Punjab

Rupnagar

CC/21/10

Harcharan Kaur - Complainant(s)

Versus

Appolo Munich Health Insurance Company Ltd. - Opp.Party(s)

Sh. M.S,Nagra, Adv.

06 Jul 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION ROPAR

 

                                  Consumer Complaint No.10 of 2021

                                  Date of institution: 17.02.2021

                                  Date of Decision: 06.07.2022

Harcharan Kaur widow of Late Sh. Rajnder Singh, resident of House No. 412, Ward No.4, Morinda, District Rupnagar 

                                                          …….Complainant

Versus

 

1. Appolo Munich Health Insurance Company Limited, Plot No.404-405, 2^nd & 3^rd Floor, Ilab Centre, Udyogvihar, Phase-III, Gurugram-122016 (now amalgamated with HDFC Ergo General Insurance Company Limited)

2. Appolo Munich Health Insurance Company Limited, Inizio, 1^st Floor, 101, Cardinal Gracious Road, Opp. O & G Plaza, Chakala, Andhei East, Mumbai (Maharashtra)- 400099. (now amalgamated with HDFC Ergo General Insurance Company Limited)

                                                      ……..Opposite Parties

 QUORUM:    

HON’BLE MR.RANJIT SINGH, PRESIDENT.

HON’BLE MRS.RANVIR KAUR, MEMBER

PRESENT:-

Sh.A.P.S. Guliani, Adv. counsel for complainant

Sh. Varun Soni, Adv. for O.Ps.

 

ORDER

      SH. RANJIT SINGH, PRESIDENT

The present order of ours will dispose of the above complaint filed under Consumer Protection Act, by the complainant against the Opposite Parties on the ground that the husband of the complainant Late. Sh. Rajinder Singh, had purchased one Group Personal accident insurance policy No.160100/22001/AXPO118915 dated 03.02.2018 valid till 02.02.2019 from the Opposite parties for a sum of Rs.15,00,000/- and paid a premium of Rs.1274/-. The insured Sh. Rajinder Singh, named the complainant as his nominee being his wife in case of exigency of his insurance policy. As per the policy in case of accident death total sum of Rs.15,00,000/- is payable by the OP. Insurance company while in case of permanent total or partial disablement the sum insured payable is as per table of benefit. On 19.09.2018, while the insured Rajinder Singh was working at his shop i.e. A-I, dry cleaners Morinda and about 6.0 PM was about to take out some cloths from godown, he was bitten by a pair of snakes. Rajinder Singh despite being bitten by the snakes caught hold both the snakes and packed them in a box alive. The insured was taken to Civil Hospital, Morinda, where he was referred to PGIMER, Chandigarh. The insured was admitted in PGIMER on 19.9.2018 at about 8.45 PM vide CR No.2018-05745156 and was discharged from PGIMER on 20.09.2018 at about 4.30 PM. It is further alleged that the insured after being discharged from PGIMER in stable condition was though taking medicines but unfortunately on 30.09.2018 when the insured had gone to Village Dholan Majra, District Ropar on his Activa Scooter and has just parked his scooter there, a snake sitting inside the right side light cup adjoining the handle of the Activa Scooter again gave bite on the right hand of the insured and caught hold his right hand finger in his mouth, which could be got released with great difficulty. After the second bite, the insured was again taken to General Hospital, Morinda from where he was again referred to PGIMER, Chandigarh on 30.09.2018. The insured was once again got admitted in PGIMER on 30.09.2018 at about 3.0 PM. The insured was discharged from PGIMER on 01.10.2018 at 4.30 PM in a stable condition. On 21.10.2018, the insured Rajinder Singh since was feeling restless, he was again taken to emergency PGIMER, where it was found that he has again been bitten by snake. During treatment in the PGI his old record of 30.09.2018 was withheld by the PGI. At about 3.35 PM on the same day, i.e. 21.10.2018, the insured Rajinder Singh breath his last and expired in PGI. Medical Certificate of cause of death of insured Rajinder Singh is attached. After the death of insured Rajinder Singh, in PGIMER, the family members including the present complainant were under tremendous shock due to the death of her husband, that all the relatives present there did not opt for post mortem due to religious reasons. Due to the untimely death of Rajinder Singh in PGIMER and due to the great shock, complainant neither could get the post mortem conducted nor get the FIR registered in the police station as the complainant could not blame anyone for the snake bites. However, on the verbal advises from the well wishers, the complainant lodged a complaint with the police on which investigation and verification police record DDR no.10 dated 19.11.2018 in Police Station City Morinda, District Ropar. The complainant on coming to know about the insurance policy having been issued by the opposite party, lodged her claim with the OP in December 2018 for release of sum insured. The OP No.1 vide their letter dated 23.1.2019 asked the complainant to submit certain documents. In continuation of the letter dated 23.01.2019, which might have been dispatched by the OP on 30.01.2019 sent another letter dated 4.2.2019 asking for the same document which were asked for in the letter dated 23.01.2019. The complainant in response to the letter dated 23.1.2019 and 4.2.2019 through insurance agent submitted the documents on 1.3.2019 in Chandigarh branch office of OP. Inspite of the fact, that the complainant have submitted the documents except FIR and post mortem report, the OP vide their letter dated 7.3.2019 have rejected the claim of the complainant on the ground of non compliance of required documents. It is further alleged that the investigation team of the insurance company could verify the treatment record from General Hospital, Morinda, as well as PGI could get cause of death from the concerned doctors of PGI and could verify all other facts from the locality before getting the claim repudiated. Since the death has caused during the validity of insurance period and the insurance policy having been operative on the date of accident and death, the complainant is entitled for the benefits under the insurance policy, but the opposite party have wrongly and illegally repudiated the claim of the complainant on flimsy grounds Thus, alleging deficiency in service on the part of O.Ps. the complainant has sought the following relief:-

1. To pay the claim amount of Rs.15,00,000/- along with interest.
2.  To pay Rs.1,00,000/- as compensation
3. To pay Rs.33,000/ as litigation expenses.

The complaint of the CC is signed and also verified.

2.             In reply, the O.Ps. has taking preliminary objection; that the complaint is not tenable as there is no deficiency in service or unfair trade practice on the part of the opposite party invoking the jurisdiction of this Hon’ble Commission; that as per Section 69 of the Consumer Protection Act, 2019, defines the limitation period for filing the complaints  under the Consumer Protection Act, 2019. As per the definition, the complaint can be filed with District Commission within 2 years from the date of cause of action having been arisen but in this case, the complainant filed the complaint after two years; that the instant complaint is a gross abuse of process of law and the complainant has approached this Commission with unclean hands and has suppressed the material facts. On merits, it is stated that on receiving the intimation from the complainant regarding the death of the insured Rajinder Singh, the OP has demanded the following documents from the complainant and detail narration of the incident, FIR, Post mortem report, attested copy of police final investigation report, cancel cheque of the nominee reflecting the printed of account holder on the cheque, discharge summary of admission dated 19.9.2018, discharge summary of admission dated 30.09.2018, receipts confirming anti venom vaccination, all receipts of hospitals conforming medication, medicine purchase complete set of treatment record of PGIMER, Chandigarh, details of other insurance on the name of insured. But the said documents has not submitted by the complainant so exact cause of death was not ruled out and claim got rejected under reason under non receipt of requirement as shared above. Rest of allegations leveled by the complainant have been denied and prayed for dismissal the complaint. 

3.             The learned counsel for the complainant has tendered into evidence his affidavit Ex.CA along with documents Ex.C1 to Ex.C13 and closed the evidence. On the other hand, the learned counsel for the Ops. has tendered affidavit of Sh. Manoj Kumar Prajapati, Manager Cooperate Legal Ex.R1 along with documents Ex.R2 to Ex.R11 and closed the evidence. 

4.             We have heard learned counsel for the parties and have gone through the file, carefully and minutely.

5.             It is pertinent to mention here that deceased Rajinder Singh husband of the complainant has brought insurance policy from the Appolo Munich Health Insurance Company Limited of Rs.15,00,000/-, which was valid from 03.02.2018 to 02.02.2019. The insured was died due to snake bite with twice and after the death of the insured, the insurance company has failed to pay the claim amount to the complainant.

6.    From the perusal of the documents, it reveals that the insurance company just to linger on or with the intention of not passing the claim of the complainant, unnecessary conditions imposed on the complainant. In support of his claim, the learned counsel for the complainant has placed on record the General Diary Details bearing No. 10 dated 19.12.2018, which is clearly mentioned by the police that Rajinder Singh (insured) had died due to snake bite. The learned counsel for the complainant also placed on record the Medical Certificate of Cause of Death of PGIMER, Chandigarh, vide which it is stated that Rajinder Singh died due to snake bite and we can consider this document as a detailed investigation report. As far as the post mortem is concerned, in her complaint and affidavit, the complainant has stated that due to religious reasons, the post mortem was not done by the complainant. The non-production of documents like Post Mortem Report or medical evidence has drawn the attention of the Commission under the Act time and again.

In 2005 (1) CPC 533 ( Life Insurance Corporation of India and others Vs. Smt. Nidhi Sahi) the case of the complainant was that the death of the insured occurred in the scooter accident and her claim was mainly challenged on the ground that no FIR was lodged nor any Post Mortem Examination had been performed on the body of the deceased. However, the factum of death was duly proved and was supported by statement of witness, who was pillion rider of the scooter at the time of accident. The complaint was allowed by the District Forum. In the appeal the same was upheld on the ground that the factum of death had been duly proved. It becomes very much clear from that judgment that even in the absence of the FIR or the Post Mortem Report, the factum of death in a particular way can be proved by producing other evidence. Similarly in 2006 (II) CPC 599 (National Insurance Company Limited Vs. Rita Devi It was held that non-production of the Post Mortem Examination report cannot be made a ground for repudiation of the claim.

The facts were similar in 2009 (1) CLT 74 ( Parkash Kaur and others Vs. ICICI Lombard General Insurance Company Limited) In that case the insured had died due to snake bite and evidence was produced for proving that fact. However, there was no post mortem report or police report for proving that fact. It was held therein that the claim cannot be repudiated simply on the ground that the post mortem report or the police report was not produced especially when the death by snake bite is proved from other.  

7.             It is important to mention here that on the application, the medical record of Rajinder Singh, (Insured) was summoned by this Commission for verifying the cause of death of Rajinder Singh. In the medical record, it is clear mentioned by the PGIMER, Chandigarh, that the Rajinder Singh was died due to snake bite. So it cannot be denied that Rajinder Singh was died due to Snake Bite. But Insurance Company deliberately not passing the claim of the complainant.

8.             It is usual with the insurance company to show all types of green postures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This take it or leave it, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-

                “It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood 15 by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.” By repudiating the genuine claim of the complainant, the opposite parties have harassed the complainant unnecessarily for a long time and it amounts to deficiency in service and unfair trade practice.

9.             In view of discussion made above, totality of the documents and law laid down by the higher authorities, we feel, that the complainant is entitled to the claim. Therefore, we allowed the present complaint with the direction to the OPs to pay the claim amount of Rs.15,00,000/- along with interest @ 7% per annum from the date of death of insured Rajinder Singh. The OP are further directed to pay Rs.50,000/- as compensation and Rs.11,000/- as litigation expenses. The OPs are further directed to comply with the said order within a period of 30 days from the date of receiving the certified copy of this order. Free certified copies of this order be sent to the parties, as per rules. The file be sent to the Record Room.

 Announced

 July 06, 2022

(Ranjit Singh)

President

                                               

(Ranvir Kaur)

Member