DISTRICT CONSUMER DISPUTES REDRESSAL FORUM<br /> Civil Station, Palakkad – 678 001, Kerala<br /> <br /> Dated this the 30th day of January, 2008<br /> <br /> Present: Prof.O.Unnikrishnan, President I/C<br /> Mrs.K.P.Suma, Member<br /> <br /> C.C.No.21/2007<br /> 1.Dr.G.Madanagopal,<br /> S/o.Govindarajulu Naidu,<br /> Proprietor,<br /> Rukmini Polyclinic,<br /> Vennakkara, Palakkad.<br /> <br /> 2.Devu,<br /> W/o.Late Valappan,<br /> <br /> 3.Mani,<br /> S/o.Late Valappan.<br /> <br /> 4.Sarojini,<br /> D/o.Late Valappan.<br /> <br /> 5.Muthukutty,<br /> S/o.Late Valappan.<br /> <br /> 6.Unnikrishnan,<br /> S/o.Late Valappan.<br /> <br /> 7.Sivanunni,<br /> S/o.Late Valappan.<br /> Complainants 2 to 7 are residing at:<br /> Chanthanpulli,<br /> Vengoli.P.O, Palakkad – 678 622. - Complainants<br /> <br /> Vs<br /> <br /> United India Insurance Co. Ltd.,<br /> Branch Office,<br /> P.B.No.41, G.B.Road,<br /> Palakkad – 678001. - Opposite party <br /> (Represented by Adv.Mohanram)<br /> : 2 :<br /> O R D E R<br /> <br /> By Prof.O.Unnikrishnan, President I/C<br /> <br /> First complainant is the Proprietor of the Rukmini Poly Clinic and the other complainants are the wife and children of deceased Vellappan and employee of the Rukmini Polyclinic. 1st complainant submits that he had taken a compact policy for 12 employees with the opposite party company with personal accidents benefit for the period from 28/8/05 to 27/8/06. Under the said policy the insurance cover is for Rs.1 lakh for each employee. Sri.Vellappan an employee of the first complainant and a beneficiary under the said policy met with an accident on 28/8/05 at 6pm at the hospital. He was immediately admitted in the hospital and was under treatment of Dr.Jose Mathew and Dr.Madanagopal. Sri.Vellappan had fracture of right femure pertrochanteric of raclure hypast pneumonia and was an inpatient till 19/9/05 then he was discharged with plaster cast and continued treatment while under bed rest he developed pneumonia and was succumbed to his injuries and pneumonia on 01/02/2006. Complainants submit that the cause of death of Sri.Vellappan was due to pneumonia which was developed as an after effect of the treatment for his fracture on right leg. Further Sri.Vellappan was not in a position to move any where after the fall and was completely bed ridden. Complainant informed the matter to the opposite party with relevant bills which was repudiated by saying that there was no stipulation to reimburse the medical bills.<br /> <br /> After death of Vellappan, on 10/02/2006 the complainant applied to the opposite party to settle the claim along with Medical certificate issued by Dr.Jose Mathew to show that the cause of the death was the accident that happened on 28/08/2005 and he died while under going treatment. As there <br /> : 3 :<br /> was no reply the complainant caused a reminder for which the opposite party replied stating that they were investigating into the matter and process the claim and would intimate later. Further the complainant states that on 2/6/06 the second opposite party vide their lr. No.10201/48/05/8890000248 has intimated that the death of Vellappan was not directly or indirectly due to the accident and the claim was repudiated. Complainant caused a letter to the opposite party's regional office, grievance cell on 3/7/06. On 14/8/06 they made a reply stating that the death was not due to an accident but pneumonia and repudiated the claim.<br /> <br /> Complainants alleged that the finding of the opposite party that the cause of death was not the proximate cause of the accident was not correct and was against medical evidence and facts of the case. Sri.Vellappan died due to the injuries sustained by him due to an accident in the course of his employment and later developed so many complications due to the injuries sustained by him and he died. <br /> <br /> Complainants alleged that the acts of opposite party amounts to deficiency of service. Further they submit that the opposite party ought to have accepted the medical evidence and should have settled the claim. Complainants submit that they have caused mental agony by the acts of the opposite party and hence the opposite party is liable to compensate for the same. Hence they filed this complaint before this forum praying to issue direction to the opposite party to pay the insured sum of Rs.1 lakh and a sum of Rs.25,000/- as damages to the mental agony suffered due to their deficiency of service.<br /> <br /> Complaint was admitted and notice was served to the opposite party for <br /> : 4 :<br /> their appearance and version. Opposite party denied all the allegations and averments made in the complaint except those that were specifically admitted. Opposite party submits that this complaint is not maintainable either in law or on facts and the same is liable to be dismissed in limine. Further the complaint is filed without any bona fide and the complainant is not entitled to get any of the reliefs claimed in the complaint. Opposite party contended that complainants 2 to 7 are the wife and children of deceased Vellappan is not correct and hence denied. Further the opposite party contended that Vellappan met with an accident on 28.08.05 at 6 pm at the hospital and he was immediately admitted in the hospital and was under treatment of Dr.Jose Mathew and Dr.Madanagopal, that Vellappan had fracture of Right femur Pertrochanteric of raclure Hypast pneumonia and was an inpatient till 19.09.05, after that with plaster cast he was removed to his residence and was continuing his treatment there while under bed rest he developed pneumonia and was succumbed to his injuries on 01.02.2006 etc are incorrect and hence denied. Opposite party states that the allegation in the complaint that the cause of death of Vellappan was due to pneumonia which was developed as an after effect of the treatment of his fracture on right leg, that he was not in a position to move any where after the fall and was completely bed ridden, that this matter was informed to the company with relevant bills which was repudiated by the company saying that there is no stipulation to reimburse the medical bills, that under the said policy the insurance cover is for Rs.1 lakh for each employee etc are incorrect and hence denied by the opposite party.<br /> <br /> Opposite party further contended that the allegation raised by the complainant that after the death of Vellappan the complainant applied to the opposite party to settle the claim with medical certificate issued by Dr.Jose <br /> : 5 :<br /> Mathew that the cause of death was the accident and that happened on 28.08.2005 and he died while under going treatment and papers to that effect were also produced are incorrect and denied.<br /> <br /> Opposite party contended that the allegation of the complainants that the findings of the opposite party that the cause of death was not the proximate cause of accident was not correct and was against medical evidence and facts of the case that Vellappan died due to the injuries sustained by him due to an accident in the course of his employment and later developed so many complications due to the injuries sustained by him and he died and the copy of the investigation was not given to the complainant and the complainant was not ignorant about the finding of the alleged investigation done by the opposite party are incorrect and hence denied.<br /> <br /> Further the opposite party stated that the allegation in the complaint that the opposite party ought to have accepted the medical evidence and should have settled the claim, that due to the deficiency in service the complainant had suffered mental agony and the opposite party is liable to pay Rs.1 lakh towards insurance amount and Rs.25,000/- towards compensation for the mental agony etc are denied by the opposite party.<br /> <br /> Opposite party states that after getting claim form the opposite party has deputed an Investigator to investigate the genuineness of the claim and also the proximate cause of death. The investigator after conducting an investigation has submitted a report stating that the patient died due to phenumonia and other complications. Even before the accident, he was not in good health condition and was highly diabetic. Opposite party avers that the report also showed that the death was direct (indirect) result of accidental fall <br /> : 6 :<br /> on 28.08.2005 as alleged in the complaint, the claim was not entertainable as per the policy conditions and hence the claim was repudiated and the allegation in the complaint that the accident has taken place on 28.08.2005 at 6 pm was also specifically denied and disputed. Opposite party further contended that since the policy commences on 28.08.2005 the exact date and time of accident must be proved by the complainants and the age of Vellappan was also misrepresented to get the policy cover. They submit that if the age of employee was correctly disclosed, they would not have issued a policy covering his risk. Opposite party further contended that since there was misrepresentation and fraud was also played by the policy holder, the policy itself is void and this opposite party is not liable to pay any compensation to the complainants. As there is no nexus between the accident and the death, this opposite party is not liable to pay any amounts to the complainants on the basis of the personal accident policy issued. Hence the opposite party prayed to uphold their contentions and to dismiss the complaint with compensatory costs to the opposite party.<br /> <br /> Complainant and opposite party filed affidavits as well as documents. Dr.Jose Mathew was examined as PW1. Exbts.A1 to A8 marked on the side of complainant and Exbts.B1 to B5 was marked on the side of opposite party. Heard the parties.<br /> <br /> We have perused the documents produced from both sides. It is evident from Exbt.A1 that the opposite party had issued a compact policy for 12 employees for Personal Accidents Benefit for the period 28/08/2005 to 27/08/2006. It is an admitted fact that Sri.Vellappan was an employee of the 1st complainant and a beneficiary under the said policy. It is obvious from the examination of PW1 (Doctor) and Exbt.A4 certificate issued by the witness that <br /> : 7 :<br /> the deceased Vellappan had fracture of Right Femur Pertrochanteric of racture and was an inpatient till 19/09/05. According to the first complainant he was removed to his residence with plaster cast and was continuing his treatment under bed rest which developed pneumonia and was succumbed to his injuries on 01/02/2006. It is noticed from Exbt.B2 that a claim form was submitted to opposite party on 10/02/2006 and the same was repudiated as per Exbt.A4 and A8. Opposite party contended that the claim is not at all entertainable since the death was not as a direct or indirect result of the accident. The investigation report which was marked as Exbt.B1 states that patient died due to pneumonia and other complications. Even before the accident, the patient was not in good health condition and was highly diabetic which can be noticed from Exbt.B5. They further contended that at the time of taking the policy, the age of the employee who died was also misrepresented to get the policy cover. Opposite party has produced a copy of Electoral Card of deceased Vellappan and the same is marked as Exbt.B3 and the copy of Ration card issued to Vellappan was also produced and marked as Exbt.B4. The voters ID card issued in 1998 shows the age of Sri.Vellappan as 75 and the Ration Card issued in 2005 shows the age as 78. According to the complainant the finding of the opposite party that the cause of death is not the proximate cause of the accident is not correct and is against medical evidence and facts of the case. Sri.Vellappan died due to the injuries sustained by him due to an accident in the course of his employment and later developed so many complications due to the injuries sustained by him. But the death was due to pneumonia. The proximate cause of death is the pneumonia which developed while under going treatment. It is due to the prolonged treatment. The deceased was under going treatment for a pretty long time after the accident. Due to the injuries sustained by him he was completely bed ridden and was not in a position to move any where. The complainant had also produced <br /> <br /> authorities in the subject of medicine to show that the prolonged treatment on bed may cause pneumonia. We agree with the argument of the complainant that the death was due to the complications that arose during the treatment. The evidence of PW1 will also support the above fact. <br /> <br /> But the Insurance Company stood on technical grounds which are formal and flimsy, which does not substantiate the question of facts. They had produced Ext.B3 and B4 to prove the age of the deceased which is not admissible. The age has to be proved through SSLC book admission register or the birth certificate issued form the local administrative body. Hence the contention of opposite party that the policy itself is void cannot be taken into consideration.<br /> <br /> The object of the consumer movement and the subsequent enactment of the Act itself envisages a liberal attitude by the Forum and not rigid adherence of various rules and regulations. A perusal of the various judgements of the High courts and Apex courts would go to show that on the basis of some minor technical lapses the bonafide claims of the insurer should not be curtailed or denied and especially a Insurance Company should not take shelter under minor and flimsy grounds. In the above circumstances we are inclined to allow the complaint.<br /> <br /> Hence we direct the opposite party to pay the insured amount to the complainants for the death of Sri.Vellappan a beneficiary under the Compact Insurance policy, along with Rs.500/- as costs of this proceedings. The aforesaid amount shall be paid within one month from the date of communication of this order failing which the complainant is entitled to get 9% interest p.a from the date of order till realisation.<br /> <br /> Pronounced in the open court on this the 30th day of January, 2008 <br /> <br /> Sd/- <br /> Prof.O.Unnikrishnan, President I/C <br /> <br /> Sd/-<br /> K.P.Suma<br /> Member<br /> Appendix<br /> <br /> Witnesses marked on the side of complainant <br /> PW1 – Dr.Jose Mathew<br /> <br /> Exhibits marked on the side of complainant<br /> Ext.A1 – Original Insurance policy<br /> Ext.A2 – Claim form (xerox copy)<br /> Ext.A3 – Medical report<br /> Ext.A4 – Certificate issued by Doctor<br /> Ext.A5 – Letter issued by 1st complainant to grievance cell<br /> Ext.A6 – Reply by grievance cell<br /> Ext.A7 – Repudiation letter by opposite party <br /> Ext.A8 – Repudiation letter from Regional Office<br /> <br /> Exhibits marked on the side of opposite party <br /> Ext.B1 – Investigation report<br /> Ext.B2 – Copy of case sheet<br /> Ext.B3 – Electoral card (photocopy)<br /> Ext.B4 – Copy of ration card<br /> Ext.B5 – Blood test report<br /> Costs (allowed)<br /> Rs.500/- (Rupees Five hundred only) allowed to complainant as costs of the proceedings<br /> Forwarded/By Order,<br /> Sd/-<br /> Senior Superintendent