Haryana

Ambala

CC/221/2014

SMT.RITA WIDOW OF LATE SHRI JAGDISH SINGH - Complainant(s)

Versus

BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LTD - Opp.Party(s)

D.P.BALIAN

13 Sep 2017

ORDER

 

       BEFORE THE DISTTCONSUMER DISPUTES REDRESSAL FORUM; AMBALA.

C.C.No.221 of 2014.

Date of Instt.:21.08.2014.

Date of Order: 13.09.2017.

1.Smt.Rita widow of late Shri Jagdish Singh son of Shri Niranjan Singh 2.Ankush, minor son 3.Gaurav minor son 4.Nisha minor daughter of Shri Jagdish Singh all minors thorugh their mother and next friend Smt.Rita Rani widow of late Shri Jagdish Singh son of Shri Niranjan Singh r/o 376, village Garnala, PO Dhankaur Tehsil & District Ambala.

..Complainant.

     Versus

1.Bajaj Allianz General Insurance Company Limited Airport Road, Yerwada, Pune 411006.

2.The Branch Manager, Bajaj Allianz General Insurance Company Limited 167/18C 2^nd Floor Hazara Singh building near Ambala Club, near Vijay Rasttan Chowk, Ambala Cantt. 133001.

          ..Opposite parties.        

Complaint under Section 12 of the Consumer

 Protection Act, 1986

 

BEFORE:       SH. D.N. ARORA, PRESIDENT.

                        SH. PUSHPENDER KUMAR, MEMBER.

                        MS. ANAMIKA GUPTA, MEMBER.

                       

Present:          Sh.D.P.Ballian, Adv. for complainant.

                        Sh.R.K.Vig, Adv. for counsel for OPs.

 

ORDER

                   Brief facts of the complaint are, as under:

                   The husband of the complainant No.1 and father of complainant Nos.2 to 4, who had died in road side accident on 20.11.2013, had purchased an insurance policy No.OG-11-1207-6401-00000626 having validity from 22.12.2010 to 17.12.2013 amounting to Rs.5 lacs. The complainants being the legal heirs of deceased are legally entitled for the claim amount, therefore, they had approached the OPs for releasing the amount of insurance but they refused to accede to the request of the complainants, therefore, they got served legal notice the insurance company but to no avail.  The act and conduct of the OPs clearly amounts to deficiency in service. In evidence, the complainants have tendered affidavits Ex.CW1, Ex.CW2 and documents Ex.1 to Ex.15.

2.                           On being served, the OPs have contested the complaint of the complainant by filing joint reply wherein it has been mentioned that there is no deficiency in service on the part of OPs. The policy was issued to the husband of the complainant No.1 having validity from 18.12.2010 to 17.12.2013 for covering the risk which runs as under:

“In case of accidental death amount payable 100 % of sum assured + children education bonus (Children bonus is Rs.5,000/- for one child or Rs.10,000/-maximum for 2 children below the age of 19 or 10 % capital sum insured which is less). In case of permanent total disability  (includes coverage for loss of sight in both eyes loss of both hands/both feet/one hand and one foot one eye and one hand one eye and one foot or other total permanent disablement as per policy-amount payable 125 % of sum assured. In case of permanent partial disability amount payable applicable percentage of sum assured depending on nature of disability”.

 

As per medical report of GHCH it is clear that Jagdish/insured had died due to “Cardiac Arrest”, therefore, the complainants are not entitled for any compensation on account of death of insured as it was not covered the risk of heart attack. The OPs have rightly and legally repudiated the claim of the complainants because the complainants have also not submitted post mortem report of the deceased to the insurance company to process the claim.  It is a case of clear cut violation of terms and conditions of the policy. Other contentions raised in the complaint have been controverted and prayer for dismissal of the complaint has been made. In evidence, the OPs have tendered affidavit Annexure RA and documents Annexure R1 to Annexure R8.

3.                          Learned counsels for the parties have been heard and the record produced on the case file has been perused meticulously.

4.                          It is not disputed that the husband of the complainant No.1 and father of complainant Nos. 2 to 4 had purchased an insurance policy No.OG-11-1207-6401-00000626 having validity from 22.12.2010 to 17.12.2013 amounting to Rs.5 lacs for covering accidental death and other benefits (Annexure C5) from OPs by paying the premium thereof. It is proved that Jagdish-deceased had met with an accident on 08.11.2013 and was admitted in Government Hospital, Ambala City as is evident from the report made on the bottom of Ex.C1 wherein it has been mentioned that the patient was brought at 3.45 P.M. with history of fall from bike. Patient was Drosy, so CT scan was advised which shows subaradintd Hemorrhage and so patient was referred to GMCH 32 Chandgiarh for further management on the same day. Ex.C2 is the admission register and Ex.C3 is the bed head ticket/treatment record issued by Civil Hospital, Ambala showing that the patient was referred to GMCH, Sector 32 Chandigarh. Ex.C4 the death summary of Jagdish reveals that he was admitted in GMCH, Chandigarh in emergency as case of road side accident and he was given medication as per hospital protocol.  The cardiac arrest was occurred at 10.30 P.M. which did not revive and the death occurred at 11.30 P.M. Ex.C7 is the death certificate issued by MC, Chandigarh wherein date of death has been mentioned as 20.11.2013. Ex.C8 is hospital treatment certificate and Ex.C9 is the Last Attending Doctor’s certificate. In Ex.C12- death report it has been mentioned that the patient had died due to cardiac arrest on 20.11.2013.

5.                          Though learned counsel for the OPs has argued that as per medical certificate and Death report (Annexure R2 and Annexure R3/Annexure 12) it is clear that the patient had died after 13 days of the due to cardiac arrest and not from the injuries of road side accident, therefore, the complainants are not entitled for any claim as the death of the deceased was not accidental death but this plea is not tenable as it is apparent that firstly the accident took place resulted in injuries and chest pain which ultimately resulted in death. The death in medical term is described as due to heart attack but the main cause for leading to heart attack was injuries caused due to accident and the accident was the basis for causing chest pain and thereafter heart attack.  The present case is fully covered by the law laid down by the  Hon’ble National Commission in case titled as Smt.Krishna Wati  Vs. LIC 2006 (1) CPJ 21. Therefore, this Forum has a confirmed view that the Ops have wrongly and illegally repudiated the claim of the complainants on account of death of Jagdish/insured due to cardiac arrest as mentioned in hospital record.

6.                The plea of insurance company qua not producing post mortem report to it is not tenable because there is ample evidence on the case file to reach at conclusion that the cause of death was accidental, therefore, the insurance company cannot take the shelter of condition regarding this, if any, mentioned in the policy terms and conditions. On this point reliance can be taken from case law decided by Hon’ble National Commission in  case titled as United India Insurance Company Limited Versus Pallamreddy Aruna, 2008 (1) CLT 167. The insurance company is not suppose to get only premium but it also liable to act fairly without taking the benefits of the weaknesses of the assured and it is also liable to indemnify all the responsibilities for which the premium has been received.

6.                          Now, we are coming on the point of compensation. As per policy terms In case of accidental death amount payable 100 % of sum assured + children education bonus (Children bonus is Rs.5,000/- for one child or Rs.10,000/-maximum for 2 children below the age of 19 or 10 % capital sum insured which is less). Since the death of deceased is an accidental death therefore, the complainants are entitled for 100 % of the sum assured i.e. Rs.5,00,000/- alogwith interest @ 9 % per annum from the date of filing of complaint till its realization. As per ration card Ex.C4, affidavit of the complainant No.1 as well as the certificate Annexure C11 issued by the Sarpanch of the village it is proved that the deceased was having three minor children at the time of filing of the complaint, therefore, they are entitled for the education children bonus, as per policy conditions, of Rs.10,000/-, subject to furnishing of school certificates qua studying of the minors in any school at the time of accident, to the insurance company within a period of 15 days to be counted from the date of receiving of the copy of this order.  It is ordered accordingly. The present complaint is allowed with costs which is assessed at Rs.5,000/-. Order qua payment of sum assured and costs be complied with within one month from the date of receiving of the copy of this order and the order qua making the payment of children education bonus be complied with within one month after submission of school certificates to the insurance company by the complainants. It is made clear that all the complainants would be entitled for equal share of the awarded amount i.e. Rs.5,00,000/- only except the education children bonus which shall be paid in equal share to each minor child. The share of the minors in the sum assured of Rs.5,00,000/-  will be deposited in shape of fixed deposit in favour of the complainants No.2 to 4 till attaining the age of maturity. Copy of this order be supplied to both the parties free of cost. File be consigned after due compliance.

 

ANNOUNCED IN OPEN FORUM                            

Dt.13.09.2017.                                           

                                                                   (D.N.Arora)

                                                                   President,

(Pushpender Kumar)                           Distt.Consumer Disputes

      (Member)                                      Redressal Forum, Ambala.

 

 

                                      (Anamika Gupta)

                                            (Member)