BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM ::
KADAPA Y.S.R DISTRICT
PRESENT SRI V.C. GUNNAIAH, B.Com., M.L., PRESIDENT
SMT. K. SIREESHA, B.L., LADY MEMBER
M.V.R. SHARMA, B.A. MEMBER
Monday, 27th April 2015
CONSUMER COMPLAINT No. 05 / 2014
Yankatapuram Tuppada Jaya Lakshmi, aged 43 years,
W/o Late Y.T. Hanumanthu, Hindu, aged 43 years,
Widow, R/at D.No. 2/658, Postal Colony, Adoni Post 518301,
Kurnool District, (A.P) ….. Complainant.
Vs.
1. The Chief Manager, Andhra Pragathi Grameena Bank,
Head Office, P.B. No. 65, Near Krishna Hall,
Beside Bollineni Diagnosis Center, Kadapa.
2. The Senior Divisional Manager,
United India Insurance Co. Ltd., Divisional Office,
D.No. 2/194 (2) Ground, Opp. Officers Club,
Laxmi Ranga Road, Kadapa city. ….. Opposite parties.
This complaint is coming before us for final hearing on 16-4-2015 and perusing complaint and other material papers on record and on hearing the arguments of Sri S.S.D. Ramaswamy & K. Vijaya Krishna, Advocates for complainant and Sri A. Raja Reddy, Advocate for O.P.1 and Sri K. Rama Kondaiah, Advocate for O.P.2 and the matter is having stood over for consideration this day, the Forum made the following:-
O R D E R
(Per Sri M.V.R. Sharma, Member),
1. This Complaint is filed under section 12 of the Consumer Protection Act 1986 requesting this forum to direct the Opposite parties:-
(a) To pay Rs. 3,00,000/- towards claim amount covered under subject master policy with interest @ 18% p.a. from the date of making the claim i.e. 3-11-2011 until realization.
(b) To pay Rs. 50,000/- towards deficiency of service.
(c) to pay Rs. 50,000/- towards mental agony.
(d) to pay Rs. 10,000/- towards costs of the compliant.
2. The averments of the complaint in brevity are that the complainant’s husband Y.T. Hanumanth, was worked as a Scale – 1 officer vide employee No. 1378 in Andhra Pragathi Grameena Bank, Adoni Branch, Kurnool District. The Opposite party No. 1 (for short herein called as O.P) introduced the scheme of personal accident insurance covering for all staff members of APGB as a welfare measure by taking master policy from O.P.2. Accordingly, the O.P.2 has issued Group Personal Accident policy to O.P.1 vide policy bearing No. 050900/42/11/03/00000003 covering the period from 12-4-2011 to 11-4-2012 in respect of all the personnel of O.P.1 by receiving a total premium amount of Rs. 33,839/-. As per the policy in case of death or total disablement of any of the personnel of the O.P.1 during the tenure of policy, the O.P.2 is liable to pay the capital sum insured as per the category wise of the staff.
3. The complainant further stated that on 3-10-2011 at 6.00 a.m her husband Y.T. Hanumanth, accidentally fallen from the cot and also he fell into the water pot in bathroom, whereby he sustained head injury consequently the nervous relating to his eyes were damaged and he was taken Sri Sai Krishna Eye Hospital on 16-10-2011. The deceased treated by the doctor O.M. Krishna Murthy, and he declared that the said Hanumanth became totally blind. Later he was taken to A.P. Government Area Hospital, Adoni on 16-10-2011and admitted there as inpatient on the same day he was referred to Kurnool General Hospital for better treatment and admitted at 2.20 midnight vide admission No. 1458/2011 and he was died at 4.00 p.m while undergoing treatment.
4. It is also stated that, as the deceased was fallen an accident one. No FIR was registered, no inquest and no post mortem was conducted. After death of her husband she claimed personal accident insurance benefit by furnishing all necessary documents from the O.P.2 through O.P.1 by giving intimation of the incident on 3-11-2011 i.e. within a period of 17 days from the date of demise of her husband in the capacity of nominee and wife. It is stated that on 24-12-2012 i.e. after 11 months she received a letter from O.P.2 that her claim is repudiated due to non-submission of certain documents. Hence, the claim cannot be entertained and file is closed and that the complainant sent a letter to O.P.2 seeking review of her claim on 12-1-2013 and the O.P.2 repudiated on 30-1-2013 stating that the deceased died due to HTN CAD C Alcoholic, which is not covered under the policy condition. Again she sent a letter to the O.P.2 on 9-2-2013 and the O.P.2 repudiated the claim by same cause. It is also stated that she visited claims review committee of the O.P.2 situated in Chennai. On 4-2-2103 and gave a representation to look into her claim and pay the policy amount. On 19-2-2013 she received a reply from U.I.I.Co. Ltd., customer care department of O.P.2 saying that the claim cannot be considered as the death of the member insured is due to consumption of alcoholic which is an exclusion under the policy. Hence, the complainant is constrained to file this complaint.
5. The opposite parties 1 & 2 filed separate counters and both parties are admitted that the husband of the complainant was worked in O.P.1 bank and O.P.1 introduced the scheme of Personal Accident Insurance covering all the staff members. Accordingly, the O.P.2 issued the above said policy to the employees of O.P.1. w.e.f 12-4-2008 and the O.P.1 paid all premiums for the year of 12-4-2011 to 11-4-2012 for an amount of Rs. 38,839/-. After receiving the premium the O.P.2 had issued a policy under policy bearing No. 050900/42/11/03/00000003.
6. The O.P.1 has stated that after the death of Y.T. Hanumanth, the complainant had sent a representation with required documents on 30-12-2011 to O.P.1 through the Regional Manager, Kurnool requesting to settle the insurance amount. On 31-10-2012 the O.P.2 office Kadapa and advice to submit the following documents :-
i. FIR duly attested by concerned police authorities.
ii. Inquest report duly attested by concerned police authorities.
iii. Post Mortem report duly attested by concerned police authorities.
iv. Final report/charge sheet duly attested by concerned police authorities.
v. Ration card / Voter card.
vi. Paper publication etc.,
After receipt of O.P.2 the O.P.1 advised the complainant to submit the said documents but she submitted only Ration card. The U.I.I.Co. Ltd., Divisional Office, Kadapa had informed her in the absence of vital documents required for settlement of claim. Hence, the claim was repudiated and file also closed. It is further stated that the O.P.2 informed by letter dt. 30-1-2013 her husband was died due to HTN CAD alcoholic which is not covered under policy conditions. Hence, the claim is not entertained and also U.I.I. Co. Ltd., Head Office, Chennai cannot be considered as the death of the member insured is due to consumption of alcoholic and also stated that this O.P acted timely at every stage to facilitate the complainant for settlement of her claim. Hence, there is no deficiency in service on the part of this O.P and prayed this Hon’ble forum pleased to dismiss the complaint.
7. On the other hand the O.P.2 stated that the complainant stated in her complaint her husband was fell in bathroom on 3-11-2011 and he was might have received some external injuries on his head and he lost his eyesight and he was shifted to the hospital on 16-10-2010 and he died,. But there is no iota of evidence to that injuries or if he had taken any treatment in the period of 13 days. It is also stated that she filed certificate who is issued by the doctor of Sai Krishna Hospital is clearly mentioned that the deceased came to the hospital with painless loss of vision of both eyes and his visible acuity was only CF 1mt and fundus was normal. The doctor suspected cortical blindness and he referred to the Kurnool Heart and Brain Center. According to the complaint she shifted her husband to the Govt. area Hospital, Adoni on 16-102-011 and it is clearly mentioned in the out post card that the loss of vision and past history was recorded therein as hypertension CAD with chronic alcoholism. Thus above facts is supported by the affidavit given by her that the deceased was in habit of taking alcohol and the deceased was shifted to Kurnool Heart and Brain Center on 17-10-2011 and he was died on 17-10-2011.
8. It is further stated that the O.P.2 repudiated the claim that the she has not produced required documentary evidence in support of her version that her husband was died due to the impact of accident taken from the cot and in bathroom and the said Y.T. Hanumanth who is the employee of O.P.1 died due to HTN CAD C Alcoholic which is not covered under the policy conditions. The complainant also made a representation to the customer grievance cell Chennai of the O.P.2 and they could not accept her claim due to the above circumstances only. It is also stated that she finally approached the insurance company ombudsmen and the ombudsmen passed an order against the complainant. Hence, there is no deficiency of service on the part of this O.P. Therefore, praying that the Hon’ble forum may be pleased to dismiss the complaint with costs.
9. Complainant himself was examined as PW1 and to prove her case, she filed an affidavit along with documents and got marked Exs. A1 to A22 and on behalf of opposite parties Exs. B1 to B34 documents are marked by consent.
10. On the basis of the above pleadings the following points are settled for determination.
- Whether the complainant is eligible for compensation as prayed by her?
- Whether there is negligence or deficiency of service on the part of opposite parties?
- To what relief?
11. Point Nos. 1 & 2. We have gone through the contentions of both parties, affidavit and documentary evidence. There is no any dispute about the complainant’s husband Y.T. Hanumanth was worked as a Scale – 1 Officer of A.P.G. Bank, Adoni Brnach, Kurnool District, the O.P.1 introduced the scheme Personal Accident insurance covering of all the staff members, as a welfare measure by taking master policy from O.P.2. The O.P.2 has issued Group personal Accident policy to O.P.1 vide policy bearing No. 050900/42/11/03/00000003 covering the period from 12-4-2011 to 11-4-2012 by receiving a total premium an amount of Rs. 33,839/-. As per the terms and conditions of the policy in case of death or total disability of any of the personnel of O.P.1 during the tenure of the policy the O.P.2 is liable to pay the capital sum assured as per the category wise of the staff. The documents Exs. A1 to A3 and B1 to B7 and B33 proved the same.
12. The complainant as PW1 has reiterated the averments of the complaint in her affidavit filed in her evidence. A perusal of the affidavit of PW1 is clearly shows that her husband Y.T. Hanumanth fallen from the cot on 3-10-2011 at 6.00 a.m also he fell in the bathroom on water pot and he sustained heavy injuries. As seen from Ex. A4 the deceased was admitted in Sai Krishna Hospital on 16-10-2011 and he was taken to A.P. Govt. Area Hospital, Adoni under Ex. A5 on the same day he was shifted to Kurnool General Hospital for better treatment and he was admitted at 2.20 p.m midnight vide admission No.1438 Head and Brain Center under Ex. A8 and he was died at 4.00 a.m under undergoing treatment. As seen from Ex. A9 Kurnool Municipal Corporation issued death certificate confirming that the death of Y.T. Hanumanth. After the death of her husband the complainant claimed above said policy benefit from O.P.2 through O.P.1. As seen from Ex. A15 O.P.2 repudiated her claim due to she has not produced required documents and the deceased died due to HTN CAD C Alcohol. The complainant again sent letter on 4-2-2013 to the O.P.2 under Ex. A17 and the O.P.2 repudiated the claim on the same cause. After that she visited the claims review committee situated in Chennai on 4-2-2013 and U.I.I. customer care department of O.P.2 also repudiated the claim due to consumption of Alcohol which is an exclusion under the policy under Ex. A19. The contention of O.P.1 that after death of Y.T. Hanumanth, the complainant had sent with all required documents on 30-12-2011 and the same is forwarded to O.P.2 on 31-10-2012 and the O.P.2 advised to submit the required documents. The O.P.1 immediately informed to the complainant to submit the above said documents but she submitted only Ration card and also contended that the O.P.1 acted timely at every stage to facilitate the complainant to comply the requirement to settle the claim and there is no negligence or deficiency on the part of the O.P.1.
13. On the other hand the O.P.2 contended that as per the contention of the complainant her husband fallen from the cot and fell in the bath room on 3-10-2011 and he was shifted to the Sri Sai Krishna Hospital after 13 days i.e. on 16-10-2011, if he might have received some external injuries on his head and he died, but there is no iota of evidence regarding to the injuries and he taken treatment in that 13 days period. The another contention of O.P.2 the doctor of the Sai Krishna Eye hospital, Adoni issued Ex. A4 a certificate which is filed by the complainant where it was clearly mentioned that the deceased came to the hospital with painless loss of vision of both eyes his visible acuity was only CF 1mt and fundus was normal the doctor suspected cortical blindness. The document Ex. A4 proved the same.
14. Further contention of the O.P.2 is that the complainant shifted her husband to the Govt. Hospital, Adoni on 16-10-2011 and it is clearly mentioned in inpatient ticket i.e. Ex. A5 that the loss of vision and past history was recorded therein as hypertension CAD with chronic alcoholism and also stated that the above statement is supported by the affidavit given by the complainant that the deceased had in the habit of alcohol. Hence, the contention of O.P.2 is sustainable.
15. Further contention of O.P.2 that the complainant made representation to the customer care main branch, Chennai of O.P.2 stated that the company could not accept her claim due to the above circumstances and also seen Ex. B31 the O.P.2 ombudsmen also passed an order against the complainant. As per the above contentions it is clear that the deceased was taken to the hospital after 13 days from the date of incident even as admitted in her complaint and affidavit. No external injuries was found on the person of complainant’s husband when he was admitted in hospital. As seen from Ex. A5 the Govt. Area Hospital, Adoni it is clearly mentioned that the past history was recorded as therein hypertension, CAD Chronic Alcoholism and the customer grievance could not accept her claim due to above circumstances and the O.P.2 company ombudsmen also passed order against the complainant.
16. As per the above discussion and circumstances of the case we hold that the claim of the complainant was rightly repudiated by O.P.2 and the complainant did not proved deficiency of service on the part of opposite parties. The points are answered against the complainant.
17. Point No. 3 In the result, the complaint is dismissed without costs.
Dictated to the Stenographer, transcribed by him, corrected and pronounced by us in the open Forum, this the 27th April 2015
MEMBER MEMBER PRESIDENT
APPENDIX OF EVIDENCE
Witnesses examined.
For Complainant
PW1 Yankatapuram Tuppada Jaya Lakshmi, dt. 7-7-2014.
For Opposite parties : NIL
Exhibits marked for Complainant: -
Ex.A1 Attested copy of Circular No.90-2008-BC-STF issued by Chairman, A.P.G
Bank, Kadapa , Dt. 23-4-2008 about introduction of personal accident
insurance scheme for the staff of A.P.G.B. w.e.f. 12-4-2008.
Ex.A2 P/c of Group Personal Accident Policy bearing
No.050900/42/11/03/00000003, Dt. 12-4-2011 issued by United India
Insurance Co., Ltd.,
Ex.A3 Original letter in Ref. No.497/HRD & IR/RTI-17-13/2013, Dt. 12-7-2013 issued by Chief Manager, A.P.G.B. Bank, Kadapa with regard to category wise sum assured details as on 17-10-2011 and amount enhanced for office scale-I for Rs.3 lakhs under policy No.050900/42/12/03/00000004.
Ex.A4 Photocopy of prescription given by Sri Sai Krishna Eye hospital relating to
medical treatment given firstly to the deceased Y.T. Hanumanthu,
Dt.6-10-11.
Ex.A5 Inpatient ticket issued by Area Hospital, Adoni stating about admission on
16-10-2011 at night and referring the case to Kurnool and discharge
particulars at 11:30 night.
Ex.A6 Attested copy of certificate issued by Civil Assistant Surgeon, Government
Hospital, Adoni, Dt. 13-12-2011 about total loss of vision of late
Y.T. Hanumanthu.
Ex.A7 P/c of CT brain plain study issued by Shantiniketan Diagnostic Centre
(P) Ltd., Kurnool, Dt. 17-10-2011.
Ex.A8 P/c of certificate issued by Kurnool Heart and Brain Hospital Centre,
about demise of the deceased Y.T. Hanumanthu on 17-10-2011 at 4 a.m.
Ex.A9 Photocoopy of certificate of death issued by Registrar of Births and Deaths,
Kurnool Municipal Corporation, dt. 24-10-2011.
Ex.A10 Registered letter sent to S.H.O. P.s. No.IIII, Adoni and the returned cover
there of, Dt. 31-10-2011.
Ex.A11 Letter given by the complainant to Chairman, AP.G.B. Bank, Kadapa
Regarding intimation of the demise of her husband.
Ex.A12 Statement given by the Agent of the respondent stating that the deceased late Y.T. Hanumanthu was hale and healthy but became totally blind due to the Accident, Dt. 18-11-2011.
Ex.A13 Letter sent bythe Chief Manager, A.P.G.B. Kadapa to the complainant
seeking requirements for claiming the personal accident insurance benefit,
Dt.1-11-12.
Ex.A14 Family Members certificate issued by Thasildhar, Adoni, Dt.12-12-2011.
Ex.A15 Letter sent by the respondent no.3 to the complainant repudiating the claim of Complainant, Dt. 24-12-2012.
Ex.A16 Letter sent by the respondent no.2 to the complainant closing the claim
file of the complainant, DT. 30-1-2013.
Ex.A17 Requisition sent to the Chairman, Claims Review Committee, UI.I. Co.,
Ltd., Chennai seeking to review the decision of repudiation, Dt. 4-2-2013.
Ex.A18 Letter sent by the S.D.M. of the respondent to the complainant about
no change in the decision of repudiation which contains no signature of
the concerned authority and not written in the postal ledger,Dt. 14-2-13.
Ex.A19 Letter sent by the respondent company to the complainant about not
considering the claim of the complainant, Dt. 19-2-2013.
Ex.A20 Investigation Report issued by the Investigator Dt.23-12-2012.
Ex.A21 Photocopy of policy service manual.
Ex.A22 Individual personal accident policy of United India Insurance Co., Ltd.,
Kadapa.
Exhibits marked on behalf of the Opposite party No.1 : - (Ex.B1 to B30)
Ex.B1 Bank Cir. No.90-2008-aCB-STF, Dt. 23-4-2008 pertaining to Personal
Accident Insurance Scheme for the Staff of the Respondent no.1.
Ex.B2 Group Personal Accident Scheme(PAS) with UII Co., Ltd- Premium
payment receipt dt. 11-4-2008.
Ex.B3 Group Personal Accident Scheme with UII Co., Ltd.,- policy
No.050900/42/08/03/00000001.
Ex.B4 Group Personal Accident Scheme with UII Co., Ltd., - Premium payment receipt dated 8-4-2010.
Ex.B5 PAS policy No.050900/42/10/03/00000002-schedule.
Ex.B6 PAS policy No.050900/42/09/03/00000003-schedule.
Ex.B7 Group Personal Accident Scheme with UII Co., Ltd.,- policy
No.050900/42/11/03/00000003.
Ex.B8 R.O. Kurnool letter no.7/A/RO-KNL/STF/E.No.1378/12, Dt. 3-1-2012
& complainant letter Dt. 30-12-2011.
Ex.B9 PAS policy no.050900/42/11/03/00000008- Schedule.
Ex.B10 Bank letter No.1187/STF/1378/PAIS/2012, Dt. 31-10-2012.
Ex.B11 Death certificate of Y.T. Hanumanthu, dt. 24-10-2011.
Ex.B12 Family Members certificate Dt.12-12-2011.
Ex.B13 Claim Intimation under P.A. Policy for S.B., A/c holders dt.22-12-2011 of
Y.T. Jayalakshmi.
Ex.B14 UII Co., Ltd., claim form for P.A. Policy for S.B. A/c holders+ Staff Group
Personal Accident Policy of Y.T. Jayalakshmi.
Ex.B15 Notarised Affidavit of Y.T. Jayalakshmi.
Ex.B16 Certificate dt.16-10-2011 of Sri Sai Krishna Eye Hospital, Adoni.
Ex.B17 A.P. Vaidya Vidhana Parishad- out patient ticket Dt.16-10-2011 of Area
Hospital, Adoni pertaining Y.T. Hanumanthu.
Ex.B18 Certificate Dt.13-12-2011 of Civil Assistant Surgeon, Area Hospital, Adoni.
Ex.B19 CT Scan brain study report dt.17-10-2011 done on Y.T. Hanumanthu at
Shantiniketan diagnostic centre,(P) Ltd.,
Ex.B20 Cash receipt Dt.16-10-2011 of Kurnool Heart and Brain Centre,
of Y.T. Hanumanthu.
Ex.B21 Admission report from Kurnool Heart & Brain Centre of Y.T. Hanumanthu.
Ex.B22 Ambulance Service receipt Dt.17-10-2011 from Kurnool to Adoni.
Ex.B23 Ambulance Service receipt Dt.16-10-2011 from Adoni to Kurnool.
Ex.B24 LIC of India claim form- Medical Attendants Certificate Dt. 17-11-2011
of Kurnool Heart & Brain Centre, Kurnool.
Ex.B25 LIC of India claim form Medical Attendants Certificate dt.,17-11-2011 of
Kurnool Heart & Brain Centre, Kurnool.
Ex.B26 UII Co., Ltd., Letter No.050900/Staff group P.A./2011, Dt.1-11-2012.
Ex.B27 Lr. No.1191/STF/1378/PAIS/2012, Dt. 1-11-2012 of APGB, H.O. Kadapa
addressed to Y.T. Jayalakshmi.
Ex.B28 UII Co., Lr. No.050900/S.B. Claims/2012-File: SB 122/2012 , dt. 24-1-2012 addressed to Y.T. Jayalakshmi.
Ex.B29 II Co., Lr. No.050900/SB. Claims/2012-File: SB 122/2012, dt. 30-1-2013
addressed to Y.T. Jayalakshmi.
Ex.B30 UII Co., Ltd., Chennai Letter Dt.19-2-2013 addressed to Y.T. Jayalakshmi.
Exhibits marked on behalf of the Opposite party No.2 : -
Ex.B31 Ombudsman Order copy.
Ex.B32 Affidavit of the Petitioner i.e., Y.T. Jayalakshmi.
Ex.B33 Group Personal Accident Policy No.050900/42/11/03/00000003.
Ex.B34 Case record of Y.T. Hanumathu issued by the A.P. Vidya Vidhana Parishad,
Hyderbad.
MEMBER MEMBER PRESIDENT
Copy to :-
- Sri S.S.D. Ramaswamy & K. Vijaya Krishna, Advocates for complainant.
- Sri A. Raja Reddy, Advocate for O.P.1
- Sri K. Rama Kondaiah, Advocate for O.P.2
B.V.P.
