Sri Devakumar.M.C.

Member

1.     The complainant has filed the complaint under section 12 of the C.P.Act 1986, against the opposite parties, to award compensation of `5,00,000/- as per Sarv Suraksha Policy and `2,00,000/- towards the mental agony, hardship caused due to negligent act, together with interest and such other reliefs.
2.     The complainant’s deceased husband has obtained the opposite party’s Sarv Suraksha Policy by paying a premium of `6,438/-.  The insured died on 03.10.2014.  The complainant submitted all the relevant documents along with claim form, to the opposite party No.2.  The opposite party No.2 repudiated the claim vide letter dated 07.11.2014.  A legal notice caused to opposite parties.  An untenable reply was issued by opposite party No.1.  Hence, aggrieved complainant alleging the deficiency in service, filed the complaint, seeking reliefs.
3.     The opposite party Nos.1 and 2 filed a common version, as the opposite party No.1 is the Corporate office and opposite party No.2 being the local branch of opposite party No.1 and admitted the issuance of the policy.  The policy was issued with the terms and conditions of the policy, accordingly the claim was repudiated since the insured ailment was not covered under the “Critical illness” as per section (1) of Critial illness.  Hence there is no deficiency in service, as such prays for dismissal of the complaint.
4.    To prove the facts, both complainant and the opposite parties have filed affidavits, with several documents.  Written arguments filed with reported judgements.  On perusal of the material on record, posted for orders.
5.     The points arose for our consideration are:-

1. Whether the complainant established the deficiency in service on the part of opposite parties, in repudiation of the claim amount under the policy and thereby she is entitled for the reliefs sought?
2.  What order?

6.    Our findings on the aforesaid points are as follows:

Point No.1 :- In the negative.

Point No.2 :- As per final order for the following

:: R E A S O N S ::

7.    Point No.1:- The complainant’s late husband had obtained a Sarv Suraksha Policy from opposite party No.2, i.e., the branch of opposite party No.1, by paying a sum of `6,438/- towards premium.  The life assured died on 03.10.2014.  The complainant, being the nominee filed a claim application by submitting the relevant documents, vide letter dated 07.11.2014.  The opposite party repudiated the claim on the ground of Critical illness to be admissible under the policy, the insured person has to survive for a period of 30 days from the day, he was diagnosed for illness.  The complainant alleged the repudiatation of her claim as deficiency in service and sought for the reliefs.
8.    The Sarv Suraksha Policy was issued with terms and conditions.  The claim was made under “Accidental Death” but as per documents, the cause of death was illness.  As per death summary, the insured admitted to hospital on 29.09.2014 with the complaint of RHD, severe mitral stenosis, PAH, septic shock with MODS and expired on 03.10.2014.  The opposite party contended that, there is no deficiency in service as claimed.  The critical illness covered under the policy has been enumerated.  Since none of the ailment covered under the purview of critical illness, the claim has been repudiated.  Further, the claim under “Accidental death” cannot be considered as the death of the insured as accidental death, as such, the complainant is not entitled for `5,00,000/- and also not entitled for any other reliefs and the complaint is liable to be dismissed.
9.     The death summary confirms that the life assured died due to illness, but not due to “accidental death”.  As the death was not caused due to any accident.  The terms of the policy are the basis for settlement of the claim.  Thus to claim the benefits under critical illness, the insured is required to survive for atleast 30 days after he has been diagnosed for illness, whereas the insured got admitted to hospital on 29.09.2014 and died on 03.10.2014.  Thus the policy conditions were not satisfied.  As such the complainant is not entitled for the reliefs sought.
10. The judgement relied by the complainant does not support the contention, whereas the below said judgement relied by the opposite parties supports their contention.
11. In view of the decision rendered by the Hon’ble National Commission reported in IV (2014) CPJ 464 (NC) – the repudiation of accidental death claim, not covered under the policy, is justified.
12. Decision reported in I (2015) CPJ 512 (NC) – the repudiation of insurance claim coverage under policy, within 10 days from obtaining the policy, is justified.
13. In view of the above discussions, the complainant is not entitled for any claim under policy and the complaint is liable to be dismissed.  Accordingly, the point No.1 is answered in the negative
14. Point No.2:- In view of the above observations, we proceed to pass the following

:: O R D E R ::

1. The complaint is dismissed.
2. Give the copies of this order to the parties, as per Rules.

(Dictated to the Stenographer transcribed, typed by her, transcript corrected by us and then pronounced in open court on this the 20^th May 2016)