Delhi

North

CC/30/2020

SARITA GOYAL - Complainant(s)

Versus

APOLLO MUNICH HEALTH INSURANCE COMPANY LTD. - Opp.Party(s)

ADITYA AGARWAL & AMIT RANA

19 May 2023

ORDER

District Consumer Disputes Redressal Commission-I (North District)

[Govt. of NCT of Delhi]

Ground Floor, Court Annexe -2 Building, Tis Hazari Court Complex, Delhi- 110054

 

Consumer Complaint No. 30/2020

In the matter of

Sarita Goyal

W/o Late Sh. Mahender Goyal

R/o H.No.174, Gali No.6, Friends Enclave

SP Road, Sultanpuri, C-Block

Delhi-110086                                                           …              Complainant

Vs

Apollo Munich Health Insurance Company Ltd.

Through its Managing Director/Chairman

Office at:

Shakti Nagar Branch Office

Ground floor, 29/7, Nangia Park

Circle Shakti Nagar, Delhi-110007

 

Also at :-                                                     

ILABS Centre, 2^nd and 3^rd floor

Plot NO.404-405, Udyog Vihar, Phase-III

Gurgaon-122016, Haryana, India.                                  …………Opposite party

         

ORDER
19/5/2023

Ms.Harpreet Kaur Charya, Member

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. 110800/21001/2000093745-05 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 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 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-I 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 Housing Development 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 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 the 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) as 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.
11. The complainant has filed the rejoinder to the written statement filed on behalf of the OP, where the contents of the complaint have been reiterated and those of the written statement have been denied.  It has been submitted that the final inquest report under Section 174, the Code of Criminal Procedure, 1973 filed by the Police official, clearly stated that it was a train accident and no offence is made out.
12. Evidence by way of affidavit has been filed by the parties.  The complainant has deposed on oath the contents of the complaint and has got exhibited the documents annexed with it.  The copy of the Aadhar card of the complainant has been exhibited as Ex.CW1/1; copy of the insurance policy as Ex.CW1/2; the copy of the inquest report prepared by the police official and copy of the post-mortem report are Ex.CW1/3 and Ex.CW1/4 respectively. The complainant has also got exhibited the repudiation of the claim through email dated 24/09/2019 as Ex.CW1/5; the copy of the statement recorded at Apollo Munich Health Insurance Co. Ltd., Central processing Centre, Gurgaon and the email sent by OP are Ex.CW1/6 and Ex.CW1/7 respectively.
13. The complainant has deposed that there are no evidences to suggest that “DLA” has committed suicide and as per the inquest report and post-mortem report, it was an accidental death in train accident. The complainant has also got exhibited the copy of the insurance cover from Paytm, where the claim has already been settled and has got the same exhibited as Ex.CW1/8 along with copy of the Aadhar card of the children of the complainant as Ex.CW1/9.
14. OP has got examined Ms. Shweta Pokhriyal, their Authorised Representative.  She has also reiterated the submission made in the written statement and has relied upon the annexure.
15. We have heard the argument of the Ld. Counsel for the complainant and Ld. 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

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 of 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:

1. 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;
2. 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;
3. Compensation of Rs.20,000/- on account of mental agony and harassment.
4. Litigation expenses of Rs. 15,000/-.
5. 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)  

Office is directed to supply the copy of this order to the parties as per rules.Order be also uploaded on the website.Thereafter, file be consigned to the record room.

 

 

(Harpreet Kaur Charya) Member

(Ashwani Kumar Mehta) Member

 

 

(Divya Jyoti Jaipuriar)

                                            President