JAGANNATH BAG, MEMBER
The present appeal is directed against the impugned Order, dated 22.10.2014 , passed by the Ld. District Consumer Disputes Redressal Forum, Purba Medinipur in Consumer Case No. 50/14 , whereby the complaint was dismissed ex- parte against the OPs without any cost.
The Complainant’s case, in brief, was as follows:
The Complainant’s wife , named , Smt. Sadhana Samanta was covered by an SBI General Personal Accident Insurance Policy for a sum of Rs. 4,00,000/-. The policy was valid from 10.05.13 to 09.05.14. The insured allegedly had an accidental fall in the bathroom at home. She was admitted to Command Hospital ( Eastern Command) at Alipore. She died on 30.11.2013 at about 10.30 a.m. The Complainant, being the nominee in respect of the subject policy, submitted a death claim before the OPs on 20.12.2013 with all papers . The claim was repudiated vide letter of OP dated 17.02.2014 on flimsy ground. The Chairman Grievance Redressal Committee by their letter dated 19th May 2014 stated that the claim was repudiated as the medical cause of death of the insured falls outside the purview of the policy . In the circumstances, the Complainant filed the petition of complaint praying for direction upon the OPs to pay the insurance claim of Rs. 4,00,000/- , a compensation of Rs. 90,000/- for deficiency in service and also a litigation cost of Rs. 10,000/- .
The OPs received notices and appeared through their respective Lawyers, but did not contest the case by filing any W.V. and as such, the case was proceeded with ex- parte against all the OPs.
Ld. Forum below heard the Ld. Advocate of the Complainant and went through the materials on record ,the photocopies of documents filed by the Complainant ,the policy certificate and the letter of repudiation addressed to the Complainant , holding that the death of the insured was due to medical causes and the same did not fall within the purview of the policy terms and conditions. Having considered the materials on record and also the pleadings of the Complainant , Ld. Forum below dismissed the complaint.
Being aggrieved by and dissatisfied with the order of the Ld. Forum below, the Complainant-turned-Appellant has come up before this Commission with prayer for direction to set aside the impugned order.
The memorandum of appeal has been filed together with copies of the impugned order, the petition of complaint, the claim form , the medical certificate of cause of death issued by the attending hospital and also the letter of repudiation dated 17.02.14 issued by the Insurance Company among other documents including the medical case sheet in respect of the insured .
Ld. Advocates for both the Appellant and the Respondent have been heard .
Ld. Advocate appearing for the Appellant submitted that the insured was covered by a Personal Accident Insurance Policy on payment of due premium . The insured had a fatal fall in the bathroom as a result of which she suffered internal haemorrhage and became unconscious . As her condition was serious , she was rushed to the Command Hospital immediately. She was under medical treatment but ultimately succumbed to her injury which was the cause of her death. Ld. Forum should have considered the case in terms of the policy and the claim was very much legitimate . By repudiating the claim, the insurance company has exposed their deficiency in service which is an unfair trade practice. The impugned order may be set aside and the compliant may be allowed with award of the insurance claim, compensation and cost.
Ld. Advocate appearing for the Respondent Insurance Company submitted that the cause of death as certified by the Hospital where the insured was admitted , was that the insured had left parietal intra cerebral haemorrhage which developed from primary Hypertension and Type 2 diabetes mellitus . In fact , that can not be treated as an accident causing the death of the insured. No proof in support of the alleged accidental fall of the insured in the bath room was filed and no postmortem report was submitted in support of the alleged accidental death of the insured. The onus of proof that the insured died in an accident was on the Complainant who failed to provide such proof. In asserting their stand , Ld. Advocate for the Respondent cited copies of orders of the Hon’ble National Consumer Disputes Redressal Commission as passed in Revision Petition No. 237/06 and Appeal No. 1298 of 2004 and also in First Appeal No. 64 of 2014 and submitted that as the Complainants in the cases as cited failed to prove that the deceased had suffered cerebral hemorrhage because of the injury as stated in the respective complaint petitions, the claims were rightly repudiated . In the present case also the Complainant failed to prove his case of accidental death and as such Ld. Forum below rightly dismissed the compliant.
Decision with Reasons:
We have gone through the materials on record, heard the Ld. Advocates appearing for both parties and perused the orders of the Hon’ble National Consumer Disputes Redressal Commission as cited by the Ld. Advocate appearing for the Respondent / Insurance Co.
There is no dispute that the deceased insured was covered by a Personal Accident Insurance Policy issued by the Respondent Insurance Co. There is also no dispute that the insured died while the policy in question was valid.
The point at issue dealt with by the Ld. Forum below was whether the cause of death was an accident as set forth in the policy.
In the policy document , the term ‘Accident’ has been defined as follows:
Accident means a sudden, unforeseen and unexpected event caused by external, violent and visible means and resulting in physical bodily injury.
In the instant case, the insured is said to have fallen in the bath room as a result of which , she became unconscious and was then hospitalized on 13. 11. 2013. There is, however, a mis-statement by the Appellant /Complainant in his petition of complaint ( Paragraphs 2-5) that the insured met with the accident on 30.11.13 at 6 a.m at home and ‘died on the same date i.e., on 30.11.2013 at 10.30 a.m.’at the hospital.
Ld. Forum below in their impugned order observed that the medical certificate about the cause of death on record and the medical case sheet issued by the Command Hospital ( E.C) , Kolkata in the name of Sadhana Samanta indicates that the patient died due to diseases or conditions of Left Parietal Intra Cerebral Haemorrhage and antecedent cause of death were a Primary Hypertension and Type-2 Diabetes Miletus .
The fact goes that the insured was admitted to the Hospital on 13.11.13 following her alleged fall in the bathroom at about 6.30 a.m ‘when she was found unconscious in the bathroom’ as noted by the attending doctor in the medical case sheet of the deceased. There was no mention about any fall and /or any event caused by external , violent and visible means resulting in physical bodily injury. The Complainant was required to prove before the Ld. Forum below with cogent evidence that the insured had actually suffered the haemorrhage because of external violent and visible means. Further, there was a gap of about 17 days between the alleged accidental fall on 13.11.13 and her death on 30.11.2013. The death of the insured does not appear to be instantaneous, i.e., the death took place after a lapse of about 17 days and not immediately after the alleged accident
It is true, as pointed out by the Ld. Advocate appearing for the Appellant/ Complainant ,that FIR was not a necessary formality as the patient had the fall at home, but the fact remains that no document or evidence was placed before the Ld. Forum below showing the relationship between the alleged fall and the injury that caused the death of the insured. It has been rightly held by the Ld. Forum below that the cause of death does not fall within the purview of the coverage of the policy in question.
We find no reason to interfere with the impugned order . The appeal does not have merit. Hence,
Ordered
That the appeal be and the same is dismissed on contest. The impugned order is confirmed. There shall be no order as to cost.
