The case of complainant is as follows: The husband of complainant was a holder of policy Nos.771283615 and 771637906 of the first respondent. The sums assured under the said polices were Rs.40,000/- and Rs.50,000/- respectively. Under the policy first respondent offered double benefit in case of death of the insured. The husband of complainant met with a motor accident on 5.7.03 and seriously injured. He remained unconscious and died on 2.3.04. The deceased was driving a two-wheeler and was hit by a tempo. He was immediately taken to Elite Hospital, Thrissur and was unconscious and fully bedridden till his discharge from that hospital on 23.8.03. He was again hospitalized at Jubilee Mission Hospital, Thrissur and Co-operative Hospital, Irinjalakuda but showed no improvement and died on 2.3.04. After the death the complainant preferred claim with the first respondent. The claim was allowed for Rs.71,128/- under the first policy and Rs.61,720/- under the second policy. But the double benefit was denied to the complainant on the ground that the death was happened by 237 days after the accident. The denial of the double benefit is illegal. The complainant sent application to Zonal Manager and an amount of Rs.45,000/- was given. The complainant was informed that he will be getting the balance Rs.45,000/- in a short while. The complainant accepted the amount under protest. She was asked to sign some papers and she signed.   But the balance amount of Rs.45,000/- was not granted. So a lawyer notice was sent to the first respondent. The 2^nd respondent sent a reply stating that there is no accident cover after 180 days of the accident and that payment of Rs.45,000/- is in full and final settlement of the claim. Hence this complaint.

 

            2. The averments in the counter are as follows: It is admitted that the complainant’s husband A.C. Janardhanan held two insurance policies on his life with policy Nos. 771283615 and 771637906. The policy No.771283615 was for a sum of Rs.40,000/- and policy No.77167906 for Rs.50,000/-. The complainant was the nominee under both policies. It is also admitted that the life assured died on 2.3.04 as per records submitted to the respondents. The averment in the complaint that double the sum assured will be payable in case of death under both policies is denied. The sum assured and the vested bonus will be payable to nominee under the policies on death of the life assured and the respondents paid Rs.71,128/- under the policy No.771283615 and Rs.71,720/- under the policy No.771637906 on 28.3.04. An additional amount equal to the sum assured will be payable only if death occurs as a result of accident.   The basic sum assured and bonus under both policies have been settled to the nominee on 28.3.04. The offer of double accident benefit is a supplementary benefit to the main death benefit. As per policy condition No.10(b) this benefit will be payable only in cases where death occurs as a result of accident within 120 days from the date of accident. The complainant’s representation to the Zonal Manager was examined in detail and sanctioned an ex-gratia amount of half the accident benefit amounting to Rs.45,000/- as a very special case. It conveyed to the complainant specifically stating that the ex-gratia payment can be made subject to her consent and agreement to receive the said amount of Rs.45,000/- in full and final satisfaction of all her claims. There was no admission on the part of the respondents that any amount is legally due and payable to her. The allegation in the complaint that the complainant was informed that she would be getting a balance amount of Rs.45,000/- in a short time is baseless and hence denied. The averments in the reply notice are true and correct. Hence dismiss the complaint.

 

            3. The points for consideration are:

(1)   Is there any deficiency in service on the part of respondents?

(2)   If so, reliefs and costs.

 

            4. The evidence consists of Exts. P1 to P6 and Exts. R1 to R11.

 

            5. Points-1 & 2: The case of complainant in brief is that the complainant’s husband A.C. Janardhanan had taken two policies vide Nos.771283615 and 771637906 from the respondents for a sum assured of Rs.40,000/- and Rs.50,000/- respectively. The complainant was the nominee under the policies. The life assured met with a motor vehicle accident on 5.7.03 and died on 2.3.04. The complainant received death benefit under these two policies worth Rs.71,128/- and Rs.61,720/-. She also got Rs.45,000/- after making application to the Zonal Manager of the respondents. But according to her, she is eligible to get double the insured amount as the death benefit. But the respondents disallowed her claim. So this complaint is filed. 

 

            6.The case of respondents is that the complainant is not entitled to get double the accident benefit as per policy condition No.10(b) . It shows that the accident benefit will be paid only in cases where death occurs as a result of accident within 180 days from the date of accident. Here the life assured met with accident on 5.7.03 and died on 2.3.04 i.e. after 237 days of accident. So according to the respondents the claim of the complainant for accident benefit is not covered under the policy conditions.

 

            7. It is admitted by both that Rs.71,128/- and Rs.61,720/- were paid to the complainant and an amount of Rs.45,000/- as ex-gratia amount. Thus total amount of Rs.1,77,848/- was received by the complainant. The dispute is with regard to the payment of balance Rs.45,000/-. According to the complainant when she has accepted Rs.45,000/- the respondents informed that she would be getting the balance Rs.45,000/- in a short while. The complainant has produced Exts. P1 to P6 to substantiate her case and did not contain any promise regarding this payment from the respondents. In Ext. P5 lawyer notice it is stated that the deceased had brain death on the date of accident itself. So she is entitled for death benefit of the policy. She has produced Ext. P2 copy of certificate issued from Jubilee Mission Hospital, Thrissur states that the deceased was in a state of altered sensorium. It also stated that the deceased responds only to pain and is totally dependant for all his needs. There is no medical record from Elite Mission Hospital in where he was admitted immediately after the accident. The complainant claims the accident benefit under this aspect only. But she failed to prove that aspect. The claim was disallowed by the respondents under Clause 10(b) of the Policy and Clause 10(b) says that “Death of the life assured: to pay an additional sum equal to the Sum Assured this policy , if the Life Assured shall sustain any bodily injury resulting solely and directly from the accident caused by outward, violent and visible means and such injury shall within 120 days of its occurrence solely, directly and independently of all other causes result in the death of the Life Assured. However, such additional sum payable in respect of this policy together with any such additional sums payable under other policies on the life of the Life Assured shall not exceed Rs.5,00,000/-.” Thereafter according to the respondents, the said period increased from 120 days to 180 days based on the recommendations of the Rajya Sabha Committee. It means that the respondents are not liable to pay accident benefit if the death of the life assured occurs after 180 days from the date of accident. According to the complainant, her husband the life assured met with an accident on 5.7.03 and expired on 2.3.04. It was after 237 days from the date of accident. Clause 10(b) says about the death of life assured. It doesn’t mean that if brain death occurs the nominee will entitle for death benefit. Death means death of a person in all aspects. The interpretation given by the complainant to avail the accident benefit is strange. The respondents acted in very gently and they paid an amount of Rs.1,32,848/- on 28.3.04 itself. It was just after the death. An amount of Rs.45,000/- also given by the respondents by considering the application made by the complainant to the Zonal Manager. Ext. R6 is the copy of the complainant’s representation to the Zonal Manager. The complainant also produced it and marked as Ext. P4. As per that an amount of Rs.45,000/- was also granted to her and it was in addition to the amount already given on 28.3.04. In this case an amount of Rs.1,77,848/- was given by the respondents to the complainant. If she is entitled for the double benefit it will come to Rs.1,80,000/- only. But she is not entitled for the double benefit as per the policy. But it is seen that the respondents paid Rs.45,000/- in addition to the initial payment only out of sympathy. The respondents had no contractual obligation to make payment of Rs.45,000/- which was paid later. The respondents stated that considering a very special case they granted this amount.

 

            8. The relation between the respondents and the deceased was a contract. So both are bound by the policy terms and conditions. Clause 10(b) is very clear and is already discussed clearly bars the claim of the complainant. So the complainant is not entitled for any amount further. On going through Exts. P1 and P2 it can be seen that the respondents granted bonus benefit also to the complainant. Since there is no evidence regarding the offer of payment of Rs.45,000/- from the respondents it can be considered that the claim of complainant through this complaint is totally baseless. She had accepted undeserved amount of Rs.45,000/- more and is not entitled for any further amount.

 

            9. In the result, the complaint is dismissed.

 

             Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum, this the 6^th day of October 2009.