BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MYSORE-570023

CONSUMER COMPLAINT NO.181/2015

DATED ON THIS THE 19^h August 2016

      Present:  1) Sri. H.M.Shivakumara Swamy

B.A., LLB., - PRESIDENT   

    2) Smt. M.V.Bharathi                    

                                   B.Sc., LLB., -  MEMBER

                     3) Sri. Devakumar.M.C.                  

                                                          B.E., LLB.,    - MEMBER

Sri Devakumar.M.C.

Member

1.     The complainant has filed the complaint under section 12 of the C.P.Act, 1986, against the opposite party, alleging the deficiency in service and seeking a direction to pay Rs.4,00,000/- with interest at 12% p.a. with cost of the proceedings and other reliefs.
2.     The complainant’s husband obtained a personal accident insurance policy for a period of one year from 11.01.2013, for a sum of Rs.4,00,000/-.  The insured died due to Acute Ischemic Heart disease, on 20.01.2013.  The complainant contacted the opposite party branch office and claimed for the policy amount.  Later, the complainant caused a legal notice on 30.12.2013.  The opposite party failed to reply.  An investigator collected all the relevant certified copies.  A rejoinder notice caused on 29.04.2014.  The opposite party repudiated the claim vide its letter dated 22.10.2014, with untenable reply.  Hence, the aggrieved complainant filed the complaint seeking reliefs.
3.     The opposite party in its version admits the issue of policy with terms and conditions valid from 11.01.2013 to 10.01.2014.  It denies the death of insured due to accidental clash occurred on 20.01.2013, but the same was due to Acute Ischemic Heart disease as a result of antemortem clot and the cause was due to natural causes.  The complaint registered by Hunsur rural police were not known, but the same learnt only on going through the document produced by the complainant.  It admits the receipt of claim intimation on 21.01.2014 and the same replied to submit the relevant documents.  On failure to comply, reminders sent to complainant on 07.02.2014 and 24.02.2014.  The opposite party vide letters dated 28.04.2014 and 29.05.2014, informed the complainant about repudiation of the claim.  Further, the insured was under influence of alcohol at the time of death, hence, as per exclusion clause, the complainant not entitled for the claim.
4.     To establish the facts, the complainant filed his affidavit with several documents.  The opposite party also filed its affidavit along with documents.  Both parties filing written arguments, submitted oral arguments.  On perusing the material on record, matter posted for orders.
5.    The points arose for our consideration are:-

1. Whether the complainant establishes the deficiency in service on the part of opposite party, in not paying the personal accident insurance policy benefits and thereby she is entitled for the reliefs sought?
2. What order?

6.    Our findings on the aforesaid points are as follows:

Point No.1 :- In the negative.

Point No.2 :- As per final order for the following

:: R E A S O N S ::

7.    Point No.1:- The complainant’s husband took a personal accident insurance policy from opposite party company, insured for a sum of Rs.4,00,000/- on 11.01.2013.  The policy was for a period of one year.  During the subsistence of the policy, the insured died on 20.01.2013, due to Acute Ischemic Heart disease as a result of Antimortum clot in left coronary artery, which he sustained in an clash on road with 3^rd party and succumbed to the injuries in the hospital while on treatment.  The jurisdictional police registered FIR No.35/13, on the complaint given by his brother-in-law, that the insured was assaulted.  After recovering from the death of insured husband, the complainant, approached the opposite party and sought for the personal accident claim as per the policy.  On submission of the claim form along with relevant documents, the opposite party vide its letter dated 22.10.2014 sent an intimation, of repudiation of the claim, as the death was natural.  Aggrieved complainant filed the complaint and sought for the reliefs.
8.    The opposite party admitted the issue of personal accident insurance policy to the deceased complainant’s husband on 11.01.2013.  Subject to the terms and conditions, the policy was issued for the period from 11.01.2013 to 10.01.2014.  The opposite party also admitted the death of the insured on 20.01.2013 and denied the cause of death due to accidental clash.
9.     The opposite party contended that the death was due to “Acute Ischemic Heart disease” as a result of antemortem clot in left anterior descending coronary artery.  Further, the insured was under the influence of alcohol at the time of death.  As per exclusion clause, the claim was repudiated, since, the policy covers death only due to accident.  Hence, prayed for dismissal of the complaint.
10. Admittedly, the cause of death of the life insured was due to Acute Ischemic Heart disease as a result of antemortem clot in the left anterior descending coronary artery.  Further, the insured was under the influence of alcohol at the time of incident.  As per policy exclusion conditions No.4, the claims under the influence of alcohol, does not entitle the claims.
11. The policy issued to the insured covers death only due to accident.  The opinion expressed by the doctor and also the literature placed on record also confirms the death due to natural causes and he was under the influence of the alcohol, which cannot be termed as death caused due to accident.  Hence, the repudiation is justified and the complainant is not entitled for any reliefs under the policy.  
12. The advocate for complainant relied on the following judgements reported in:

1. I (2016) CPJ 414 (NC).
2. I (2016) CPJ 347 (NC).
3. I (2016) CPJ 196 (NC).

to establish her claim under the personal accident insurance policy.  But, they never support the contention of cause of death of the insured as accident.

13. The opposite party relied on articles on the ischemic heart disease and the doctor’s opinion with several judgements, which supports the cause of death was due to the heart disease, and same cannot be termed as accidental death, hence the contention of opposite party is justified and the repudiation of claim held as correct. Accordingly, point no.1 is answered in the negative.
14. Point No.2:- With the above observations, we proceed to pass the following,

:: O R D E R ::

1. The complaint is dismissed.
2.  Give the copies of this order to the parties, as per Rules.

(Dictated to the Stenographer transcribed, typed by her, transcript corrected by us and then pronounced in open court on this the 19^th day of August 2016)