DISTRICT CONSUMER DISPUTES REDRESSAL FORUM;BHADRAK
…………………
C.D.Case No.56 of 2014
Smt.Minati Senapti, aged about 42 years
W/o: Late Jitendriya Senpati
At: Bania, PO: Saragadia, Via: Charampa
PS/Dist:Bhadrak(Rural)
……………………………..Complainant
(Vrs.)
1. The Branch Manager,
The Oriental Insurance Company Ltd.,
Bhadrak Branch,
At: By-Pass(R.C.Behera Market Complex)
PO/PS/Dist:Bhadrak(Town)
2. The Chief Regional Manager,
The Oriental Insurance Company Ltd.,
Alok Bharti Tower, Saheed Nagar,Bhubaneswar
…………………………….Opp.Parties
Order No.17 dt.22.05.2015:
Complainant who is the wife of deceased life assured Jitendriya Senpati has filed this case alleging deficiency in service on the part of O.Ps in illegal repudiation of her insurance claim.
The case of the Complainant is that her husband Jitendriya Senapati has obtained “NAGRIKA SURAKSHA INDIVIDUAL POLICY” bearing No.345701/48/2013/1268 which reveals that insured period for 1 year from 19.11.2012 to 18.11.2013 for the amount of Rs.5,00,000/- and accordingly the O.Ps duly received the amount of Rs.380/- as premium. On 15.04.2013 the husband of the Complainant while sitting on chair fell down and became unconscious and thereafter, the life assured was admitted in District Headquarters Hospital, Bhadrak and for better treatment he was shifted to Aditya Care Hospital, Bhubaneswar and subsequently shifted to Kalinga Hospital Ltd., Bhubaneswar. However, the life assured died on 17.04.2013 leaving the Complainant as legal heir & successor in interest in spite of spending lakhs of rupees in due course of treatment in different hospital. Complainant reported the said accident to Bhadrak Rural Police Station and informed the O.Ps.-Insurance Company. Complainant lodged claim Form before O.Ps. and approached the O.P.No.1 for disbursement of Policy amount and submitted all requisite documents as required by O.Ps. The Complainant on several occasions approached the O.Ps to expedite the genuine grievance and for settlement of claim. Suddenly, the Complainant received letter dt.19.06.2014 wherein the O.P.No.2 repudiated the claim in fictitious and colorable plea without providing the copy of Investigator’s Report or without any explanation from the Complainant before repudiation of the claim. So alleging deficiency in service on the part of O.Ps the Complainant filed this case on 01.07.2014 praying for a direction to the O.Ps to pay Rs.5,00,000/- with interest @ 18% per annum from the period of accident i.e. 17.04.2013 till its realization along with compensation of Rs.4,50,000/- towards mental agony and harassment besides litigation cost.
O.Ps in their written version stated that the deceased Jitendriya Senapati had taken a Nagarika Surakshya Individual Policy bearing No.345701/48/2013/1268 for the period from 19.11.2012 to midnight of 18.11.2013 for sum insured of Rs.5,00,000/- out of which Rs.4,00,000/- towards personal accident and rest of sum insured of Rs.1,00,000/- towards hospitalization, covering risk of death, permanent total disability, loss of limb(s) and permanent partial disability including reimbursement of hospitalization expenses as specified under the schedule of insurance Policy due to bodily injury resulting solely and directly from accident cause by outward violent and visible means. On 08.05.2013 the Complainant intimated the O.P.No.1 that her deceased husband Jitendriya Senapati has expired on 17.04.2013 by falling down from chair. On receiving the death intimation of life assured, the O.P.No.1 provided the claim Form to the Complainant with a request to submit the same after duly filled in and signed by her along with FIR, Postmortem report and all treatment papers. The Complainant on 23.05.2013 submitted the claim Form along with Xerox copies of documents. On receiving the claim Form and its enclosures the O.P.No.1 appointed investigator Sri Tushar Kanta Das, Advocate to investigate the claim of the Complainant. After due investigation, the investigator Sri Tushar Kanta Das,Advocate submitted the investigation report with the O.P.No.1 on 29.10.2013 expressing his inability to determine the cause of death of the deceased Jitendriya Senapati since the authority of Aditya Care Hospital and Kalinga Hospital, Bhubaneswar did not co-operate him. On receiving the investigation report of Sri Tushar Kanta Das, the O.P.No.1 asked the Complainant to submit the postmortem report of the deceased, original Discharge/Referral Certificate of DHQ Hospital, Bhadrak, Original Retail Invoice issued by M/s.Ranjan Kumar & Brothers, Station Road, Bhadrak, Original Discharge Summary of Aditya Care Hospital vide Sl.No.130415A21027, Original inpatient Final Bill Summary of Aditya Care Hospital vide Bill No.BB1300021446, BB1300312251, Original Outpatient prescription of Kalinga Hospital, Bhubaneswar vide dt.15.04.2013, Original Final Bill of Kalinga Hospital dt.17.04.2013 and Original Medical Certificate of cause of death issued by Kalinga Hospital, Bhubaneswar and other relevant papers in original vide letter dt.27.11.2013. On 04.12.2013 the Complainant submitted the Original Referral Certificate of DHQ Hospital, Bhadrak, Original Retail Invoice issued by R.K.Brothers Ambulance Service receipt bearing No.466 & 479 dt.15.04.2013 and 17.04.2013, coloured photo copy of Discharge Summary of Department of Neurology of Aditya Care Hospital, Bhubaneswar, Original inpatient Final Bill summary of Aditya Care Hospital containing 4 pages dt.15.04.2013, coloured photo copy of outpatient prescription of Kaling Hospital, Bhubaneswar dt.15.04.2013, coloured photo copy of receipt issued by Central Red Cross Blood Bank dt.16.04.2013 vide Sl.No.AP-928, original service charges for blood components vide receipt No.29489, 29490 and 29491, original Trial Bill details of Kalinga Hospital containing 2 pages, coloured photo copy of Medical Certificate of cause of death by Kalinga Hospital,Bhubaneswar, coloured photo copy of Death Summary issued by Kalinga Hospital, Bhubaneswar without postmortem report of the deceased Jitendriya Senapati. On 10.12.2013 the Complainant entered into the Office chamber of O.P.No.1 and compelled to settle her claim without PM report citing two decisions of the Hon’ble NCDRC, New Delhi for which the O.P.No.1 forwarded the claim filed to his Divisional Office, Balasore on 09.01.2014 for necessary action. On receiving the claim file on 10.01.2014 the Divisional Office of the O.P.No.1 sent the same to Technical Department of its Regional Office, Bhubaneswar/O.P.No.2 on 30.01.2014. On receiving the claim file the O.P.No.2 appointed an investigator Sri Sambhu Nath Pattnaik, LL.B., Rtd. Warrant Officer, Indian Air Force on 28.02.2014 to investigate the claim for the death of the deceased Jitendriya Senapati. After due investigation the deputed Investigator Sri Sambhu Nath Pattnaik submitted the investigation report with the O.P.No.2 on 22.05.2014 stating that no doctor has certified that the cause of death is due to accident in nature and as the death of the deceased was natural, hospital authority has not intimated to the police and as such postmortem examination is not carried out. On receiving the investigation report of the deputed investigator Sri Sambhu Nath Pattanaik, the O.P.No.2 scrutinized the claim file and ascertained that the deceased Jitendriya Senapati was suffering from Coronary Artery(CAD), Diabetic and Hypertension disease from 2010 and fell down on 15.04.2013 morning while sitting on chair followed by vomiting and became unconscious and shifted to DHQ Hospital, Bhadrak and after preliminary treatment he was referred to SCB Medical College & Hospital, Cuttack but he was admitted in the Department of Neurology of Aditya Care Hospital, Bhubaneswar and thereafter in Kalinga Hospital, Chandrasekharpur, Bhubaneswar on the same day with final diagnosis of Coronary Artery(CAD) Type 2 DM, HTN(Hypertension) Lt.Thalamo Capsular Bleed with IVH. Hence, the disease/ailment for which he was admitted in DHQ Hospital, Bhadrak, Aditya Care Hospital and Kalinga Hospital Ltd., Bhubaneswar on 15.04.2013 are pre-existing disease which he was suffering from 2010 and not due to any injury caused by an accident fall from chair and died on 17.04.2013 during his treatment at Kalinga Hospital Ltd., Bhubaneswar and from coloured photo copy of Medical Certificate of cause of death in the name of the deceased Jitendriya Senapati submitted by the Complainant it is ascertained that he died due to Lt.Thalamo Capsular Bleed with IVH caused due to/consequence of hypertension(HTN) and Type 2 DM(heart related disease).Hence, hypertension is the proximate cause of fall down while sitting on the chair followed by vomiting and hemorrhage and he had not sustained head injury due to any accident/falling from chair. Hence, the deceased Jitendriya Senapati died due to disease/ailment related to heart disease and such death of the deceased is natural for which the medical officer of the Kalinga Hospital, Bhubaneswar did not inform the Police to conduct postmortem examination over the dead body of the deceased Jitendriya Senapati. Further, the deceased had not died due to bodily injury resulting solely and directly from accident caused by outward, violent and visible means for which the O.P.No.2 repudiated the claim of the Complainant and intimated the Complainant on 19.06.2014.
We have heard the Ld.Counsel appearing on both sides and perused the documents available on record. During course of hearing Ld.Counsel for Complainant submitted that the deceased life assured on 15.04.2013 while sitting on chair fell down and became unconscious for which he was shifted to District Headquarters Hospital, Bhadrak and for better treatment he was shifted to Aditya Care Hospital, Bhubaneswar and thereafter Kalinga Hospital Ltd., Bhubaneswar. The deceased life assured while undergoing treatment expired in Kaling Hospital Ltd., Bhubaneswar on 17.04.2013. The said accident was reported to Bhadrak Rural Police, Bhadrak and the Insurance Company. But the O.P.-Insurance Company repudiated the claim of the Complainant on 19.06.2014 basing on the investigation report of Sri Sambhu Nath Pattnaik without providing the copy of the said investigator’s report or seeking clarification on the real cause of death. On the other hand the Ld.Counsel for O.Ps submitted that deceased Jitendriya Senapati died due to Lt.Thalamo Capsular Bleed with IVH caused due to hypertension (HTN) and Type 2 DM(heart related disease). Deceased Jitendriya Senapati was suffering from heart disease since 2010. As such, hypertension is the proximate cause of fall down while sitting on the chair followed by vomiting and hemorrhage and he had not sustained head injury due to any accident falling from chair. Hence, the death was natural due to heart related disease for which no Postmortem examination was conducted over the dead body of deceased and the Complainant is not entitled to get the benefit under the policy.
Thus, It is to be decided as to whether there has been any deficiency in service on the part of O.Ps in repudiating the claim of the Complainant basing on the report of the Investigator and other documents? On perusal of record, it is found that the O.P.No.1 in the repudiation letter No.nil dt.19.06.2014 to Complainant has stated that;
“Based on the investigation report, we are sorry to inform you that our Regional Office, Bhubaneswar has repudiated your above mentioned claim. We are enclosing herewith Xerox copy of their mail dated 4th June,2014 for your perusal and reference”
Further, the said mail dated 4th June,2014 reads as follows:
“This is with reference to your note dated 30/1/2014 seeking advice from us regarding the fate of the claim. Since then, we had appointed an investigator for enquiring into the facts of the cause of death. Based on the investigator’s report and other documents enclosed by you in the claim file, the CRM has repudiated the claim”.
The O.Ps in their written version at Sl. No.15 (f) have stated that after due investigation the deputed investigator Sri Tushaar Kanta Das(Adv.) submitted the investigation report with the O.P.No.1 on 29.10.2013 expressing his inability to determine the cause of death of the deceased Jitendriya Senapati since the authority of the Aditya Care Hospital and Kalinga Hospital, Bhubaneswar did not co-operate him. Further, the O.Ps in Sl.No.15 (l) have stated that after due investigation the deputed investigator Sri Sambhu Nath Pattanaik submitted the investigation report with the O.P.No.2 on 22.05.2014 stating that no doctor has certified that the cause of death is due to accidental in nature and as the death of the deceased was natural, hospital authority has not intimated to the Police and as such postmortem examination is not carried out. Admittedly, the report of the Investigator Sri Sambhu Nath Pattnaik dt.22.05.2014, basing on which the claim of the Complainant has been repudiated by the O.Ps has not been filed by the O.Ps in this case for our perusal. We entertain doubt in the investigation report of Sri Sambhu Nath Pattnaik particularly when another investigator namely Sri Tushaar Kanta Das(Adv.) expressed his inability to determine the cause of death of Jitendriya Senapati on the ground that the authority of the Aditya Care Hospital and Kalinga Hospital, Bhubaneswar did not co-operate him. If the authority of Aditya Care Hospital and Kalinga Hospital, Bhubaneswar did not co-operate investigator Sri Tushaar Kanta Das(Adv.) to determine the cause of death, how the same authority extended cooperation to another Investigator Sri Sambhu Nath Pattnaik to come to the conclusion that they have not certified the cause of death is due to accidental in nature?
During pendency of the case, Ld.Counsel for O.Ps filed a petition praying to direct the Authority of Kalinga Hospital Ltd.,Bhubaneswar to submit the medical certificate of cause of death of the deceased Jitendriya Senapati dt.17.04.2013 as the Complainant has submitted the coloured photo copy of Medical Certificate of cause of death of deceased putting tick mark against word “injury” after the words “state the disease” and before the words “or complication under the heading of “Immediate cause” and against the word “accident” before the words “suicide, Homicide(specify)”. It has been admitted by O.Ps in their written version that when the deputed Investigator Tushar Kanta Das(Adv) expressed his inability to determine the cause of death from the Xerox copy of documents filed by him on 23.05.2013, the O.Ps asked the Complainant to produce all original documents including Medical Certificate of cause of death issued by Kalinga Hospital Ltd.,Bhubaneswar. The said original documents were submitted by Complainant before the O.Ps on 04.12.2013 which according O.Ps are coloured photo copy of original documents. The O.Ps have not filed the so called coloured photocopy of Medical Certificate of cause of death issued by Kalinga Hospital in their list of documents for the reasons best known to them. On the other hand by filing the Xerox copy of Medical Certificate of cause of death issued by Kalinga Hospital and submitted by the Complainant, the O.Ps called for the original of the said document through the Forum. If original Medical Certificate of cause of death was issued to Complainant by Kalinga Hospital and it was submitted before Insurance Company may be coloured photocopy of the original, how Kalinga Hospital produced again original Medical Certificate of cause of death of the deceased before this Forum on 19.11.2014? The carbon copy of the original Medical Certificate of cause of death could have been filed by Kalinga Hospital, Bhubaneswar. Original document is always one and single. It is no doubt true that Forum is the expert of the experts. On comparison of the so called original Medical Certificate of cause of death submitted by Kalinga Hospital, Bhubaneswar, as per direction of the Forum, with the Xerox copy of Medical Certificate of cause of death filed by O.Ps on 27.10.2014 certain discrepancies are noticed which creates doubt in the mind of Forum that it was manufactured/prepared to defeat the case of the Complainant. On scrutinization of Medical Certificate of cause of death, it is noticed that the scribe is one, there is overwriting of “M” under sex column in both the documents (perhaps tried to make facsimile copy of original), there is much gap between seal and signature of the Duty Medical Officer of Kalinga Hospital, filled up the Form without maintaining due gap etc.. Assuming for the sake of argument that the Medical Certificate of cause of death filed by Kalinga Hospital is the original one, how much difference is noticed in Xerox copy/ carbon copy or facsimile copy of Medical Certificate of cause of death filed by O.Ps in this case on 27.10.2014? Further, if the Complainant had submitted the coloured photocopy of documents before the O.Ps on 04.12.2013 why did not they ask the Complainant to produce the original of Xerox copies then and there? So we are convinced that the death of deceased Jitendriya Senapati was accidental which is revealed from the Xerox copy of Medical Certificate of cause of death filed by O.Ps on 27.10.2014 and in order to disallow the genuine claim of the Complainant the 2nd investigator Sambhu Nath Pattnaik convinced the authority of Kalinga Hospital in obtaining a favourable report as narrated above. As such, Medical Certificate of cause of death filed by Complainant was original one and filed before the O.Ps without any manipulation as alleged by the O.Ps.
Further, it has been contended by the O.Ps that that the deceased Jitendriya Senapati was suffering from heart related disease since 2010 and died due to Lt.Thalamo Capsular Bleed with IVH caused due to hypertension (HTN) and Type 2 DM. So hypertension is the proximate cause of fall down while sitting on the chair followed by vomiting and hemorrhage and he had not sustained head injury due to any accident/falling from chair. Hence, the deceased Jitendriya Senapati died due to disease/ailment related to heart disease and such death of the deceased is natural for which the medical officer of the Kalinga Hospital, Bhubaneswar did not inform the Police to conduct postmortem examination over the dead body of the deceased Jitendriya Senapati. Admittedly, no treatment particulars has been filed by the O.Ps or Kalinga Hospital that the deceased Jitendriya Senapati was suffering from heart related disease since 2010 except Death Summary of Kalinga Hospital wherein it has been mentioned under Clinical Summary that known hypertensive diabetic angioplasty done on Dec.,2010 at KHL. It is also an admitted fact that no P.M. examination has been conducted over the dead body of life assured. It is no doubt true that the life assured was admitted in the District Headquarters Hospital, Bhadrak vide Regn.No.1559 dt.15.04.2013 after sustaining head injury and was referred to SCB Medical College & Hospital, Cuttack but for better treatment the life assured was admitted in Aditya Care Hospital, Bhubaneswar on 15.04.2013 and for better treatment he was also again shifted to Kalinga Hospital Ltd., Bhubaneswar on 15.04.2013. Treating Physician of Aditya Care Hospital, Bhubaneswar has categorically mentioned in the Discharge summary dt.15.04.2013 under the heading “HISTORY” that;
“55 years old male a known diabetic with H/o-CAD-S/P PTCA to LAD & OM1 on 28.12.2013 at KHL. Patient was on Dual Antiplatelet drug, fell down today morning while sitting on chair followed by vomiting & became unconscious. Patient primarily treated at DHQ, Bhadrak & referred here”.
Further, it has been mentioned in the said Discharge Summary under the heading “COURSE IN HOSPITAL” that ;
“On admission patient was comatose, GCS-3. Patient immediately intubated & put on ventilator. CT scan of brain showed Lt.Thalamic ICH with IVE large bleed with mass effect. Patient was treated with Inj.Mannitol, Tab.Asomex, Inj.Lasix, Poor prognosis explained to relatives. Patient was planned to shift to Kaling Hospital for Surgical intervention. Hence discharged today”.
It has also been mentioned in the outpatient prescription dt.15.04.2013 of Kalinga Hospital Limited,Bhubaneswar that “today morning 8 AM while sitting, fell down from chair, became unconscious”. Medical Certificate of cause of Death dt.17.04.13 issued by Kalinga Hospital Ltd.,Bhubaneswar also reveals that immediate cause of death was due to Left Thalamo capsular bleed with IVH(Inter Vascular Hemorrhage). Discharge Summary of Kalinga Hospital Ltd.,Bhubaneswar dt.29.10.2014 also makes it clear that the patient fell down while sitting on chair followed by vomiting and became unconscious due to head injury. The IIC, Bhadrak(R) PS who is a Public Servant, as is evidenced from the certificate dt.06.05.2013, that he has also enquired into the matter locally and ascertained that on 15.04.2013 morning at 8 AM while sitting on chair in a meeting at Saraswati Sishu Mandira, Bania the deceased fell down and became unconscious which fact has been entered in Bhadrak (R) PS SDE No.77 dt.03.05.2013. So, all these things taken together go to show that the deceased Jitendriya Senapati was injured due to falling down from chair and sustained head injury and the cause of death of the deceased has nexus with head injury sustained by him. The Ld.Counsel for Complainant has relied on a decision of the Hon’ble National Commission reported in CPR-2013(4), Page-563 in the case of Life Insurance Corporation of India, Through Assistant Secretary, Northern Zonal Office- Petitioner Vs. N.Shanker Reddy-Respondent, where in it has been held by the Hon’ble National Commission that to prove death by accident either Police report or hospital records confirming death as to accidental are to be produced. Further, it has been held by the Hon’ble National Commission in the case of New India Assurance Co.Ltd. Vs. Jatinder Kumar Sharma reported in 2013(2) CPR 433(NC) that non-lodging of FIR cannot be sole ground for repudiation of claim. The said has also been relied on by the Ld.Counsel for the Complainant. On the other hand the Ld.Counsel for the O.Ps has relied on a decision of the Hon’ble National Commission reported in 2010940 CPR 60(NC) in the case of Dr.Chandra Bhushan Prasad Vs. Life Insurance Corporation of India, through Branch Manager to prove their case that death by heart disease cannot be treated as accidental death. When the Complainant has been able to prove her case that the cause of death of deceased was due to accidental and not due to heart disease, the decision cited by O.Ps is not applicable to the present case. For the forgoing reasons when the Complainant has been able to prove her case by adducing documents that deceased Jitendriya Senpati sustained head injury due to accident falling from chair, repudiation of claim by O.Ps on flimsy ground amounts to deficiency in service.
The Complainant has claimed Rs.5,00,000/- from O.Ps with interest @ 18% per annum from the date of death of the policy holder i.e. 17.04.2013 till its realization. Deceased Jitendriya Senapati had taken Nagarika Surakshya Individual Policy bearing No.345701/48/2013/1268 for the period from 19.11.2012 to midnight of 18.11.2013 for the sum insured of Rs.5,00,000/-, out of which Rs.4,00,000/- towards personal accident and rest of sum insured of Rs.1,00,000/- towards hospitalization. The Complainant has submitted Xerox copies of certain money receipts towards hospitalization charges of deceased Jitendriya Senapati in this case. It is not known whether the said documents have been filed before the O.Ps or not. If the Complainant would have filed the money receipts towards hospitalization charges, the same may be considered by O.Ps as per actual. Accordingly, it is ordered:
O R D E R
In the result, the Complainant is allowed in part on contest against the O.Ps 1 & 2. The O.Ps are directed to pay the payable insurance claim under the policy No. 345701/48/2013/1268 to the complainant with interest @ 9% p.a. from the date of repudiation i.e. 19.06.2014 till final payment is made along with litigation cost of Rs.2,000/- within a period of 30 days of receipt of this order.
