1. Facts as per the complaint are that, the wife of the complainant namely Mrs.Suparna Jain (the deceased life assured hereinafter referred as DLA) had purchased a Jeevan Anand  policy (with profits with accident benefits) vide policy No.114951794;date of commencement of risk as 13/10/2006 for sum of Rs.8,00,000/- from OP. 

2. Late Mrs. Suparna Jain had also purchased another New Jeevan Anand Policy (with profits with accident benefits) vide policy No.127335863; the date of commencement of risk as 28/02/2015 for Rs.27,00,000/-.

3. On 02/09/2018, around 10.36 p.m. the DLA met with a fatal accident and succumbed to injuries while her treatment at Lok Nayak Jaiprakash Hospital, Delhi on 03/09/2018.  An FIR NO.224/18 dated 03/09/2018 was registered at Police Station Darya Ganj on basis of DD No.39A at 22.36 hrs. on call made by Dr. Sunil Kumar, Medical In-charge, SDMC, Government dispensary, Ansari Road, Darya Ganj, Delhi.

4. It has been stated that Ld.MM, Central District, Tis Hazari Court, Delhi took cognizance of the offences under section 279/304-A IPC.  However, the proceedings were abated and file was consigned to record room vide order dated 20/03/2019.  The Ld. Judge, MACT-I, Central Delhi, Tis Hazari Courts, Delhi also closed the DAR vide order dated 29/03/2019.  

5. The complainant being the nominee in the above-mentioned policies received an amount of Rs.8,32,743/- under policy No.114951794 on 12/04/2019 and Rs.38,58,400/- under policy No.127335863 on 28/06/2019.  However, double accident benefit under clause 10(b) and clause 11(b) respectively was denied by OP.  

6. In reply to the RTI application filed by the complainant it was informed that the OP shall not be liable to pay the additional sum if the disability or the death of the life assured shall be (i) caused due to intentional self injury, attempted suicide, insanity or immorality or whilst the life assured is under the influence of intoxicating liquor, drug or narcotic and with respect to policy no. 144915794, it was stated that the policy clause which determined accidental death does not qualify for accidental benefits. 

7. Legal notice dated 02/08/2019 was issued to OP calling them to pay the amount due on account of accident benefit under the above-mentioned two policies.  However, the same was not complied with.  

8. The complainant has further stated that the death of the complainant’s wife was due to sudden accident and was neither intentional self injury nor any traces of intoxication were found in the FSL samples.  

9. Feeling aggrieved by the non-settlement of the claim on account of accidental death the complainant has prayed for direction to OP:-

A. To pay an amount of Rs.27,00,000/- towards double accident benefit under the policy no.127335863 and Rs.8,00,000/- towards policy No.114951794 alongwith interest @18% p.a.from the date it became payable till the filing of the present complaint.

B. Award future interest from the date of filing of present complaint till realization.

C. Pay legal expenses amounting to Rs.55,000/- .

D. To pay Rs.1,00,000/- towards mental torture and harassment caused to the complainant;

E. Any other relief.

10. The complainant has annexed the copy of the marriage certificate, birth certificate of the children of the complainant issued by GNCT Delhi as Annexure C-1 ( Colly);  copy of the policy bond bearing NO.114951794 as Annexure C-2;  copy of the policy bond bearing NO.127335863  as Annexure C-3; Flight ticket of the complainant from Bangalore to Delhi as Annexure-C-4; copy of Private Car package policy issued by United India Insurance Co. Ltd. and the driving license of the DLA as AnnexureC-5 and Annexure C-6 respectively.  The copy of the FIR No.0224 dated 3/09/2018 with PS: Darya Ganj; post-mortem Examination report dated 03/09/2018, Format of mechanical inspection report dated 03/09/2018 as Annexure C-7 to Annexure-C-9.   Detailed Accident Report (DAR) as Annexure C-10, Final report as Annexure-C-11, order of Ld.MM-01 (C), THC/Delhi dated 20/03/2019 and order of Ld. Judge, MACT-1(Central) Delhi Dated 29/03/2019 as Annexure-12 and Annexure-13 respectively, online RTI request Forms details, replies thereto and orders in appeals are Annexure C-14 to Annexure-21, legal notice dated 22/08/2019 as Annecure-C-22.  

11. Notice of the present complaint was issued to OP.  Thereafter, written statement was filed.  They have taken preliminary objections such as; present complaint is misconceived, groundless, baseless and frivolous, vexatious and unsustainable, thus, liable to dismissed.

12. It has been submitted that as per the condition expressly stated in clause 11(b)of the policy bond under policy No.127335863 which states “the corporation shall not be liable to pay the additional sum equal to Accident Benefit if the death of LA shall be caused by intentional self -injury, attempted suicide, insanity or immorality or whilst the life assured is under the influence of or under the consumption of intoxicating liquor, narcotic or drug (unless prescribed by doctor as a part of treatment)”.

13. It has been further submitted that the final police report dated 02/03/2019, it is established that the death of LA was due to self-hit and negligence which clearly mentions that the DLA drove the car at very high speed, because of which the vehicle went out of control and the driver (DLA) ended up hitting the gate and wall. Thus, the complainant is not entitled to accident benefit payable under the policy.  

14. As per the policy status an amount of Rs.38,58,400/- was paid on  28/06/2019, under policy No. 127335863 and Rs.8,32,743/- under policy No. 114951791 on 12/04/2019 towards death claim. Rest of the contents of the complaint have been denied. 

15. Evidence by way of affidavit has been filed by both the parties reiterating the contents of their respective complaint and written statement.  The complainant has relied on the copy of the marriage certificate, birth certificate of the children of the complainant issued by GNCT Delhi and has got the same exhibited as Ex. CW/1 and Ex. CW/2;  copy of the policy bond no.114951794 as Ex. CW/3;  copy of the policy bond bearing NO.127335863  as Ex. CW/4; Flight ticket of the complainant from Bangalore to Delhi as Ex. CW/5; copy of Private Car package policy issued by United India Insurance Co. Ltd. and the driving license of the DLA as Ex. CW/6 and Ex. CW/7  respectively.  The copy of the FIR No.0224 dated 3/09/2018 with PS: Darya Ganj; post-mortem Examination report dated 03/09/2018 Ex. CW/8 to Ex. CW/9, copy of mechanical inspection report dated 03/09/2018 as Ex. CW/10   Detailed Accident Report (DAR) as Ex. CW/11, Final report as Ex. CW/12, order of Ld.MM-01 (C), THC/Delhi dated 20/03/2019 and order of Ld. Judge, MACT-1(Central) Delhi Dated 29/03/2019 as Ex. CW/13 and  Ex. CW/14 respectively, online RTI request Forms details, replies thereto and orders in appeals are Ex. CW/15 to Ex. CW/22, legal notice dated 22/08/2019 as Ex. CW/23.

16. We have heard the arguments of Ld. Counsel for the complainant and Ld. Counsel for the OP.  We have also perused the material placed on record.  It is an admitted fact that OP has paid the death claim of Rs.38,58,400/- on 28/06/2019 under policy no. 127335863 and Rs.8,32,743/- under policy no. 114951791.  However, the dispute is with respect to non-payment of death due to accident benefit.  

17. The OP has rejected the accidental benefit on the ground that the death of the DLA was self-inflicted, which is in contravention to the clause 11(b) of the policy terms and conditions. OP has relied on the final report dated 02/03/2019, where FIR bearing No.224/18 has been abated.

18. If we look at letter dated 15/07/2019 (Ex.CW-1/16) reply by OP in response to the information sought by the complainant under RTI Act, 2005.  It states: 

“The competent authority has decided that the deceased was driving a vehicle with high speed, carelessly and is a case of inflicted self-injury, therefore, Accident Benefit is not payable under the policy”.   

19. Final Report (Ex.-CW1/12) where  the DLA has been arrayed as accused.  The FIR has been abated as the accused/DLA died. In case of criminal proceedings the guilt is to be proved beyond reasonable doubt as there was no trial in the criminal proceedings filed against the DLA.  At the same time, there is no eye-witness who can testify that the DLA had self-inflicted injuries or she was negligent. Further, the complainant in the FIR is ASI Udaybeer Singh, who again is not the eye-witness.

20. We have also gone through the mechanical inspection report dated 03/09/2018 Ex.CW-1/10 it bears 10) left side rear body frame damaged; 11) rear (illegible) door frame damaged and glass broken. These observations in the mechanical inspection report seem to have been ignored by the IO. Since, there was no trial, it cannot be ruled out that it might be a case of hit by some other vehicle to the rear side of the vehicle being driven by the DLA.

21. Abatement of FIR leads to termination of criminal proceedings against the DLA.  Since, the DLA did not have opportunity to defend the allegations/investigation made against her. Therefore, by implication, any charges against the DLA were effectively dismissed, therefore, the case ended without any determination of guilt or innocence.

22. Nowhere in the forensic report, has it been stated that the DLA was intoxicated. We are unable to understand as to how O.P. has drawn an inference that the death of the DLA was due to self-inflicted injury and accident benefit is not payable.

23. It is noted that word “decided” has been used in the said letter, however, the O.P. has failed to explain how they have concluded that the DLA was driving a vehicle with high speed, carelessly and it’s a case of inflicted self injury. The non-payment of the accident benefits to the complainant without any logical reasoning on arbitrary grounds definitely amounts to deficiency in service and unfair trade practice.

24. Therefore, in the facts and circumstances of the present complaint we feel that the complainant is entitled to Accident benefit as per the policy terms and conditions. Hence, we direct O.P. to pay 

a) The Accident benefit sum assured under both the policies i.e policy No.114951794and policy No.127335863.

b) Interest @ 7% p.a. on the amount calculated in clause a) above from the date of settlement of death claim till realisation

c) Rs. 50,000/- as compensation on account of mental harassment, inclusive of litigation expenses.

25. The order be complied with in 30 days from the date of receipt of order. In case of non-compliance within the stipulated time, the OP shall be liable to pay interest @9% per annum on (a)+(b)+(c), from the date of order till realisation.

Office is directed to supply the copy of this order to the parties as per rules. Order be also uploaded on the website.  Thereafter, file be consigned to the record room.

 

                   (Harpreet Kaur Charya)

                               Member                

                                                                                                                          Member

                                                        (Divya Jyoti Jaipuriar)

                                                                   President