Order No.  13  dt.  02/08/2017 

          The case of the complainant in brief is that the complainant obtained a workmen compensation policy being policy no.OG-15-2401-2801-00000075 effective from 27.09.2014 to 26.09.2015 for covering WC in respect of its workmen at Rungagora Tea Estate, Assam. During the continuance of the said policy a permanent employee of the complainant namely Khiro Turi sustained injury and she was taken to hospital whereby she succumbed to her injuries. On the basis of the said fact a compensation proceeding was started an award of Rs.4,52,372/- was passed by the Ld Tribunal. The complainant paid the said  amount to the legal heirs of the deceased.

            On the basis of the said fact the complainant made claim to the insurance company but the insurance company repudiated the same on the basis of the report submitted by an Investigator of the company. It was stated in the report that no post mortem examination was held and on the basis of the said technical ground to come to this conclusion that the death occurred due to an accident the repudiation was made.

            Being aggrieved with the decision of the insurance company the complainant filed this case praying for direction upon the o.p1 for releasing the amount of Rs.4,52,372/- in favour of the complainant along with compensation and litigation cost.

             The o.p.nos. 1 and 2 contested the case by filing w/v denying all the material allegations of the complaint. It was stated that the claim made by the complainant has already been decided before the Commissioner for Employees Compensation, Golaghat, Assam in case no. EC27 of 2015. Since the matter has already been disposed of by a Tribunal, this Forum has no jurisdiction to entertain the case. It was alleged that after getting an intimation by the insurance company regarding the said claim the insurer appointed an Investigator namely Mr Dipak Das to investigate the facts and circumstances of the claim. The Investigator in the report stated that deceased was a patient of high blood pressure and the cause of death was due to said decease. Since the death was normal no post mortem examination was conducted by the police. It was further alleged that as per the terms and conditions of the policy if any employee sustained personal injury by accident or disease arising out of and in the course of the employment by the insured in the business and if the insurer shall be liable to pay compensation for such injury under the law(s) set out in the schedule or at common law, then subject to the terms exceptions and conditions contained herein or endorsed the company will indemnify the insured against all sums for which the insured shall be so liable and will in addition be responsible for all costs and expenses incurred with its consent defending any claim for such compensation.

            Accordingly the claim of the complainant was repudiated. In view of the facts and circumstances of the case as stated above the o.ps prayed for dismissal of the case.

            On the basis of the pleadings of parties the following points are to be decided :

1. Whether the complainant was insured with the insurance company for covering the injury/death sustained by the employees?
2. Whether the employee of the complainant fell ill during her employment?
3. Whether the compensation paid by the company to its employees to be reimbursed by the insurance company?
4. Whether there was any deficiency in service on the part of the o.p.?
5. Whether the complainant will be entitled to get the relief as prayed for?

Decision with reasons :-

            All the points are taken up together for the sake of brevity and avoidance of repetition of facts.

            The Ld lawyer for the complainant argued that  during the subsistence of the policy with the o.p.1 and employee of the complainant sustained injury and she was removed to hospital whereby she succumbed to her injuries. A claim for compensation of the said employee was started before a Tribunal an award was passed to that effect. The complainant paid the said amount. Subsequently the complainant for reimbursement of the said amount asked the o.p.1 to pay the said amount but the insurance Co.repudiated the said claim by raising objection that since no p.m. examination was held, the death cannot be said  to be an unnatural one. But it was emphasized by the Ld Lawyer for the complainant that since the deceased belonged to a tribal family the family members did not want the p.m. examination of the deceased as such  p.m. was not held. On the basis of the said fact the Ld lawyer for the complainant prayed for direction upon the o.p. for reimbursement of the amount paid by the complainant and for compensation of the amount as well as for cost.

            The Ld lawyer for the o.p. argued that  since no p.m. examination was held it cannot be ascertained as to how the death occurred. After the claim of the complainant the insurance company appointed an Investigator who collected the reports/materials from the hospital as well as from the attending doctor wherefrom the investigator came to learn that the said employee was suffering from high blood pressure and during the  time of her performing duty she fell on the earth and sustained injuries. Since the employee did not sustain any injury due to an accident during her employment therefore the claim of the complainant was not entertained. In view of the said fact the o.p. prayed for dismissal of the case.

            Considering the submission of the respective parties it appears that Smt Khiru Turi was an employee of the complainant’s company while she was in employment she met with an accident and due to the  said accident she died. After her demise her son filed a case before the Commissioner for Employees Compensation, Golaghat, Assam and the Ld Tribunal was pleased to allow the compensation amounting to Rs.4,52,372/-  The complainant also  filed the document to show that the order of Ld Tribunal was complied by the complainant. It is also an admitted fact that the policy was valid during the time of the said accident. It is crystal clear that the policy covered the employees of the complainant in case of sustaining any injury or death due to the injury sustained by the employee. Here in this case the o.p.insurance company in order to evade the payment of the reimbursement of the compensation took this plea since the p.m examination was not held thereby the claim of the complainant cannot be entertained. From the materials on record it is found that Ld Tribunal accepted the plea of the complainant  regarding the accident faced by the mother of the complainant and the compensation was allowed. In this respect we should consider that the accident took place in a tea garden situated in a remote area in Assam and it is the  usual practice in remote village that the family members of the deceased do not want that further p.m.examination and herein this case the said fact occurred thereby the p.m. examination was not held. On the basis of the said fact we hold  that the complainant will be entitled to get the reimbursement of the amount paid to the family members of the deceased and there was also deficiency in service on the part of the o.p. insurance company and accordingly we hold that the complainant will be entitled to get the relief as prayed for.

            Hence, ordered.

            that the case no.189/2016 is allowed on contest with cost against the o.p. nos. 1 and 2. O.p. nos. 1 and 2 are jointly and severally directed to pay Rs.4,52,372/- and also to pay compensation of Rs.50,000/- as well as litigation cost of Rs.10,000/- within 30 days from the date of communication of this order, i.d. an interest @ 10% p.a. shall accrue over the entire sum due to the credit of the complainant till full realization.

             Supply certified copy of this order to the parties free of cost.