DOF.24.6.2004 DOO.5.1.2011 IN THE CONSUMER DISPUTES REDRESSAL FORUM, KANNUR Present: Sri.K.Gopalan: President Smt.K.P.Prethakumari: Member Smt.M.D.Jessy: Member Dated this, the 5th day of January 2011 OP.NO.140/2004 Amban Chandran, Arakkandy House, Kudukki motta, Complainant P.O.Kanhirod,Kannur 670 592 (PAH.C.Mahesan,Gokulam, Kolachery,Kannur) (Rep. by Adv.P.V.Abhayakumar) 1.The Divisional Manager, The New India Assurance Company Ltd. Divisional Office, Kottarathil Buildings, Palayam, Opposite parties Thiruvananthapuram. 2. The Claim Service Officer, New India Assurance Company, Sadhoo Building, Near Municipal Bus stand, Kannur. (Rep. by Adv.V.K.Rajeev) O R D E R Sri.K.Gopalan, President This is a complaint filed under section12 of consumer protection Act for an order to directing the opposite parties to pay an amount of `3,05, 000/- as insurance amount and compensation. The case of the complainant in nutshell are as follows: The complainant is a member of the Pravasi Suraksha Kudumba Arogya Scheme introduced by the department for non resident Keralities affairs, NORKA in association with the New India Assurance Company to protect the welfare of NRIs and their family. Complainant, his wife and daughters were covered under the scheme. During the currency of the certificate of insurance, the spouse or any of the children of the insured NRI dies the insured shall be reimbursed the air-fare to and fro home town in India to attend the funeral ceremonies subject to a maximum of `50, 000/-. The wife of the complainant was admitted at the JJS Hospital, Kannur for delivery on 8.4.2001 and on 9.4.2001 due to bleeding she happened to die. Complainant came to the hometown for a last meet of his wife. Complainant sent the preliminary intimation to the claim service office of the New India Assurance Company on 16.9.2001. Initial stage opposite party stated that complainant was not entitled for the benefit stating that it was not accidental death. Complainant contacted claim service office as well as the Divisional office. The reply was that they were verifying the claim and would be decided sooner. In the month of January 2004 also the respondent had assured the complainant that the amount would be paid sooner. But they are delaying the claim amount, though they are liable to pay the amount as per the stipulations in the insurance policy. The complainant spent `45, 000/- as to and fro Air charges. The opposite parties are liable to pay `2,50,000/- as capital sum insured and `45,000/- being the air charges together with `10, 000/- as compensation. Opposite parties filed version denying the material allegations and averments in the complaint. It is admitted that the policy was issued and complainant is a member of the PRAVASI SURAKSHA KUDUMBAAROGYA SCHEME. But the opposite party is not liable to pay any amount as compensation to the complainant as per the specific conditions of the policy. The averment that under the scheme during the currency of the policy “if the spouse or any of the children of the NRI dies, the insured shall be reimbursed with the air fare to and fro from the home town in India to attend the funeral ceremonies subjected to maximum of `50, 000/- is not fully correct. As per rules up to `50, 000/- is paid to the incident only if the family members dies abroad due to accident. But in the case of the complainant the wife of the complaint was admitted in JJS Nursing Home, Kannur for delivery, and she died in the hospital due to complaint of ‘placenta previa” bleeding after delivery which resulted in cardiac arrest. The death of the complainant’s wife was not due to any accident as contemplated in condition No.1 (7) of the policy. Hence these opposite parties are not liable to pay any amount as compensation. These opposite party had informed the complainant regarding the repudiation of the claim by the letter dt.25.9.01. The claim for `10, 000/- towards the mental and physical strains is not maintainable. Hence to accept the contentions of opposite party and to dismiss the complaint. Opposite parties filed additional statement on the basis of the amendment of the complaint contending that the enhancement of claim from `50,000 to `2, 50,000 is not made of any reasonable ground. Opposite party is not liable either to pay `50,000 incurred for traveling expense nor `2, 50,000 being the half of the same assured. Since his wife is died at native place due to ‘placenta previa’ bleeding after delivery which does not come within the purview of condition No.I (7) of the policy. On the above pleadings the following issues have been taken for consideration. 1. Whether there is any deficiency on the part of the opposite parties? 2. Whether the complainant is entitled for the air fare up to `50000? 3. Whether the complainant is entitled for` 2, 50,000 as half of the assured amount? 4. Relief and cost. The evidence consists of the oral testimonies of the complainant as PW1, DW1 and documentary evidence Ext.A1 to A11, B1 to B3 This complaint was once heard and decided and is taken up again as per the order of the Hon’ble Consumer Disputes Redressal Commission for consideration of relief sought by the complainant through amendment of the complaint. Complainant field an Inter locutary application to get the original complaint amended for the purpose of enhancing the claim from `55,000 to `3, 05,000. The Forum allowed amendment petition and additional version also filed. But the amendment was not carried out and there by the final order omited to consider the relief sought by the complainant through amendment, complainant went appeal and the Hon’ble commission pleased to allow the appeal and set-asided the impugned order for the purpose of passing a detailed order on the additional relief sought by the complainant. Issue Nos. 1 to 4 Admittedly complainant is a member of the PRAVASI SURAKSHA KUDUMBA AROOGYA SCHEME. Clause 7 of policy speaks thus: If during the currency of the policy, the spouse or any of the children of the insured NRI dies due to an accident occurring in India as defined herein above, the insured shall be reimbursed the airfare to and fro home town in India to attend the last rites subject to a maximum of `50, 000/- once during the policy period of 5 years. Herein the wife of the complainant died in India. Opposite party repudiated the claim. The contention of opposite party that “as per the Peravasi Suraksha scheme” Air fare is payable to the insured only if the family members dies abroad due to accident is absolutely wrong and not acceptable. The clause attached to and forming part of pravasi suraksha insurance policy specifically stated in clause 1(7) that the spouse or any of the children of the insured NRI dies due to an accident occurring in India as defined herein above, the insured shall be reimbursed. So accident occurring in “India” is specific and free from doubt. The main point to be answered is whether the death of the spouse of the complainant was happened out of an accident as contemplated under the clause attached to Pravasi Surakasha Insurnace policy or not? The wife of complainant died out of profuse bleeding after delivery. Now the question arose whether this bleeding is accident or not? What is an accident? Simple and plane meaning of accident is an unexpected happening. It is a happening that is not wanted or expected. Accident is a chance or what happens by chance. It is an event that happens when quite unlooked for and unforeseen and undersigned injury to a person. Hence the death of the wife of assured complaint can be said to be out of accident since it is due to unexpected happening of bleeding. The opposite party does not deny the cause of death. The opposite party admitted that she died in the hospital due to complaint “placenta previa” bleeding after delivery. This bleeding is a quite unexpected event. The opposite party has no disagreement that the death of the complainant’s wife was an unexpected event, which is occurred without design. No one can say that it is an outcome of calculated event. In the case united India Insurance Co. Ltd. vs. State of Bihar reported in2003 (3) KLT.316 (Patna) Para 13 the word ‘accident’ is also defined in the following terms: - “Accident; Accidental; accidentally. The courts have established a long time of cases which identify the essential characteristics of an accident or an event which was neither expected nor intended and which causes hurt of loss”. In the case Branch Manger, Life Insurance Corporation of India Vs. Rajkumar Mishra reported in I (2000) CPJ113 it is held that “from the perusal of the dictionary meaning of accident and accidental’ it will be clear that any event which happens without any cause or is not expected to be caused in normal circumstances is covered under it. It is also an unfortunate event causing physical harm or damage caused by some unintentional act. It is also pointed out in Para 6 that the word accidental has also been defined as under “Happening by chance, unintentionally or unexpectedly” Hence we have no hesitation to hold that the event, which occurred in the case of the complainant’s spouse, is by chance accident and not natural phenomenon occurring, so often. Thus the repudiation of the claim of the complainant is totally baseless and devoid of any reasoning which can only be considered as deficiency in service on the part of opposite party. The complainant is entitled for a reimbursement of the airfare from Bahrain to his hometown. The opposite party has also raised a question that if the death was due to the accident the complainant should have furnished a copy of the records from the police as evidences of accidental death. Opposite party pointed out that there was no FIR and no postmortem report. It is pertinent to note that there is no criminal offence taken place in the present case. There is no need to commit a criminal offence in all accidental death. In the case life Insurance corporation of India Vs.Vaijayanti Bai reported in II (2005) CPJ 445 held that filing of ‘FIR not necessary in absence of violent act of any out side agency. Accident benefit was denied in absence of FIR and post mortem report but complaint was allowed in the above case. Thus there is no point in denying accident benefit on the ground of absence of FIR and postmortem report. Hence opposite party is liable to pay `45, 000/- which the complainant spent for to and fro Air charge to attend the cremation of his spouse. More over clause 4 of 2nd conditions provides thus: “If the applicant NRI as well as spouse are employed abroad both can choose the same Sum Insured as given in either PS-I or PS-II; if only one is employed abroad, the other can take 50% of the Sum Insured chosen by the employed Spouse; and for children, 25% of the Sum Insured chosen by the employed Spouse. The NRI and family members will have to be under the same Scheme PS-I or PS-II. Since the policy specifically provided for compensation when the death of the spouse has been caused due to an accident, the complainant is entitled for `2, 50,000 towards half of the sum insured as per the said clause II (4) conditions applicable to Pravasi Suraksha (PS).Opposite party is also liable to pay `45, 000/-, which the complainant spent for to, and fro Air charge to attend the cremation of his spouse. Complainant is also entitled to get a compensation of `1500/- and `1000/- as cost of litigation. Hence issues 1 to 4 are answered in favour of complainant and order passed accordingly In the result, complaint is allowed directing the opposite parties to pay an amount of `2,95, 000/-(Rupees Two lakhs Ninety five thousand only) as insurance claim and `1500/-(One thousand five hundred only) as compensation along with a sum of `1000/- (Rupees One thousand only) as cost of litigation to the complainant within one month from the date of receipt of this order, failing which the complainant is allowed to execute the order against the opposite parties as per the provisions of the consumer protection act. Sd/- Sd/- Sd/- President Member Member APPENDIX Exhibits for the complainant A1.Passenger ticket A2.copy of the claim letter A3.Copy of the letter sent to Minister A4.Copy of the Mangalam weekly A5.copy of the letter sent by OP A6. Copy of the passport of the complainant A7. The discharge summary, A8. Copy of the terms and conditions of policy. A9.Directions of policy. A10.Copy of the policy A11.Copy of the death certificate of Ameri Sajitha. Exhibits for the opposite parties B1,Copy of the policy B2.Claim form submitted by the complainant B3.Letter dt.25.9.01 sent to complainant Witness examined for the complainant PW1.C.Maheshan Witness examined for the opposite parties DW1.R.Suresh Babu /forwarded by order/ Senior Superintendent Consumer Disputes Redressal Forum, Kannur.
| | [HONORABLE PREETHAKUMARI.K.P] Member[HONORABLE MR. GOPALAN.K] PRESIDENT[HONORABLE JESSY.M.D] Member | | 
