District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.405/2021.
Date of Institution: 11.08.2021.
Date of Order: 21.11.2022.
1. Mrs. Bela Ratra wife of Shri Subhash Chander Ratra, resident of House No. D-8, Nehru Ground, NIT, Faridabad (Haryana).
2. Ms. Ruhi Ratra @ Roohi Ratra aged about 38 years (Date of birth 6.9.1982) wife of late Shri Ankush Ratra, presently residing at House No.2-B/42, NIT, Faridabad, holding PAN:AJLPR4284P, having Adhaar card No. 466523873993.
3. Master Saksham Ratra S/o Shri Ankush Ratra R/o House No.2-B.42, NIT, Faridabad Minor through his mother/guardian/next friend Ruch Ratra @ Roohi Ratra.
4. Ms. Sanya Ratra D/o Ltd. Shri Ankush Ratra R/o House No.2-B/42, NIT, Faridabad Minor through her mothe
r/guardian/next friend Ruhi Ratra @ Roohi Ratra.
…….Complainants……..
Versus
HDFC ERGO General Insurance Limited (formerly known as Apollo Munich Health Insurance Co. Ltd.) Ist floor, SCF-19, Sector-14, Gurgaon – 122001 (Service be affected through ground floor, Shop NO. 35 & 36, Om Shubham Tower, Neelam Bata Chowk, NIT, Faridabad- 121001.
…Opposite party……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
PRESENT: Sh. Ajay Yadav, counsel for the complainant.
Sh. Rakesh Dabaas, counsel for opposite party.
ORDER:
The facts in brief of the complaint are that complainant No.1 was the mother, complainant No.2 was the wife and complainant No.s3 & 4 were the minor children of late Shri Ankush Ratra who had died on 06.02.2020 in a Rail accident. Ankush Ratra had obtained an accidental cover insurance policy from opposite party bearing policy No.111100/21002/2000187095-03. Shri Ankush Ratra was born on 10.08.1982. After completing his studies he had joined the family business. Right since his young age of 23 years well prior to this marriage with complainant NO.2, Shri Ankush Ratra had inculcate the habit of his safeguarding life by way of insurance policies i.e medical insurance policies from different service providers and life insurance policies from Life Insurance company. Details regarding said two kind of insurance policies were:
A. Medical insurance policies:
i. As on 18.05.2005, i.e at the age of 23 years, said Shri Ankush Ratra had taken medical policy from United India Insurance co. Ltd., wherein he has self insured. The same was renewed in May 2006. Again it was renewed on 17.05.2007. further, the same was renewed on 17.05.2008.
ii. As on 18.05.2019 above said medical policy with United India Insurance Limited was renewed whereby said Shri Ankush Ratra. Complainant
Nos.2 to 4 and Subhash Chander Ratra were insured. Rellllliance was placed on cover note dated 19.05.2010 issued by the said insurance company. The same would provide the information that the date of first ever policy issued by United India Insurance co. Ltd was issue don 18.05.2005.
iii. As in the year 2011 insurer was changed form United India Insurance Co. Ltd., to Apollo Munich Health Insurance vide medical insurance cover note dated 18.05.2011 all the four member of Shri Ankush ratra i.e. self, wife, son and daughter were insured for a sum of Rs.1,00,000/-.
It was submitted that till his death Shri Ankush Ratra had never claimed any benefit out of said annual medical policies.
Policy No. Date of issue Name of policy Amount(Rs.) Maturity
121744820 28.03.2002 Medical 1,00,000/- 28.03.2022
122099706 28.07.2003 Jeevan Surbhi 1,00,000/- 28.07.2008.
28.03.2006 05,03,2006 Endowment insurance 50,000/- 28.03.2021
124768257 03.12.2009 Jeevan Saral 15,00,000/- 03.12.2025
126572727 10.08.2013 Jeevan Anand 9,95,000/- 10.05.2034
126573318 28.09.2013 Jeevan Arogya 28.09.2062.
127407466 28.06.2014 Amulya Jeevan -2 1,50,00,000/- 28.06.2048
128012628 09.02.2018 Amulya Jeevan-2 2,00,00,000/- 09.02.2052
128017959 01.12.2018 Amulya Jeevan-2 1,00,00,000/- 18.12.2051.
The above mentioned Accident Covery policy ebaring No. C/11001/00181191
was obtained in the usual mannber by Shri Ankush Ratra and the same was valid for the period of 21.05.2019 to 20.05.2020 and a premium of Rs.4,227.94 was duly paid by Shri Ankush Ratra.
Base Policy coverage & Benefit:
i. Accidental death : Rs.25,00,000/-
ii. Temporary total Disablement : Rs.10,00,000/-
iii. Accident Hospitalization (in patient) : Rs, ,00,000/-
Apart from the above benefits the insured was also having a benefit of cumulative bonus of Rs.3,75,000/- under the above said policy. Beside the above said Shri Ankush Ratra had obtained following other insurance policies:
i. HDFC Ergo Health Insurance – appolo Munich bearing policy No.111100/21002/2000187095-03.
Said policy used to be renewed every year.
ii. MAX Newyork Life, bearing policy No. 132087107
iv. Personal project policies from ICICI Lombard.
As usual said Shri Ankush Ratra had started the day on 06.02.2020 by attending to his duties as a partner/employee of M/s. Metropole, a partnership firm. Due to exignencies of the business of manufacture and sale of tubes that the partners of the said Firms ha dto go at times from Faridabad to delhi through Train and at
times he used to visit truck repairer shps and other vendors dealing in truck spare parts as the firm also owns some trucks and such shops were located near the railway track. As such on 06.02.2020 Shri ankush Ratra was crossing the railway line New Town Railway Station, Faridabad. While passing through the level crossing path he died on Track III at about 1.35 p.m. being run over by a good train (STPB) from Agra to Tuglakabad, Delhi. The Loco Piolt Shri Sandeep Kumar gave intimation of the above fatal accident to Shri Manish Vijay, deputy SS, Faridabad who in turn gave the information to Shri H.P.Kashyap, Station Master, Faridabad. Shri H.P.Kashyap, through his hand written Ruka while informing the SHO, GRP, Faridabad about the said accident, based on the information received by him through the mode as above but as perceived by him, that a man jumped ahead of train at Km. 1505/26 IIIrd Line at Faridabad and that dead body was lying on IIIrd line track. Having found address of the deceased form the search as above, said SPO Sri Gajinder Singh came to the residence of the complainant No.1 at House No. d-8, Nehru Ground, NIT, Faridabad, Haryana at 3.30p.m. on 06.02.2020 to inform them about the abovesaid rail accident and death of Shri Ankush Ratra at New Town, Faridabad Railway Station. Hearing the hews hell broke upon their head. Shri Subhash Ratra, father of deceased alongiwth brother of the deceased as well as other relatives reached the site of accident and at the police station, GRP, Old Faridabad. Vide application dated 06.02.2020 Shri SubhashChander Ratra requested SHO, GRP, Old Faridabad for conducting investigation against accidental death of Shri Ankush Ratra.
The police at the said GRP police station conducted the Inquest proceedings. Statement of different persons were recorded. The testimony of the
Loco Pilot left no manner of doubt that Shri Ankush Ratra was run over by the train while crossing the railway track and that Shri Ankush Ratra died in an accident. On the support of above Ruka, statements police prepared the Inquest report. As per the final police report filed in Inquest Report cause of death of Shri Ankush Ratra was due to railway accident. None was to be blamed for the death of Shri Ankush Ratra. The fact of death of Shri Ankush Ratara was duly registered with Municpal Corporation, NIT, Faridabad vide NO. D-2020:6-90213-000726 dated 02.03.2020. The claim on the death of Ankush Ratra was lodged with opposite party HDFC ERGO as per the format supplied by the opposite party itself, claiming thereby, a sum of Rs.28,75,000/- on account of accidental death of Shri Ankush Ratra. As such, necessary required documents were submitted to the opposite party. As submitted above deceased had obtained different insurance policies from Life Insurance Corporation . Accordingly, claims were lodged with LIC; Vide three separate Communications dated 05.06.2020 following detailed three claims were settled.
i. Net claim of Rs.11,74,450/- was sanctioned under policy NO. 126572727.
ii. Net claim of Rs.2,27,338/- was sanctioned under policy No. 124768257.
iii. Ne claim of Rs.1,50,00,000/- was sanctioned under policy No. 127407466.
iv. Thereafter, through another communication dated 28.09.2020 LIC
had intimated the sanction of another claim of Rs.2,00,00,000/- was sanctioned under policy No. 128012628.
v. Against policy No. 126572727 claim amount of Rs.5,00,000/- was paid on 20.11.2020.
vi. Against policy No. 121744820 claim amount of Rs.1,00,000/- was paid on 20.11.2020.
vii. Against policy No. 122099706 claim amount of Rs,1,00,000/- was paid on 20.11.2020.
After having remained sitting on the claim file for a period of six months tha the opposite party acting in a malafide manner had repudiate the claim as communicated through its repudiation letter dated 05.03.2021. Claim had been repudiated citing untenable plea that Shri Ankush Ratra had committed suicide. Opposite party had repudiated the claim on assumptions and presumptions as neither the attending circumstances nor the evidence, including policy finding supported such a plea. At this stage vide application dated 30.12.2020 information was sought under RTI Act, form State Public Information Officer cum Deputy Superintendent of Police, Railways, Haryana, Ambala Cantt. In response to the said RTI application said RTI Authority, vide its communication dated 03.02.2021 had supplied the complete Inquest Report qua the said Rail accident on 06.02.2020. On the support of information, documents, records available with the complainants, more so, on the support of the documents obtained through RTI as above, it was humbly submitted that the repudiation of the claim was
riddled with extraneous reasons “As per the submitted documents and investigation claim had been valuated as Suicide case hence claim in not admissible as per General Condition of the policy: 4) General Exclusion Applicable to all Benefits:
b) intentional Self inflicted Injury, Suicide while sane or insane, nervous disorder of condition, insanity, anxiety or depression” whereas the police after conducting a proper investigation had given a final report and the police in its final report had clearly stated the death of Shri Ankush Ratra to be a rail accident. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) pay the claim amount of Rs.28,75,000/- alongwith interest @ 18% since of the death of insured Shri Ankush Ratra i.e. 06.02.2020.
b) pay Rs.10,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs.1,00,000/ -as litigation expenses
2. Opposite party put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that the instant consumer complaint filed by the complainants were devoid of any merit in law and the same had been done so as to make illegal and unscrupulous gains at the expense of the opposite party. It was submitted by the answering opposite party that the consumer complaint conveniently suppressed material facts that the deceased policyholder had committed suicide, due to which the insurance claim had been repudiated herein. Even prima facie, it was abundantly clear that the claim had been invalidated as per the terms, conditions and policies enumerated and agreed upon by both party and there could be no dispute regarding the same.
The deceased policyholder had submitted a proposal from bearing No. 2101179894 for purchasing an Individual Personal Accident premium insurance policy in his name for sum insured of Rs.25,00,000/- on 16th May 2016 from the answering opposite party. Based on the said proposal form and other documents submitted by the deceased policyholder, a personal accident insurance premium policy bearing No. 110103/21002/2000187095 for a sum insured of Rs.25,00,000/- was issued in the name of the deceased policy holder for the period 18 May 2016 to 17.5.2017. The policy was renewed form time to time, last renewal being for the period 21.5.2019 to 20.5.2020. It was submitted that the deceased policyholder had signed the proposal form after duly going through the terms and conditions and had full knowledge of the same. The deceased policy holder had taken an insurance policy from the answering opposite party and the total sum insured in the said policy after including the cumulative bonus as on date of the claim was Rs.28,75,000/-. On the very first page of the policy terms and conditions it was clearly mentioned that suicide or attempted suicide wee not covered in the policy and were excluded. As per clause 4(b) of the terms and conditions policy self inflicted injury, suicide or attempted suicide were clearly excluded. On 13.04.2020 he answering opposite party had received a claim in the policy claiming an amount of Rs.28,75,000/- inclusive of cumulative bouns from the complainant son account of death of the policyholder Mr. Ankush Ratra on 06.02.2020. The answering opposite party thereafter had referred the said insurance claim for investigation through an independent investigator. During the investigation it was noted that the Loco Pilot of the train with which deceased policyholder had died had in his “
Rukka” sent to the Station Master had clearly stated that ”one man jumped in front f his train and his dead body was lying in the III Track. In his statement to the police, the Loco Pilot had further stated that “Bhid me se ek aadme bhag kar
railway line paar karne laga jo mere ghadi me chapet me aa gya” and from the same it was clear that when train was approaching the track, there were many persons who were waiting thee for the train to pass so that they could cross the track after passing of the train however when the train approached near the deceased policyholder, he jumped in front of the train and it was also known fact that nobody would risk his life by crossing the track in front of the approaching train and that too when many other people at same place were waiting for the train to cross, until and unless that person would like to commit suicide by jumping in front of the train. The company had also sent the claim documents for taking an expert opinion and the expert opinion was given after review of all the available documents including various statements, looking after the injuries mentioned in the post mortem report of the deceased policyholder and the opinion had concluded that the death of the deceased policyholder was suicidal in nature. From the complainant itself it was noticed by the answering opposite party that the deceased policyholder had also purchased multiple insurance policy from other insurance companies viz. Life Insurance Company, ICICI Insurance and Max Newyork Life Insurance Company. Further it was noted that few of the insurance policies were prior to the policy taken from the answering insurance company and those were not disclosed in the proposal form and as such this become a material non-disclosure on the part of the deceased policyholder. It was worth mentioning that had the deceased policyholder had disclosed his previous insurance policies he already had, the opposite party would not had given him the policy for such sum insured of Rs.25 lacs and if had given, it would had been n a different terms and conditions. It was worth mentioning that deceased policyholder had taken many insurance policy and in the proposal form of the policy taken from opposite party, the answering opposite party had specifically asked whether the proposer was having
any other existing accidental insurance policy from other insurance companies. It was pertinent to mention that the deceased policyholder had multiple insurance policy prior to availing the insurance from the answering opposite party. The suppression of this material fact in the proposal form was a clear cut non disclosure on the part of the deceased policy holder. It was submitted by the answering opposite party that the deceased policy holder had intentionally committed suicide due to some personal reason. Further it was also relevant to mention that no railway ticket or platform ticket was found with the deceased policyholder. It was submitted that the deceased policyholder had no other reason for going to the track after parking his car on the road as his home as well office/work was not on the tracks and as such he only purpose of visiting the railway track was the sole intention of committing suicide. Thus from the facts and circumstances herein it could not be said that the death of the policyholder was accidental under any circumstance rather the circumstances clearly establish that the motive of the deceased policyholder was to commit suicide. It was prima-facie apparent form the bare perusal of the complaint that the complainants had failed to establish the alleged statement of accident in any manner whatsoever and there had been no negligence of deficiency in service whatsoever, on the part of the opposite party in dealing with the concerned policy as the claim was rightly repudiated as per clause 4(b) of General Exclusions. Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite party – HDFC ERGO General Limited with the prayer to : a) pay
the claim amount of Rs.28,75,000/- alongwith interest @ 18% since of the death of insured Shri Ankush Ratra i.e. 06.02.2020. b) pay Rs.10,00,000/- as compensation for causing mental agony and harassment . c) pay Rs.1,00,000/ -as litigation expenses.
To establish his case the complainant has led in his evidence Ex.C-1 – letter regarding renewal of your individual personal accident premium insurance policy, Ex.C-2 – Policy schedule – individual personal accident premium, Ex.C-3 – medical insurance, Ex.C-4 – individual health insurance policy, Ex.C-5 – Schedule – Easy Health Individual Standard,, Ex.C-6 & 7– LIC Amulya jeevan-3, EX.C-8 – Lic Jeevan anand, Ex.C-9 to 13 – LIC, Ex.C-14 – LIC Jeevan Anand, Ex.C-15 – LIC’s Amulya Jeevan-2, Ex.C-16 & 17– Optima Restore policy schedule, Ex.C-18 to 23 - letters regarding renewal of optima restore policy, Ex.C-24 - letter to SHO, Ex.C-25 - Fard Jama talasi report, Ex.C-26 - letter regarding request for investigation, EX.C-27 & 28– post mortem examination report, Ex.C-29 (colly) – post mortem examination report,, Ex.C-30 to 32– newspaper cutting, Ex.C-33 – Statement of Gajender Singh,, Ex.C-34 – Statement of Subhash chand,, Ex.C-35 – letter regarding RTI, Ex.C-36 – Inquest report, Ex.C-37 – letter , Ex.C-38 – letter to SHO GRP, Faridabad, Ex.C-39 – death report, Ex.C-40 – Fard Jama Talasi report, Ex.C-41- statement of Gajender Singh, Ex.C-42 – statement of Harish,, Ex.C-43 – Shri Pankaj, Ex.C-44 – Post mortem examination report,, Ex.C-45 – Post Mortem examination report,, Ex.C-46 – receipt dead body, Ex.C-47 & 48 - statements, Ex.C-49 – death certificate,, Ex.C-50 to 52– letter not readable,, Ex.C-53 – letter, Ex.C-54 to C-56– status reports, Ex.C-57 – rejection letter dated 05.03.2021,, Ex.C-58 – RTI lette, Ex.C-60 – letter regarding post mortem,, Ex.C-61 – letter to SHO GRP, Ex.C-63 – death report,, Ex.C-64 – statement of Gajender Singh,, Ex.C-65 – Harish,, Ex,C-66 - statement, Ex.C-67 & 68 – Post Mortem
examination report,, Ex.C-69 – receipt dead body,, Ex.C-70 – statement,, Ex.C-71 – antim report, Ex.C-72 – statement,
On the other hand counsel for the opposite party strongly agitated and opposed. As per the evidence of the opposite party, Ex.RW1/A – affidavit of Shri Vivek Yadav, Senior Manager, HDFC ERGO General Insurance Company Limited having its office at 208,2nd floor, Sewa Corporate Park, Mehrauli – Gurgaon Road, Gurugram, Haryana, Ex.RW1/B – India Non Judicial, Ex.RW1/C - affidavit of Dr. C.H.Asrani, DNB, MBBS, Advanced Diploma in Fornsic Medicine and Toxicology and a Post Graduate Diploma in Medico Legal systems (from Symbiosis Centre of health Care) aged about 68 years, S/o late Shri Hukamchand Asrani, R/o B 903/904 Skypan CHS Ltd., Oshiwara Link Rd. Andheri (W), Mumbai – 400 053, Ex.R1 – Individual Personal Accident, Ex.R-2 – Reimbursement Investigation Report, Ex.R-3 - certificate of Dr. C.H.Asrani, Ex.R-4 – Rejection letter to customer.
6. In this complaint , the complaint was filed by the complainant with the prayer of death of Ankush Ratra who was died on 06.02.2020 in a railway accident. It was repudiated opposite parties by taking flimsy plea that the insured committed the suicide. But after going through the evidence led by the complainant from Ex.C1 to C-23 which shows deceased was having multiple life insurance policies from different companies. The certificate issued by the opposite parties i.e HDFC ERGO General Insurance Limited (formerly known as Apollo Munich Health Insurance Co. Ltd). No doubt the person was insured with a premium of Rs.4227/- as per Ex.C-2 by the opposite party.
As per the evidence led by the complainant from Ex.C25to C48, as per the proceedings of 175 Cr.P.C and the final report filed by the complainant of 175 Cr.P.C. proceedings and report of DSP ( HQ) GRP also submitted the report in the RTI which is exhibited by the counsel for the complainant and the statement of Locomotive Pilot of the railway and the statement of Sandeep Kumar who was the eye witness stating “Bheed main Ek Aadmi Bhag Kar railway Line paar karne haga jo meri gaadi ke chapat main aa gya”. Then in the Inquest report the opinion given is “In my opinion the cause of death in this case due to Railway accident”. Further, in the final report by police the cause of death is Railway Accident. Similarly, in tasdeek byThana Prabhandak it has been held as a case of Railway Accident. Not only thus but the insured was also having LIC policies with Double benefit in case of accidental death, the LIC after thorough investigation passed the Death Claim of Shri Ankush Ratra and paid Double sum insured holding the death of Ankush Ratra in an accident.
7. In this complaint, the complainant deceased has obtained the Life Insurance Policy also from the LIC Carriers. They have paid the double of the claim amount to the complainant. As per the evidence led by the complainant and also paid the benefit of the double amount in case of accident. As per evidence Ex.C-34(colly regarding the statement of Shri Sandeep Kumar in which it has been stated that “Bheed main Ek Aadmi Bhag Kar railway Line paar karne bhaga jo meri gaadi ke chapat main aa gya”. The complainant also led in his evidence Annexure Ex.C-35 i.e. DSP Head Quarter of GRP has given his report and information in RTI to the complainant. As per the information of the DSP Head Quarter dated 03.02.2021 , it was a case of railway accident . After going through the postmortum report and page No. 71 RajPal SI given the post mortum report in which the cause of death is railway accident and the final report of SHO GRP, Faridabad on page No. 93 is proving the same and also filed the final report of the death on page 93. Cause of death is railway accident and as per Annexure A17, the documents of LIC and Ex.C-54 on page 99. it shows the double benefit amount was given to the complainant by the LIC.
8. The Counsel for the complainant has placed on reliance the authority titled JSK Industries Vs. Oriental Insurance Company passed by the Hon’ble Apex Court while deciding Civil Appeal No. 7630 of 2022.
Ratio of the authority is applicable to the facts of the present case
9. After going through the report of DSP, SHO, SI and documents of the LIC, the Commission is of the opinion that no doubt this was a case of railway accident and the complainant has the insurance policy. Hence, the complaint is allowed. Opposite party No.1 is directed to process the claim of the complainant and issue the claim of the complainant in due course of law within 30 days of receipt of the copy of order and pay the due amount to the complainant along with interest @ 9% p.a. from the date of filing of claim of the complainant till its realization. The opposite party No.1 is also directed to pay Rs.11,000/- as compensation on account of mental tension, agony and harassment alongwith Rs.11,000/- as litigation expenses to the complainant. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 21.11.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
