wife and other passengers of his village. The said deceased was managing his family consisting of 6 members including himself and dependant parents and he was the only earning member of the family upon whom all others were depending for their rice & bread. Prior to the accidental death of the husband of the complainant, the life of the deceased was insured with the O.Ps vide policy No- 585393854 commencing from dt. 15.11.2003 under New Janarakshya Scheme. But soon after accident the deceased husband of the complainant was taken to different hospitals and finally breathed his last in S.C.B Medical Collage & Hospital, Cuttack which comes under Mangalbag police Station. Soon after the death of her husband, complainant submitted the claim proposal to OP No. 1 for settlement of the claim and after several persuasions, O.Ps settled the claim excluding the accident benefits which is the legitimate right of the claimant/complainant. After receipt of the claim amount from O.Ps complainant came to know that she has not been paid the accident benefit which should not be less than the sum insured. Complainant ran to OP No. 1 time and again to raise her claim but O.Ps did not pay any heed to the complainant which forced her to file dispute against O.Ps seeking relief for settlement of her legitimate claim & compensation for mental agony and harassment including cost of litigation.

O.ps resisted the claim and contested the case. The written version submitted by the O.Ps contains the objection on maintainability on the ground of suppression of truth and as the O.Ps have not caused any deficiency in service. Further O.Ps have questioned the death of the insured weather accidental or normal. In the entire written version, O.P’s concentrated on the issue of death caused due to accident or accidental. According to O.P’s pleadings whether the death has been caused due to accident or the death is accidental. If the death is caused due to accident, complainant will be entitled to accidental bereft as per policy condition and if it is an accidental death, complainant is not eligible for any accidental benefit and O.Ps have left the issue on the complainant to strict proof as to the death is caused due to accident. It is also stated that complainant has stated differently at different places in the complaint which are contradictory to each other such as at some places it is mentioned that death is accidental and at some places, death caused due to accident. O.Ps have derived the version of NCDRF in a Judgment which differentiates accidental death and death due to accident and according to such interpretation the death is accidental, it does not permit the complainant to get the accidental benefits and therefore the complainant is not entitled to any claim as prayed for.

OBSERVATION/FINDINGS

Heard the counsel for complainant and O.Ps and perused materials on record. It is an admitted fact that the deceased is the husband of the complainant and an insured under the insurer (O.Ps) vide policy number- 585393854 and the O.Ps have settled the claim for Rs 44,820/- excluding the accidental benefits. But the dispute arises between the parties on the ground of payment of accident benefits to the complainant or the survivors of deceased. 

1. O.ps have submitted in course of hearing that the complainant has stated in the complaint mentioning the death occurred at the spot of accident for the careless and negligent driving of the driver without mentioning the date of accident and simultaneously other records furnished by the complainant reveal that the life assured died in S.C.B Medical Collage and Hospital, Cuttack which is contradictory to each other. On the contrary counsel for complainant submitted that after accident occurred on dt. 18.06.2013 at Bhanupur Chhack, Basantia under Bonth P.S. Soon after the accident took place, the friends and relatives travelling in the said vehicle took the 1^st step to save the life of the insured and took him to Mareigaon PHC and then to Bhadrak District Head quarter Hospital. When his condition was found extremely critical, the insured was referred to SCB Medical Collage & Hospital, Cuttack for appropriate treatment which is not made available at Bhadrak Hospital. The complainant with the help of her relatives took her husband to Cuttack and admitted in S.C.B Medical Collage & Hospital, Cuttack where the insured was under treatment for a couple of days. In spite of all sincere efforts made by the treating doctors, the insured was declared dead and since it was an accident case, the matter was taken up by Mangalbag Police. Te postmortem was administered in the S.C.B, MC&H Cuttack by the professor FM & T Deptt. which makes clear that the cause of death due to carnie cerebral injuries. The complain report of the complainant filed in the court of SDJM, Bhadrak vide ICC No- 1905/13, on dt. 19.12.2013 and the investigation report of ASI, Bonth P.S in P.S case No- 6 dt. 25.01.2014 give a clear indication about the accident and how the insured was taken to different places for treatment till his death on dt 22.06.2013 in S.C.B Medical Collage & Hospital, Cuttack. On perusal of materials on record it is observed that the pleadings and submissions at the time of hearing made by the advocate of  complainant do not have any mismatching or discrepancy of the date of accident & death. Hence the objection, regarding different dates of death, raised by O.Ps does not hold good and is also not sustainable.

2. Regarding settlement of insurance claim O.Ps have stated to have settled the claim for Rs 44,820/- as per policy conditions and the said amount has been paid to the complainant. On the contrary complainant submitted and agreed to have received the amount as mentioned herein which does not include the accident benefits as she is entitled to get. As per policy conditions of New Jana Surakshya Policy, it is clearly mentioned that the insured or his/her nominee is entitled to get sum assured + vested bonus in the event of death before maturity, sum assured + vested bonus + accidental in the event of death due to accident. Apart from this, O.Ps have admitted in para 6 to have paid the amount which covers the sum assured + vested bonus and have also admitted in paragraph 7 “If the complainant submits genuine documents before the opposite parties that in fact it is a death due to accident as per policy conditions, than the opposite parties are bound to disburse accidental death benefits to the complainant.” In the instant case complainant filed a complaint petition in the Court of Honorable SDJM Bhadrak, praying for a direction to Bonth Police Station for conducting investigation, which speaks of the date of accident treatment was given in different Medical/Hospital / Health Center and the death occurred on 22.06.2013. The police investigation report and C.S submitted in the Honorable Court of SDJM clearly speaks the date of accident and Hospitalization for treatment at Mareigaon PHC/Bhadrak District Hospital and finally in SCB, MC&H Cuttack where death occurred. Hence the insured has died after 4 days of accident and such death was caused due to an accident. The complainant has submitted all the evidences pertaining to accident, treatment at different places, death and autopsy conducted with report of conducting doctor. Thus it is held that the death of the insured was caused due to accident which compiles the policy conditions. Therefore the O.Ps, as agreed in the written version at paragraph 7, have to pay the accident benefits along with other benefits as claimed by the complainant.

3. O.Ps have pleaded in the written version and also submitted during hearing that the cause of death is “Carnie Cerebral Injuries.” The learned council for O.Ps has tactically derived few words from the entire postmortem report with a view to avoid payment of accident benefits. On analysis of all reports starting from complaint petition in Honorable Court to submission of postmortem report by Prof. FM&T of SCB, MC&H Cuttack, we have arrived at the conclusion that the effect is death due to intra cerebral haemerage which is caused due to accident. Fairley it can be said that the death of insured was due to accident. It is, therefore, held that the O.Ps are liable to pay accident benefits to the complainant and their refusal to pay such benefit tantamount to deficiency of service.

In view of the facts narrated in foregoing paragraphs and considering from all angles with reference to material evidence on record it is finally concluded that the O.Ps have deliberately refused the legitimate claim of the complainant for payment of accident benefit equivalent to the sum insured along with compensation and cost of litigation. Hence it is ordered;

ORDER

               The complainant be and the same is allowed against the O.Ps. O.Ps are directed to pay a sum of Rs 30,000/- as accident benefit, Rs 7000/- as compensation for mental agony and harassment and litigation cost of Rs 3,000/- to the complainant within 30 days from the date of receipt of this order and such payment must be made by NEFT in crediting the SBD account of the complainant bearing No- 12200110025898 maintained with U.Co Bank, Dolasahi Branch under intimation to the complainant. In the event of failure in compliance of this order by the O.Ps within the stipulated time, interest @ 11% shall be charged from the date of order till the date of payment.

This order is pronounced in the open Forum on the 28^th day of March, 2017 under my hand and seal of the Forum.