O R D E R

1.         The brief history of complaint in brief is that, the complainant being the wife and nominee of late Gangadhar Behera who was procured two numbers of policies during his life time named “Sarv Suraksha” bearing policy nos.2950201111228400000 & another No.2950201312681200000, the first one was valid from 02.07.2015 to 01.07.2020 and second one was valid from 03.02.2016 to 02.02.2021 by depositing premium Rs.4004/- each for sum assured of each policy was Rs.4,00,000/- with the OP.s. She contends that, she is entitled to get the above sum assured along with Rs.5000/- each extra as transportation amount against both policies. That unfortunately due to a severe bike accident on dt.06.02.2016 the insured sustained multiple fractures in his left leg, knee joint, ankle and on 21.02.16 suffering from severe pain he was admitted at Govt. Hospital Jeypore and observing serious condition he was referred to Koraput Dist Headquarter Hospital, where the policy holder breathe his last on 22.02.2016.

2.       That the complainant being wife and nominee of the two policies approached the OP.1 for settlement but the OP.1 rejected her claim on 08.09.2016 for which she inflicted to severe monetary pressure and mental agony by the illegal and unfair practice of OP.s, amounts to deficiency in service, she craves leave of this commission and prayed to allow the assured sum of above two policies along with 18% interest p.a. and to direct the OP.s to pay for Rs.1,00,000/- towards compensation for her losses in the ends of justice. The complainant has filed copy of relevant documents along with affidavit in support of her claims.

3.       The learned counsel for OP.s has filed his counter version to contend that, the allegations made by the complainant are false, incorrect, baseless and misconceived and is without jurisdiction, hence not maintainable. Admitting the policy details the OP alleged that the complainant had never intimated any claim before the OP.s, hence there is no deficiency in service on their part. As per the case sheets and discharge summary issued by the Dist Head Quarter Hospital, Koraput where in no mentioned that the insured had any other complains other than pain in chest and Acute Myocardial Infarction, so as to establish that the cause of death of the insured had any connection with the alleged accident as claimed by the complainant. Hence he alleged that the case is filed intentional for the purpose of undue gain. He further submitted that, the claim does not fall under the head of the benefit for critical illness and in the terms of policy, for critical illness benefit to be admissible, the insured was to survive for 30 days from the date of manifestation or occurrence of illness. However in the present case the insured died on the same day on which the illness Myocardial Infarction was diagnosed and as such the condition prescribed for payment under critical illness was not fulfilled. According to the relevant clause, “if the insured person named in the schedule is diagnosed as suffering from critical illness which first occurs or manifests itself during the policy period and the insured survives for a minimum of 15-30 days from the date of diagnosis”. Since the losses claimed under critical illness are not covered as per above policy, the OP treated the claim as “No claim”.

          He further contends that as per claim form filed by the claimant the death was due to myocardial infarction as mentioned by her and she has no where mentioned that the insured had suffered any injuries caused in the accident or that such injuries had resulted in the death of the insured but no supporting document or police paper or P.M. report has been filed by the complainant to support her claim. So he submitted that there is no deficiency in service on their part as the case is not maintainable, hence prayed to dismiss the case with cost. The learned counsel for OP.s has filed copy of some relevant documents along with affidavits in support of their claims. Matter heard from both sides and the submissions considered.

4.       On perusal of record it is admitted by parties that, Sri Gangadhar Behera during his life time had opted two Insurance policies as elaborated above being allured with attractive advertisement and convinced by the agent of local HDFC Bank, Jeypore Dist of Koraput and it is also fact that the deceased/insured had expired within valid insurance period in a road accident while he was driving his bike. The question arises here that despite submitting claim forms along with required relevant documents by the complainant/widow/nominee, the OP.s repudiated the claim under “No Claim” with a ground that the said policies does not covers death under Acute Myocardial Infractions since it is covers only on the occasion of accidental death of insured. So the complainant being the wife/nominee of the insured filed the present case alleging unfair, illegal and deficiency in service on part of OP.s.

5.       It is revealed that the deceased insured had procured two insurance policies during his life time named “Sarv Suraksha” bearing policy nos.2950201111228400000 & another No.2950201312681200000, the first one was valid from 02.07.2015 to 01.07.2020 and second one was valid from 03.02.2016 to 02.02.2021 by depositing premium Rs.4004/- each for sum assured of each policy was Rs.4,00,000/- with the OP.s and the complainant being the wife and nominee of late Gangadhar Behera has filed the present complaint. She contends that, she is entitled to get the above sum assured of each Rs.4,00,000/- along with Rs.5000/- each extra as cost of transportation for both policies. Due to a severe bike accident on dt.06.02.2016 the insured inflicted multiple fractures in his left leg, knee joint, ankle and on 21.02.16 the insured feeling intolerable pain in his fractured leg & chest was admitted at Govt. Hospital Jeypore and where observing serious condition of the insured the doctors present there referred him to Koraput Dist Headquarter Hospital, where the insured breathe his last on 22.02.2016.

6.       On verification of medical papers it is seen that the physicians of Koraput DHH were discharged him mentioning their discharge slip that the patient died due to Acute Myocardial Infarctions. The OP.s taking the said plea rejected the claims said to have that the accident could not be treated as accidental since it is not related to his bike accident. From the medical papers it is also ascertained that, the doctor concerned has discharged the insured with a common ground of Acute Myocardial Infractions i.e. likely to say in common as cardiac arrest. In many cases it is seen, after death of a patient, the physicians describes in their discharge paper, patient died due to cardiac arrest, Acute Myocardial Infractions, heart attack etc. The complainant along with the friend of insured contends through their affidavit that the insured after a few day’s of accident severely infected with septicemia in his left leg, hence he was sufferings intolerable pain in his leg and gradually the pain developed to his upper side chest and the day of accident to till the day of his death he was regular in touch with the physicians Dr Asis Panigrahi & Dr K.Mohapatra, Orthopedic specialist.

7.       On observation of some similar instances we found that, acute myocardial infarction is the medical name for a heart attack. Heart attack is a life threatening condition that occurs when blood flow to the heart muscle is abruptly cut off, causing tissue damage. This is usually the result of a blockage in one or more of the coronary arteries.

8.       We are inclined to mention here some other examples relied by ALAN F MACKINTOSH, HUGH A FLEMING from the Regional Cardiac Unit, Papworth Hospital, Cambridge University, that there is various examples of cardiac damage secondary to non penetrating trauma in road accidents are described. In all cases the lesion was not recognized at the time of the accident but became detected clinically important 02 days to 17 years later. As the patients were young or had unusual lesions, the damage could be attributed to the accident. In older patients with common cardiac problems the trauma might not be recognized as the following cause:

9.       Non -Penetrating trauma to the chest, often sustained in a road accident, can damage the heart. A wide variety of lesions in the valves, myocardium, coronary arteries, and pericardium has been documented. Most reports have dealt with necropsy findings or have described cardiac injuries presenting immediately after the accident. In the following examples of cardiac damage, which was unrecognized at the time of the accident but became clinically important later are described.

Instance-1:             An 18 year old man was riding a motorcycle through a cloud of smoke when he ran into a fire engine fighting a stubble fire. He sustained multiple injuries including bruising on the left anterior chest wall and a ruptured spleen. No cardiac trauma was detected at the time of admission but two days later he became breathless with pulmonary oedema. An electrocardiogram showed a large transmural anterior infarct. With the help of digoxin and diuretic therapy he made a good recovery. Four years later he is asymptomatic but a third sound and a cardiac enlargement persist.

Instance-2:             A 24 year old man was involved in an accident while riding a motorcycle. Few details are available, though he sustained multiple injuries. Immediately after the accident his jugular enous pressure was noticed to be raised but no cardiac damage was detected. He was making a good recovery 10 days after the accident when he suddenly became unconscious and developed a right hemiplegia. An electrocardiogram showed a transmural anteroseptal infarct. A diagnosis of a cerebral embolus secondary to a mural thrombus from the infarction site was made. His recovery was only partial and epileptic fits proved difficult to control. He died two years after the accident. Necropsy showed recent and old cerebral infarction secondary to emboli. The coronary arteries were normal apart from complete occlusion of the left anterior descending artery three centimeters from its origin. Microscopy of the occlusion showed periarterial haemosiderosis and breaks in the external elastic lamina, these findings are consistent with traumatic damage to the artery. An old anterior myocardial infarction was probably the source of the recent and old emboli.

10.     Cardiac trauma may be missed after road accidents. In none of these above cases was the cardiac damage recognized immediately after the accident. This delayed appearance of cardiac damage has not been commented upon in previous reports though late presentation of aortic rupture as an aneurysm is well recognized. In the cases described here the cardiac abnormality was linked to an injury because the accidents were severe and the patients were young or developed a lesion which was unlikely to have any other aetiology.

11.     We are also inclined to rely some important reports of death after surgery on bone fracture by Mr Atsushi Kurata, MD, Jun Nishida, MD….department of Orthopedics, Tokyo Medical University….. We have recently experienced 2 cases of sudden death after bone fracture surgery, in which AMI and pulmonary thromboembolism were clinically suspected as causes of death. Case-1 was a 60 year old male who died 7 days after surgery for Lisfranc dislocation fracture. Case 2 was a 75 year old female who died several hours after surgery for proximal femur fracture.

12.     An injury that breaks a bone may also seriously damage other tissues, including the skin, nerves, blood vessels, muscles, and organs. These injuries can complicate treatment of the fracture and/or cause temporary or serious permanent problems. Death following orthopedic surgery has become rare, but does occur. Acute myocardial infarction can be a cause of such death, but diagnosis of AMI is often challenging even by autopsy.

13.     It is further ascertained that the OP has taken the plea for rejecting the claim is that the deceased policy holder / insured person died on the same day on which the MI was diagnosed, in this connection, we would like to make it clear that though the Discharge Certificate reflects the death of insured person directly caused due to AMI, but the OP have forgotten to analyze the PMH, which clearly reflects that the insured policy holder was already suffering from multiple fracture injuries since many days prior to his admission in the DHH, Koraput, which were also never been challenged by the OP.s at any time. From the PMH, it is clearly proves that the insured person was on critical condition on the date of admission in DHH, Koraput. Hence it could never be said that the insured policy holder was admitted not in a critical condition. Further the MI or Heart Attack or Cardiac Arrest, whatever it be known in name, may be caused due to impact of any other disease. Hence we do not think that the cause of death of insured policy holder is no way related with the accident occurred in bike. The C.P.Act is only for beneficial of the consumer hence always the technical plea shall not be applicable in general to adjudicate a case.  

14.     On verification of record it is found that the complainant had no habits of smoking, drinking or consume any other tobaccos. It has also not challenged by the OP.s that the insured was a chronic patient of diabetic or hypertension or any other pre-existing diseases. The counsel for OP has not challenged that the insured had above irregularities prior to commencement of the policies. It is seen in so many death cases that the doctors casually reported “patient died due to cardiac arrest”, Heart attack, Ac M.I. etc and at the outset neither the attendants of patient could noticed the death papers nor the doctor on their part required to report pre existing treatments of the patients. Hence in the present case we have no doubt that the insured died due to acute myocardial infarctions which were acutely causes multiple injuries & fractures of insured due to the bike accident.

15.     According to I.R.D.A. guidelines the basic concept of insurance is to provide protection to the continuous livelihood of the dependents of the life insured. It shall not be treated as investment or savings. It is a means of providing an instant estate for the survivors on the death of an insured person or head of the family or the earner of the family. Ordinarily when the earning member of a family dies, the cash flow which was the basic of livelihood of non earning dependent collapses, and the basic needs and dignity of the dependents is shattered for day to day survival. Insurance is thus opted, for protection of the family members from financial disasters, on the death of the bread earner insured.

16.     The OP is an insurance company and the business affair as far as the practice with customers concerned is regulated by statutory authorities IRDA. The IRDA has prescribed rules in order to protect the interest of policy holders, thus by rules framed in 2002. In the present case, we did not find that the OP has not only adhered to the guidelines mechanism but also repudiated the claims without going to the history of treatment/hospitalization after accident which simply depicts unethical and unfair practice on part of OP.s dealing with grievance of complainant. The omission cannot be termed as misfeasance but malfeasance and thus injuring the interest and rights of policyholders, cannot leave the culprit, as the OP.s at present escaped from compensation & cost be impounded with. As such we find gross deficiency in service on part of OP.s and the complainant is entitled to get the legitimate assured sum as claimed along with compensatory relieves.

ORDER

i.        The opp. Parties are hereby directed to pay the assured sum covered under the two alleged policies from the date of filing of this case i.e. 20.12.2017 to till the date of such payment with 6% interest p.a. Inter alia, to pay Rs.5000/- as litigation cost to the complainant.

ii.       The above order shall be complied expeditiously within 45 days of receipt of this order, failing which the entire amount shall carry 12% interest per annum till its realization. Pronounced on 22nd day of Sept’ 2021.