PRESIDENT DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

                                                    CONSUMER COMPLAINT NO. 203/2023

Present-Dr. Ramakanta Satapathy, President,

  Sri. Sadananda Tripathy, Member,

Mst. Sangita Dhal,

W/O-Late Subrat Kumar Sahu,                                         

R/O-Jambubati Bhawan, Subhashshri Vihar, Ainthapali,

Po-Budharaja, Ps-Ainthapali,

Dist- Sambalpur-768004, Odisha.

………….......Complainant

-Vrs.-

Aditya Birla Health Insurance Company Limited,

Represented through the Branch Manager, Sambalpur,

2^nd Floor, Harichitra Tower, Plot No. 1792/3923, Holding No. 568,

Unit-5, V, S.S. Marg Tower, Sambalpur, Po-Sambalpur,

PS-Dhanupali, Dist-Sambalpur,

Odisha, PIN-768001.                                           .....................Opp.Party

Counsels:-

1. For the Complainant         :- Sri. R.P. Nanda & Associates
2. For the O.P.s                       :- Ex-parte

Date of Filing:09.11.2023,Date of Hearing :16.01.2024,Date of Judgement :11.03.2024

  Presented by Dr. Ramakanta Satapathy, PRESIDENT

1. The Complainant is the nominee in Health policy No. 12-19-0014360-00 for the period 14.05.2019 to 13.05.2021 issued by O.P. in favour of late Subrata Kumar Sahu, husband of the Complainant. The policy has personal accident coverage of Rs. 25.00 lakhs of the insured. On 11.07.2020 in road traffic accident Subrat Kumar Sahu died and Ainthapali P.S. Case No. 0335 was registered. Claim form along with Rs. 1496/- for fire wood expenses and Rs. 1500/- other expenses death benefits were claimed on 12.05.2021. The O.P. vide mail dated 30.05.2022 rejected the claim as per term and condition No. 13 of the policy bond. On the ground of negligence of the deceased policy holder, claim was repudiated.

Being aggrieved complaint has been filed.

2. The O.P. has been set ex-parte.
3. The Complainant submitted the following photo copies of documents:

1. Health insurance policy No. 12-19-0014630-00.
2. Claim form dated 12.05.2021.
3. E-mail of O.P. dated 30.05.2022.
4. Letter of O.P. dated 30.05.202 intimating repudiation of the claim.
5. Wood bill dated 07.11.2020.
6. Funeral expenses bill dated 11.07.2020.
7. Copy of F.I.R. in P.S. Case No. 0335 of 11.07.2020.
8. Copy of P.M. report of late Sabrat Sahu.

4. Perused the documents and submissions of the Complainant. Vide receipt No. R70486777 dated 14.05.2019 RS. 6684/- has been paid by insured Subrat Kumar Sahu. The product features of the policy covers personal accident, critical illness, cancer secure, Hospital cash and wellness a 2yr/ 3yr cover and insured enjoys a 7.5% discount on premium for a 3 years terms and 10% discount on a 3 years term. Sum insured is Rs. 25.00 lakhs. In case of accidental death or permanent total disablement  then in addition to the amount payable a lump sum amount of (Rs. 2,50,000/- or Rs. 5.00 lakhs) to-wards the education of surviving dependent to be paid. In addition that from the spot of accident to the nearest hospital by road Ambulance expenses maximum upto Rs. 10,000/- shall be payable. Funeral expenses maximum Rs. 50,000/- raising from Rs. 25,000/- to the nominee shall be payable. The Complainant spent Rs. 1496/- to-wards wood expenses and Rs. 1500/- funeral expenses.

The O.P. repudiated the claim on the following ground: “It is observed, negligently driving the motorcycle while incident happened. Hence claim stands repudiated as per terms and conditions 13”.

The F.I.R. has been lodged by Sandip Kumar Dhal on 11.07.2020. Post Mortem of the deceased Sarat Sahu discloses that due to Hemorrhagic shock resulting from liver rupture caused by blunt trauma. At the time of coming to home near Anugulia Pada truck No. OD-15L-7235 dashed the deceased, who was with Bullet No. OD-15P-1830. The parties have not submitted the details of the vehicles. The O.P. has not submitted any documentary evidence that the deceased was driving negligently. On what basis the insurer came to the conclusion and repudiated the claim is wanting. In absence of those documents from available documents it can be concluded that the repudiation is not proper.

Accordingly, following order is passed.

ORDER

The complaint is allowed ex-parte against the O.P. The O.P. is directed to pay the claim amount of Rs. 25.00 lakhs, Rs. 1496/- to-wardsfire wood expenses and Rs. 1500/- other expenses and compensation amount of Rs. 2.00 lakhs within one month of this order. In case of non-payment the amount will carry 12% interest P.A. from the date of submission of claim form i.e. 12.05.2021 till realisation. The O.P. is to pay litigation expenses of Rs. 20,000/-.

Order pronounced in the open court on this 11^th day of March 2024.

Supply free copies to the parties.