(Passed on 18/03/2024 )

Per Mr. Sachin Vinodkumar Jaiswal, Hon’ble Member

1. The complainant had filed the present complaint under Section 12 of Consumer Protection Act, 1986.
2. The brief facts of the case are as under.

That the complainant No. 1 is the widow and complainant Nos. 2 and 3 are the daughter and son of deceased Mr. Rajesh Shankarrao Dudhalkar respectively. The deceased husband of the complainant had taken the policies from the Ops. The details of the policies are as given below.

The deceased was regularly paying the premiums of the polices and during the subsistence of the policy met with an accident on 4/8/2021 and suffered fracture injuries on left leg and head injuries in the accident. The deceased over and above, the premium of the policy had paid Rs. 25/- under the first policy and Rs. 100/- under the 2^nd policy for total accident benefit rider and therefore was liable for sum assured of Rs. 1,00,000/- each under the polices in case of accidental death. The deceased died on 19/04/2019 during the treatment at District General Hospital, Chandrapur because of the accidental injuries and the complainant had filed the claim under both polices with the Ops immediately. After regular follow up for the claim under both policies, the Ops had paid the basic amount of Rs. 1,00,000/- each under policy to the complainant in last quarter of 2020 but failed to provide or pay the claim under the accidental benefit to the complainant’s.

3. The complainants were running pillar to post  for the remaining claim amount. The Ops are giving only hollow assurances  that their claim  would be paid shortly but no amount under the benefit of accidental rider had been paid by Ops to the complainants.
4. The complainant further submits that left with no alternative, the complainant sent legal notice to the Ops through their counsel and asked for the remaining claim amount of Rs. 2,00,000/- under the policies but all requests of the complainant fall into the deaf ears of the OP and therefore the complainant filed the present complaint seeking claim of Rs. 1,00,000/- each under the insurance polices with 10 percent interest from the date of filing of the claim along with Rs. 25,000/- towards mental agony and harassment and Rs. 15,000/- towards cost of litigation.
5. After admission of complaint, notices were issued to the Ops. The Ops appeared and filed their detailed reply, denying all the allegations made against them by the complainant.
6. The OP Nos. 1 and 2 specifically submitted that the complainant had not made any specific claim under the policy for accidental death benefit with the OP and therefore the complaint is pre-mature and liable to the dismissed on this ground alone.
7. The OP further submitted that treatment papers filed by OP along with reply shows that the deceased was admitted into Government Medical College & Hospital, Chandrapur on 22/03/2019 and discharged card shows the treatment was given to the deceased for Chronic Alcoholic Hepatitis  and also certificate given by medical attendant shows cause of death and Chronic Alcoholic Hepatitis. The statement made by the complainant as well as in the claim form mentioned reason of death of the deceased as Heart Attack and this reason cannot be considered as death because of accident and therefore  the claim of the deceased/complainant  was not considered by the Ops for accidental death benefit. The OP further submitted that as per the policy, the accident means “ An accident is a sudden unforeseen and involuntary event cause by external, violent and visibal means.”  
8. The Ops further take the re-course visible of policy terms and conditions which read as under.

“ The Corporation shall not be liable to pay the additional Accident benefit Sum Assured, if the death of the life assured shall …….. (vi) Occur after 180 days from the death of accident of the life assured.”

It is therefore submitted by the Ops that because of the reason mentioned, the accidental rider benefit cannot be given to the complainant as well as the Ops further submits that basic claim for the claim payable by the OP to the complainant had already been paid and the same had been confirmed by the complainant in their complaint.

REASONING

9. We heard both the counsels at length. The counsel for the complainant, submitted that the OP failed to pay legitimate claim of the complainant for the death benefits under the policy for which the deceased was paying the premium regularly to secure the family of the deceased after his death and relying on tagline of the Ops which says “JINDAGI KE SATH BHI, JINDAGI KE BAAD BHI”  are denying the genuine  claim of the complainant. The OP had indulged in unfair trade practice and deficient in providing services to the complainant and therefore the complaint of the complainant is liable to be allowed with reference to the prayers made in prayer clause of the complaint.
10. The counsel for OP vehemently argued   mainly on the aspect that if the OP had paid the claim amount of Rs. 1,00,000/- each under both the polices which was payable as per the terms and conditions of the policy there would be no reason for the Ops to not pay the claim under the accidental death benefit to the complainant if the same falls within the purview of terms and conditions of the policy. It is further submitted by the OP that the accident of deceased occurred on 4/8/2018 and the life assured died on 19/04/2019 which is beyond  180 days and as per the terms and conditions of the policy, accidental death benefit cannot be granted. The Ops were well within the  purview  of terms and condition of the policy and were not deficient in providing any services to the complainant and therefore the complaint is liable to be dismissed with exemplary cost.
11. After going through the documents filed, arguments extended, Commission finds no force  in the arguments of the Ops as the Ops have filed treatment papers of the deceased that the deceased husband of the complainant was in continuous treatment after the accident till his death. The Commission pass following order.

ORDER

1. The complaint is partly allowed.
2. The OP Nos. 1 and 2 jointly and severally are directed  to pay the accidental death benefit to the complainant of Rs. 1,00,000/- each under the policy bearing No. 909791265 and 909795882 with 9 percent interest per annum from the date of complaint i.e. 21/06/2021 till realization.
3. The OP Nos. 1 and 2 jointly and severally   further directed to pay Rs. 15,000/- toward mental agony and harassment and Rs. 10,000/- towards cost of litigation.
4. Copy of order be furnished to all parties, free of cost.