IN THE CONSUMER DISPUTES REDRESSAL FORUM, KOLLAM
DATED THIS THE 27TH DAY OF JULY 2015
Present: - Smt. G.Vasanthakumari, President
Adv. Ravisusha, Member
Adv.M.Praveen Kumar, Member
CC.No.89/2013
Prasanna.P. : Complainant
W/o Unnikrishnan (Late)
Mangalasseril, Kanjiracode
Mulavana P.O
Kollam – 691503
[By Adv.Ram Manoj.A.S, Kollam]
V/S
1. Director : Opposite Parties
Comprehensive Health Insurance
Agency, Kerala (CHIAK)
7th Floor, Trans Towers
Vazhuthacadu
Thiruvananthapuram
[By Adv.Ashik.K.Mohamed Ali & Manoj Kumar]
2. The Divisional Manager
M/s United India Insurance Co.Ltd.
Divisional Office, SKP Building
Beach Road
Kollam – 691577
[By Adv. S.Subash Chandra Babu,Kollam]
ORDER
ADV. RAVISUSHA, MEMBER
Complainant’s case is that the complainant is the mother of the deceased Unmesh, S/o Unnikrishnan (Late), Mangalasseril, Kanjiracode, Mulavana, Kollam. Her one and only daughter Unnimaya is married and settled at Kadakkal. The complainant is ailing with several diseases for the last 15 years. Moreover her husband Unnikrishnan was a chronic diabetic patient and after a prolonged treatment he expired in the year 2010. Thereafter the deceased Unmesh took all the responsibilities of their family and he was the head of the family. He was working as a Gymnasium Instructor and thereby look after the complainant. He was the one and only bread winner of his family. Though he was the head of the family and one and only source of income
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of the family for the last 3 years, after his father’s death, as a usual practice, the authorities mentioned the complainants name as the head of the family in the Ration card instead of inserting the name of the deceased Unmesh as the head of the family. Even the premium of RSBY also remitted by the deceased Unmesh.
On 09/11/2012, the deceased Unmesh met with an accident at a place in front of Gemini Vehicles Service Status, Keralapuram while he was riding his motorcycle bearing No.KL-24-D-516 and succumbed to his injuries at Kollam District Hospital, on the same day itself. The complainant and the deceased Unmesh were members of RSBY (Rashtriya Swasthya Bima Yojana) by Policy No.00575607320125604. As per the said scheme the opposite parties are bound to give personal accident insurance claim of an amount of Rs.2,00,000/- (Rupees Two Lakhs Only) to the complainant. The opposite parties have not issued the policy conditions to the complainant at the time of issuing the policy or thereafter.
Being the members of RSBY scheme, the complainant submitted a claim form before the 2nd opposite party on 13/03/2013. Since no policy conditions has been issued to the complainant, she was not aware of the formalities for lodging the claim applications. The delay in lodging the claim form is only due to the mental shock sustained to the complainant due to the sudden death of her one and only son. The second opposite party rejected the claim forms without conducting proper enquiry and without hearing the complainant and straight away rejected the claim application and issued a letter dated 18/03/2013 stating that 2nd opposite party is not able to admit the claim since the deceased is the son of the complainant. The rejection of the claim application filed by the complainant is not at all sustainable either on law or on facts. The application filed by the complainant is not properly considered. The opposite party is deliberately abstaining from disbursing the personal accident insurance claim amount to the complainant. The very act of the opposite parties amounts to deficiency in service and culpable negligence and omission. Hence filed this complaint.
Opposite party 2 filed version contending that the complainant is the smart card holder, head of her family and beneficiary under the scheme of RSBY CHIS. The deceased Unmesh was not the head of the family. Since the smart card is issued in the name of the complainant she is the head of the family and no other person will be considered as head of the family. The ration card of the complainant bearing card No.1207175053 also shows that the complainant is the head of the family and the deceased Unmesh was the youngest member of the family. The
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complainants own reasons mentioned in the said paragraph to show that the deceased was the head of her family is not legally sustainable.
As per the conditions of the said agreement an additional benefit of Rs.2,00,000/ -(Two Lakhs) will be provided, only in the case of accidental death happened on the Head of the family or the spouse of the card holder under the scheme of personal accidents claims offered by the company. Therefore the accidental death of the complainant’s younger son has no coverage under the scheme because he was neither the head of the family nor the spouse of the card holder. The complainant submitted claim form before the opposite party only on 13/03/2013. The date of death of the complainant’s son is on 09/11/2012. But the claim form submitted after the delay of more than 4months. As per the scheme the beneficiary or the eligible person has to report immediately for making the company’s internal investigations. The cause of the delay is not explained also in the claim application. RSBY is a welfare health scheme implemented by the Union Government for below poverty line people and their family members, as defined by the Planning Commission. The scheme is implemented by the labour and rehabilitation department of the State Government as the nodal department after due publication by all means vide news papers, visual medias, and distribution of pamphlets, public notices etc to the card holders and the public. Hence the averment that the complainant did not get policy conditions and thereby she was not aware of the formalities for lodging the claim application is absolutely falsehood. Death of a person having no policy coverage over him. Therefore the opposite party had sufficient reason to reject the claim application. Moreover it was a delayed application also not sufficiently explained the delay. There is no willful latch or deficiency of service or dereliction of duty or any unfair trade practice by the 2nd opposite party in dealing the claim application. Hence prays for dismissal of complaint.
The points that would arise for consideration are:-
(1).Whether there is any deficiency in service on the part of opposite parties?
(2).Reliefs and costs?
The evidence in this case consists of oral evidence of PW1 and documentary evidence Exts P1 to P6 and D1 and D2.
The Points: In this case complainant is claiming Rs.2,00,000/- as personal accident insurance claim in case of accidental death of her son. As per the conditions of the agreement an additional
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benefit of Rs.2,00,000/- will be provided only in the case of accidental death of the head of the family or the spouse of the card holder. According to complainant her son was the head of that family.
Opposite parties contentions are that the deceased son was not the head of the family of the complainant. The complainant alone was the head of the family. Hence the complainant is not eligible to get personal accident claim in connection with the accidental death of her son.
Here the only question to be discussed is that whether the deceased Unmesh was the head of the family of the complainant. For finding out that point the authentic records are RSBY card and ration card of the complainant. Complainant produced those documents and were marked as Ext P1 and P6 respectively.
From Ext.P1 smart card and Ext.P6 ration card, it can be seen that the complainant is the head of the family. The deceased was the youngest member in the family. Complainant also admits that after the death of her husband, the authorities entered her name as the head of the family in the ration card. As per Ext.P6 the deceased was only a member. Moreover Ext.P1 smart card is issued in the name of the complainant. If the contention of the complainant that her deceased son was the head of the family, was correct, the smart card ought to have issued in the name of the deceased son. Since Ext.P1 and P6 documents are seen against the contention of the complainant, she is not entitled to get any relief as prayed in the complaint.
Opposite party produced the agreement and it was marked as Ext.D1. In Ext.D1 there is a contention of additional benefit of Rs.2,00,000/- as personal accident claim in the case of accidental death. As per clause 6 of the D1, the head of the family and his spouse shall be covered for a sum of Rs.2,00,000/- each against accidental death only as per the standard personal accident policy of the insurer. One of the allegations of the complainant is that the opposite parties had not issued the policy conditions to her. Ext.D2 produced by the opposite party is a published document and as such it is presumed that the complainant was aware of the formalities and procedure of the scheme.
Here there is no scrap of paper to show that the deceased Unmesh was the head of the family. Since the death of the person having no policy coverage over him, the rejection of claim application of the complainant by the opposite party is justifiable.
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There is no deficiency in service or unfair trade practice on the part of opposite parties.
In the result, the complaint fails and dismissed. No cost.
Dated this the 27th day of July 2015.
G.VASANTHAKUMARI:Sd/-
ADV.RAVISUSHA: Sd/-
ADV.M.PRAVEENKUMAR: Sd/-
Forwarded/by Order
Senior Superintendent
I N D E X
PW.1:-Presanna.P
Ext.P1:-Copy of RSBY card No.00575607320125604
Ext.P2:- Copy of FIR
Ext.P3:-Copy of death certificate
Ext.P4:-Copy of personal accident insurance statement
Ext.P5:- Letter from United India Insurance Company dated 18/03/2013
Ext.P6:-Copy of ration card
Ext.D.1:-Agreement
Ext.D.2:- Copy of terms and conditions
