Naveen Puri, President;

1     The present resolve has been in compliance to the Orders dated 01.11.2017 of the Hon'ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh (PSCDRC); in Transfer Application No 08 of 2017 by virtue of which the Consumer Compliant # 141 of 2016 titled as: Baljinder Kaur Vs Bajaj Allianz Life Ins. Co. Ltd., Amritsar’ pending before the District Consumer Forum, Amritsar; stood transferred to this Forum with directions to decide the same preferably within a period of 15 days  from the date fixed i.e., 17.11.2017.

2        The case of the complainant in brief is that Davinder Singh son of Puran Singh (since deceased) husband of the complainant was insured with the opposite party and the complainant being the nominee of the insured is competent to sign, verify and institute the present complaint as envisaged under law. Sh. Davinder Singh son of Puran Singh aged about 51 years husband of complainant was insured with the opposite party and he had obtained one life insurance policy dated 21.9.2012 under the scheme of Group Master Policy No. 0177675666 under Sarv Shakti Suraksha for sum assured of Rs. 1,25,000/- alongwith Rider sum assured Rs. 1,25,000/- and he had been regularly paying installments of amount of premium of said policy; that on 2.2.2015 the husband of complainant was going from Amritsar to Fatehgarh Churian on his motorcycle bearing registration No. PB-18-R-5568 and his brother Sakattar Singh was also following him on his own motorcycle and when they reached near Baba Resort, Nawan Pind at about 6.00 p.m. suddenly one dog came in front of the bike of husband of complainant and in making attempt to save the said dog the husband of complainant met with an accident due to unbalancing his motorcycle and resultantly he received multiple, serious and grievous injuries on his different parts of body and more particularly on his head. Sakattar Singh took his brother Davinder Singh, to CHC Fatehgarh Churian on ambulance, but on account of serious injuries on the head of Davinder Singh, the concerned medical officer referred the patient to shift him in Guru Nanak Dev Hospital, Amritsar, but while going to Guru Nanak Dev Hospital Amritsar, the husband of complainant namely Davinder Singh died on the way to said hospital due to multiple, serious injuries received in the said road accident on 2.2.2015 and later on the matter was reported by Sakattar Singh to the police and the statement of Sakattar Singh brother of deceased husband  of complainant was recorded on 3.2.2015 under Section 174 Cr.P.C at Police Station Jhander. A Panchyatnama was also written by respectable members of Panchyat of Gram Panchyat Kotla Gujjran, Amritsar with respect to the death of Davinder Singh husband of complainant in road accident; that thereafter information with respect to the death of Davinder Singh in the said road accident was given to the opposite party and the death claim of husband of complainant was filed by complainant. All the requisite documents as demanded by the opposite party were provided to the opposite party. All the original papers and original policy bonds were also handed over to the opposite party and the complainant had fulfilled all the formalities as per asking of opposite party but inspite of all that, the opposite party has only given claim of sum assured of Rs. 1,25,000/- alongwith bonus of Rs. 12,264/-, in all Rs. 1,37,264/- by considering the death of Davinder Singh as natural death, whereas the fact remains that Davinder Singh died in the road accident as stated above and as such he was also entitled for Rider Sum Assured of Rs. 1,25,000/-  but the opposite party has failed to pay the above said genuine and legitimate claim of Rider Sum Assured of Rs. 1,25,000/- to the complainant to which the complainant is legally entitled to; that the complainant requested the opposite party on so many occasions to pay the above said amount of claim to the complainant i.e. Rider Sum Assured of Rs. 1,25,000/- because the husband of complainant died in road accident. But the opposite party refused to make the payment of the claim to the complainant. By not giving the claim of the complainant, the act of the opposite party is illegal, arbitrary and it amounts to gross negligence, carelessness, deficiency in service and unfair trade practice on the part of the opposite party. Hence the present complaint.

3        After formal admission of the complaint, notice was issued to the Opposite Party and Opposite Party appeared through counsel and filed written version contesting the complaint on the Preliminary Objections that the opposite party has not committed any deficiency in service qua the complainant, hence the present complaint is not maintainable in the eyes of law under the provisions of Consumer Protection Act; that the present complaint is filed on mere conjectures and surmises. There is no deficiency in services on the part of the opposite party; that the claim of the complainant has already been settled and the insured amount alongwith due bonus payment, has already been remitted to the account of the complainant with Punab Gramin Bank vide cheque No. 124432 dated 23.3.2015 and as such nothing is payable to the complainant towards settlement of the claim in question. The claim amount has been paid as per terms and conditions of the insurance policy. The complainant is not entitled to any alleged additional claim amount as claimed in the present complaint as per policy terms and conditions; that the present complaint is not maintainable in the present form and false and baseless submissions have been made therein and complainant has not approached this Forum with clean hands and as such the same is liable to be dismissed on this score alone; that the complainant is estopped to file the instant complaint as there is no deficiency in service on the part of opposite party as defined in Section 2(I)(g) of consumer Protection Act 1986 under the heading Deficiency; that the complaint against the opposite party does not lie before the Forum under the Consumer Protection Act 1986 with regard to the partly rejected claim. The matter is also to be decided by a civil court at full scale trial requiring the complete pleadings and evidence according to law; that in view of the provisions contained in the Insurance Act 1938 which is a specific statue meant for dealing with the disputes under the contract of insurance the provisions of Consumer Protection Act 1986 cannot be invoked for dealing with the matter covered by Insurance Act. On merits, It is pleaded that no separate premium for the alleged Rider sum assured of Rs. 1,25,000/- was paid by the insured and the due amount of claim as per terms and conditions of the policy has already been paid to the complainant by the opposite party. As admitted by the complainant herself she has already received assured amount of Rs. 1,25,000/- alongwith due bonus amounting to Rs. 12,264/- and the said claim has been paid to the complainant as per terms and conditions of the policy and the proposal form submitted by the insured at the time of purchasing the insurance product which are a contract of insurance between the parties. The complainant is not entitled to additional amount of Rs. 1,25,000/-.  All other allegations mentioned in the complaint were denied being incorrect and prayer was made for dismissal of the complaint with costs.

4        Sufficient opportunities were granted to the parties to lead evidence in order to prove their respective case. The complainant tendered in to evidence her affidavit Ex. CW1/A alongwith documents Ex. C-1 to C-27 and also examined one witness Dr. Sukhjinder Singh, Emergency Medical Officer, CHC Fatehgarh Churian presently posted at PHC Kot Santokh Rai, District Gurdaspur and closed the evidence and thereafter, Ld. Counsel for the Opposite Party tendered in to evidence affidavit of Sh. Sandeep Gupta Manager O.P/1 and closed the evidence.

5        We have heard the Ld. Counsel for the parties and also thoroughly examined the available documents/ evidence on the records so as to statutorily interpret the meaning and purpose of each document. We find that the present dispute is comprised of one prime issue only as to whether the DLA’s death under the prevalent scenario can be taken as ‘accidental’ death at the face of non-conduct of the Post Mortem of the dead body.

6.       The learned counsel for the complainant has throughout argued that the DLA has been a strong healthy middle-aged person and there has been no evidence on record that he did ever suffer from any ailment of whatsoever that might have caused a somewhat untimely & and sudden death except the multiple injuries (including the grave fore-head injury) that he did receive during the fall on the metal road from the running motorcycle. It was further emphasized that an otherwise duly evidenced accidental death cannot be termed as ‘natural’ death simply on the ground that the formality of Post Mortem was not conducted on the DLA’s dead body and similarly an eligible insurance-claim benefit cannot be repudiated on the technical grounds of its being not accompanied with the PMR. The learned counsel has also cited a good number of senior courts’ judgments that do validly support his above arguments; as:

i) PSCDRC 2017(3) CLT  378  in FA # 1091 of 2015 titled Narinder Kaur vs Bajaj Allianz Ins Co Ltd.;

ii) PSDRC 2013(4) CLT 192  in FA # 1816 of 2009 titled Darbara Singh & Ors. Vs The Taprian,  Amar Singh Co-op Ag Services Society Ltd., & Ors;

iii) NCDRC 2011(3) CPC  422  in RP # 2495-96 of 2011 titled 15, TPD Gram Sewa Sahkari Samiti                                                                                      Ltd., & Ors. Vs. Charanjit Kaur & Ors;

7.       On the other hand, Sh. S K Vyas Advocate the learned counsel for the OP Insurers has vehemently argued that the PMR (Post Mortem Report) has been an essential and mandatory document to accompany every accidental-death insurance-claim since it is only the PMR that establishes the cause of death to be accidental and or otherwise and the same being a requisitioned document as per the prescribed ‘term’ of the related policy the same cannot be done with during the claim settlement exercise and thus the accidental death benefit has been rightly repudiated by the OP Insurers. Mr. Vyas has also cited some senior court judgments to inspire strength to his version but fails to convince us; as:

i) NCDRC 2014(3) CLT  47  in RP # 1289 of 2011 titled V K Kariana Store vs. Oriental Ins. Co Ltd.;

        Here the issue was as to the address of the insured premises.

ii) PSCDRC 2001(2) CLT  632  in FA # 501 of 1998 titled: LIC of India vs. Anju Hunjan;

        PMR was desired since there has been no physical injuries on the dead body;

8.       Somehow, we have been inclined to examine the validity & legality of the impugned repudiation (of the related portion of accidental-death insurance-claim) in the back-drop of the preceding and also the succeeding acts & events in the light of the facts on records and current law on insurance vis-à-vis consumer subject matter, in issue. We find that the DLA had been so grievously injured (including the head injury) that he was referred to the Guru Nanak Hospital, Amritsar by the attending doctor at the Primary Health Centre, Fatehgarh Churian but he could not survive his injuries on the way. The Post Mortem was not felt necessary since the death was caused by ‘fall’ from Motorcycle after hitting a stray Dog and did not involve any offence/ litigation etc. However, the related FIR and Village Panchayat resolution do prove the accidental death perused with the other documents as produced by the complainant and exhibited as Ex.C1 to Ex.C27 along with his affidavit Ex.CW1/A. In return, the OP insurers could produce its affidavit simply deposing the version as put forth in their written statement in which the issue of the absence/ non-availability of the PMR has not even been touched, throughout. Further, the terms of the policy do state that the insurers shall be entitled to receive all information and documents sought which includes but is not limited to # 10.7 ‘PMR’ plus others as U/clause 10 (Claim Process). It shall be pertinent here to mention that it is not only the PMR that alone proves accidental death but other relevant circumstances can also cogently prove ‘accidental-death’ as in the present situation. The PMR may pin-point the exact injury causing ‘death’ but the injuries (causing death) received in an ‘accident’ are even otherwise proved as in the present case. We are of the considered opinion that in such-like cases PMR can indeed be assistive (may be conclusive) but certainly cannot be all-exclusive i.e., accidental-death can even be established in the absence/ non-availability of the PMR by virtue of other circumstantial but cogent evidence and the legal proposition gets sufficiently support of the basic statute (Evidence Act, 1872). Finally, we are supported by the tenet law in our above view that an otherwise valid right may not be crucified at the altar of academic technicality.

9.       We find that the OP insurers here have arbitrarily repudiated the present claim merely on the flimsy ‘presumption’ that in the absence of PMR accidental death cannot be established. To remove all ambiguity, it may be clarified here that an ‘insurance claim’ and for that matter any ‘issue’ can be neither legally ‘favored’ nor legally ‘ousted’ on the basis of mere ‘presumption’ how strong it might appear to be. The OP insurers must realize that their administrative decisions in settling insurance claims are open to judicial review and thus need be taken with due application of mind and not arbitrarily and these should also be speaking in nature duly explaining the reason and logic of the decision as to how the same has been reached. The facts in issue need be appreciated while awarding sanctity to the current applicable law.  

10.     In the matter pertaining to the present complaint and in the light of the all above, we set aside the OP’s impugned repudiation of the accidental-death claim being arbitrary (contra to laws of natural justice) and amounting to ‘deficiency in service’. Thus, we ORDER the OP insurers to settle and pay the impugned ‘insurance claim’ in to its full ADB pertaining to the related Policy in question with full accrued benefits etc. if any, along with Rs.20,000/- as compensation for the undue harassment inflicted besides Rs.10,000/- as cost of litigation; within 30 days of receipt of the copy of these orders, otherwise the entire awarded amount shall attract interest        @ 9% PA form the date of orders till actually paid.

11.     Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.