BEFORE THE CIRCUIT BENCH   A.P.STATE CONSUMER DISPUTES REDRESSAL COMMISSION: AT VISAKHAPATNAM

F.A.No. 647  OF 2012 AGAINST C.C.NO.371 OF 2011 DISTRICT CONSUMER FORUM-I VISAKHAPATNAM

Between
Smt Sirasala Madhavi W/o Naga Suresh
D/o Peyyala Adinaidu, Aged 25 years,
R/o Thummapala Street, Anakapalli Mandal
Visakhapatnam                                          
                                                                                        Appellant/complainant

        A N D

1.   M/s ICICI Lombard General Insurance Co.Ltd.,
by its authorized signatory D.No.14-714
Manohar, Arcade, Anakapalli Dist: Visakhapatnam

2.   M/s ICICI Lombard General Insurance co.Ltd.,
rep. by its Customer Service Manager, Personal Accident
Claims, TGV Mansions, 5th & 6th Floor, Plot No.6-2-1012
ICICI Bank Khairatabad, Hyderabad-004

                                                                                        Respondent/opposite parties

Counsel for the Appellant              M/s P.P.Ramayya

Counsel for the Respondent           M/s Ravishankar Jandhyala

  QUORUM:        SRI R.LAKSHMINARSIMHA RAO, HON’BLE MEMBER

                                                &

                        SRI S.BHUJANGA RAO, HON’BLE MEMBER

                         FRIDAY THE  SECOND DAY OF AUGUST

TWO THOUSAND THIRTEEN

                Oral Order ( As per R.Lakshminarsimha Rao, Member)
                                                     ***

1.             The complainant is the appellant. He filed complaint claiming a sum of `10,00,000/- towards the sum assured under the insurance policy with interest thereon and an amount of `1,00,000/- towards damages.

2.             The appellant’s father  during his lifetime obtained personal accident insurance policy bearing Certificate No.4018/IPA-386941000043/00/000 valid for the period from 02.11.2008 to 01.11.2009  and appointed the appellant as his nominee. The appellant’s father died on 12.01.2009 and the appellant had sent death intimation through letter dated 14.02..2009 and the respondent  issued claim form to the appellant and appointed investigator who on 26.08.2009 sought for submission of documents which the appellant submitted to him on 3.12.2009.

3.             The appellant submitted that his father sustained injuries in an accident on 12.01.2009 when he fell from bullock-cart and he was taken to Sri Mother Theresa First Aid Clinic for first aid and from there to his house and then to Government Hospital Anakapalli on 12.01.2009 where he died and the death of the insured is confirmed by Grampanchayat, Buchirayapeta. He submitted relevant documents to the appellant and the investigator and as the respondent failed to settle the claim, he filed the complaint.

4.             The respondent resisted the claim on the premise that the appellant is not a consumer and he filed the complaint based on fabricated documents. The respondent is not aware of the accidental fall of the insured from bullock cart on 12.01.2009 and his death on 12.01.2009 as also his treatment in Mother Teresa Hospital till the intimation after 32 days of the incident was given by the appellant. As per the terms of the insurance policy, the death intimation has to be given immediately after cremation or within 30 days to enable the appellant to ascertain the claim. 

5.             The appellant as required by the terms of the policy did not furnish copies of FIR, Inquest Report and Report of Postmortem Examination to show the cause of death of the insured. The OP chit does not disclose that the insured sustained injuries in an accident and the appellant colluding with his relative who is a RMP doctor created treatment certificates. It is contended that Grampanchayat is not competent to decide cause of death of an individual and the sarpanch did not inform the matter to the Police concerned and the claim is not admissible as per the terms and conditions of the insurance policy.

5.             The appellant in support of her claim, filed his affidavit and the documents, Exs.A1 to A12.  On behalf of the respondents, their Manager (Legal) filed his affidavit and the documents, Exs.B1 and B2.

6.             The District Forum dismissed the complaint on the premise that the appellant failed to prove that the insured met with accident and died due to injuries sustained in the accident.  The District Forum observed that the insured was given general treatment in Area Hospital and there was no deficiency in service on the part of the respondent-insurance company in rejecting the claim.

7.             Aggrieved by the order of the District Forum, the complainant has filed appeal contending that the District Forum failed to consider the certificate issued by the Medical Superintendent of Area Hospital that the insured came to the hospital for treatment and was issued outpatient ticket with registration number and that Dr.Ramesh Babu of Mother Teresa Hospital treated the insured for the head injury and that Sarpanch Grampanchayat of Bucharayapeta issued certificate  to the effect that the appellant’s father died due to injuries sustained when he fell from a bullock cart.

8.             The learned counsel for the appellant has filed written arguments.

9.             The point for consideration is that whether the death of the insured is an accident?

10.            The respondent-insurance company has raised objections for settlement of claim on the ground that the appellant failed to give death intimation within time and she failed to submit documents such as FIR, Inquest Report and Report of Postmortem Examination as also that the death of the insured is not an accidental death. Admittedly, the appellant’s father died on 12.01.2009. Cause of his death of the insured plays vital role in settlement or repudiation of the claim. The insurance policy issued in favour of the appellant’s father is personal accident insurance policy and the sum assured is payable by the respondent to the insurance on the death of the insured in an accident. Condition No. Part-II5(1) and (2) of the insurance policy reads as under:

        5.         Policy Related Terms and Conditions:

(i)         Upon the happening of any event, which may give rise to a claim under the Policy, written notice with full particulars must be given to the Company immediately in case of death, written notice must be given before the internment cremation and in any case, within one calendar month after the death, unless reasonable cause is shown in the event of loss of sight or amputation of limbs written notice thereof must be given within one calendar month after such loss of sight or amputation.

ii)         Proof satisfactory to the Company shall be furnished of all matters upon which a claim is based.  Any medical or other agent of the company shall be allowed to examine the Insurance Person(s) on the occasion of any alleged injury or disablement when and so often as the same may reasonably be required on behalf of the Company and in the event of death to make a post-mortem examination of the body of the Insured Person.  Such evidence as the Company  may from time to time require shall be furnished and a post-mortem examination report be furnished within a period of thirty days.

11.            The appellant’s contention is that her father fell from a bullock-cart on 8.01.20009 and he sustained head injury. The appellant had stated that immediately after the accident, her father was taken to Mother Teresa Hospital where first aid was given to him and from there he was taken home. Further, she had stated that as  her father developed body pains he was taken to Government Hospital, Anakapalli and he died on 12.01.2009 at his house. 

12.            The respondent contended that the appellant invented the theory of the insured falling from bullock cart and receiving head injuries. It is contended that Dr.K.Ramesh Babu is a private medical practitioner and he is not competent to administer treatment to any patient and he is a relation of the appellant as also there is a Government Hospital where the insured resided which improbablize    the occurrence of accident and the insured  sustains the head injury .

12.            It is not denied by the appellant that Dr.Ramesh Babu is her relative and a private medical practitioner.  Dr.Ramesh Babu issued prescription on 8.01.2009 prescribing ‘zofar, Toxin and Disprovin’ on the premise that the patient ’P.Adinaidu’ sustained head injuries due to fall from a bullock cart. If the prescription is taken on its face value for a while as issued for treatment of head injury of the patient, the nature of injury is not mentioned by the doctor and he being a competent to give first-aid , it is not known as to how he could treat such injury which is considered as fatal compared to the injuries caused to other parts of the body of a person. Many more doubts can be entertained by merely looking at the prescription.

13.            According to the appellant, her father was taken to his house from the hospital of Dr.Ramesh Babu and there were no any complaint of pain from him till 12.01.2009 whereon he was taken to the Government Hospital, Anakapalli where he was administered general treatment not for any injury sustained in any accident. The Medical Superintendent, Anakapalli issued certificate to the effect that the appellant’s father was registered as outpatient for general treatment. Nowhere in the outpatient chit or in the certificate is it mentioned  that the patient sustained any injuries.

14.            The other ground of appeal is relating to  non-consideration by the District Forum the certificate issued by the Grampanchayat, Kothapalli.    The sarpanch of the Grampanchayat issued certificate to the effect that the appellant’s father died on 12.01.2009 due to injuries sustained in an accident involving bullock cart.  It is interesting to see the sarpanch stating that the cause of death of the insured is injury sustained in the accident where no inquest or postmortem examination of the body of the appellant’s father was conducted. The contention of the respondent-company that the sarpanch is not competent to decide cause of death of the insured has acceptable force and this Commission does accept the death of the insured is natural death and such being the position clearly pointing out to the insured being administered general treatment, no deficiency can be found on the part of the respondent-insurance company in repudiating the claim. This Commission does not find any infirmity with the order passed by the District Forum.

15.            In the result, the appeal is dismissed confirming the order of the District Forum. There shall be no separate order as to costs.

                                                                        MEMBER

                                                                        MEMBER

                                                                    Dt.02.08.2013

కె.ఎం.కె*