BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.199 of 2016

Date of Instt. 03.05.2016

Date of Decision: 13.09.2017

Amarjit Singh Kathuria son of Late S. Pritam Singh resident of House No.305, Guru Teg Bahadur Nagar, Jalandhar.

..........Complainant

Versus

1. National Insurance Co. Ltd., Registered and Head Office, 3 Middleton Street, Prafulla Chandra Sen Sarani, Kolkata (West Bengal) 700071 through it's Chairman cum Managing Director.

2. National Insurance Co. Ltd., C/o M/s G.S. Magestic Developer Ltd. Near Homoeopathic College, Canal Road, South City, Ludhiana through it's Chief Regional Manager.

3. National Insurance Co. Ltd., Divisional Office-II, Panesar Complex, 20- G.T. Road, Jalandhar 144001 through it's Sr. Divisi onal Manager.

….… Opposite parties

Complaint Under the Consumer Protection Act.

Before: Sh. Karnail Singh (President)

Sh. Parminder Sharma (Member)

Present: Sh. YV Rishi, Adv Counsel for the complainant.

Sh. RS Arora, Adv Counsel for OP No.1 to 3.

Order

Karnail Singh (President)

1. This complaint filed by the complainant, wherein alleged that the father of the complainant Late S. Pritam Singh son of Sh. Havela Singh resident of House No.305, Guru Teg Bahadur Nagar, Jalandhar obtained an insurance policy bearing No.404300/21/48/81/0000367, while he was alive, from the OPs for Rs.10,00,000/- as sum insured plus Rs.5,00,000/- as cumulative bonus, totaling Rs.15,00,000/- with death benefit under administrative control of OP No.3. The father of the complainant namely Pritam Singh, the life assured while descending the stairs near the main door of his house on his way to his doctor for routine checkup on 20.03.2015 at about 10:30 A.M, he was walking with a stick which slipped and he sustained serious head injuries due to fall in the stairs and he was immediately in an unconscious state taken and rushed to Doaba Hospital, Lajpat Nagar, Near Nakodar Chowk, Jalandhar for his treatment. He remained admitted in the said hospital upto 27.03.2015 and due to no significant improvement and still in unconscious condition, he was shifted to Global Hospital, Link Road, Jalandhar on 27.03.2015 and he remained in Global Hospital till 31.03.2015, when he was discharged in unconscious state without any improvement and he succumbed to head injuries suffered by him in the said accident, causing his death on 03.04.2015. The injuries caused by accident was the proximate cause of death of Pritam Singh, Life Assured, inspite of all necessary steps taken for his protection and survival. That after death of Pritam Singh, Life Assured, complainant as nominee of Pritam Singh submitted an insurance claim to the OP to pay the due to accidental death of Pritam Singh, the claim was enclosed with relevant documents i.e. death claim intimation, photostat copy of the discharge card and other related documents, photostat copy of the bills etc and other related documents, original death certificate of Pritam Singh.

2. That OP No.3 in order to verify the facts about accidental death of S. Pritam Singh, Life Assured and to process claims filed by the complainant, entrusted it's investigation of true facts to its authorized investigators and consultants, M/s S.A. Investigating & Consulting Agency, 'Ashiana', Canal View Enclave, Abrol Nagar, Pathankot, who after through investigation submitted a detailed report and fact finding report with their letter dated 04.05.2015 to the OPs. In the said report, the investigator confirmed that after detailed investigation, they found that Pritam Singh, life assured had died due to serious head injury suffered by him in accidental fall while descending from the stairs of his house on his way to routine medical checkup from doctor on 20.03.2015. The accidental death was never disputed by the OPs while passing other medical claim bill amounting to Rs.1,76,150/- on 24.07.2015 to the complainant but in regard to personal accident claim, filed by the complainant, the OPs demanded some documents which were supplied well within time and it was specifically informed to the OPs that the life assured suffered for an injury, no FIR or Post Mortem was required despite that the claim of the complainant was wrongly, illegally and in an arbitrary manner repudiated by the OP, vide repudiation letter dated 18.01.2016 and as such necessity arose to file the present complaint with the prayer that the instant complaint may be accepted and OPs be directed to settle and pay the Personal Accident Insurance Claim of Rs.10,00,000/- as sum insured plus Rs.5,00,000/- as cumulative bonus in total Rs.15,00,000/- and further OPs be directed to pay interest @ 18% per annum on the aforesaid insured amount, from the date of death till realization and further OPs be directed to pay compensation for harassment to the complainant to the tune of Rs.50,000/- and litigation expenses of Rs.10,000/-.

3. Notice of the complaint was given to the OPs and accordingly all the OPs appeared through their counsel and filed their joint reply and contested the complaint by taking a plea that one mediclaim policy for reimbursement of the medical expenses on the hospitalization of Late S. Pritam Singh, which was paid Rs.1,76,150/- and accepted by the complainant, the other claim under the personal accident insurance policy purchased by Late Pritam Singh, which was declined because the complainant had not furnished any document, which could establish that the deceased died on account of head injury sustained due to fall from the stairs. Though the MRI was got done, the MRI film and report were not produced by the complainant. For their non-production, he took the plea before filing the present complaint that the film and the reports were drained into the holy water during deceased's bone ossification ceremony, hence not available, but in the complaint the complainant took the different and contradictory plea. The fact on the record, which came to surface from the OPD prescription was that the MRI did not show any fresh infarct, so it was a strategic compulsion for the complainant to show it “drained” and keep it away from the insurance company. The medical papers of both the Doaba Hospital and Global Hospital nowhere indicate that there was even any superficial injury, if could be one on which area of the head or of which size. The hospital prescription tells that MRI of the brain of the deceased did not show any infarct (clotting in the brain). No X-Ray was done to find out if there was any fracture in any part of the body by fall. In short, visible external injury in this case were not established by way of supporting documents submitted by the complainant. It is further submitted that why the medical record, bills, prescription, discharge certificates were not drained, only the MRI film and the report drained and further submitted that the deceased Pritam Singh was old patient of diabetes Mallitus, Hypertension, DB Nephropathy, Chest infection and even there is a gangrene of foot and the CVA and if the deceased was patient of gangrene then how he can walk by stick and his own all alone in this condition of gangrene of foot and as such this story is un-believable. It is further averred that the controversy cannot be decided in a summary procedure in this Forum, only the Civil Court could have the jurisdiction where thorough cross-examination is needed of the witnesses. On merits, the averments in regard to purchase of the insurance policy by the deceased Pritam Singh is not denied and it is also admitted that the complainant submitted a claim under personal accidental insurance policy of the deceased Pritam Singh and it is also admitted that some documents were received from the complainant but the remaining documents were not supplied and other averments made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merit and the same may be dismissed.

4. In order to prove the case of the complainant, counsel for the complainant tendered into evidence affidavit of the complainant Ex.C1 and some documents Ex.C2 to Ex.C41 and then closed the evidence of the complainant.

5. Similarly counsel for the OP No.1 to 3 tendered into evidence two affidavits Ex.O1 and Ex.O2 alongwith documents Ex.O3 to Ex.O5 and closed the evidence on behalf of the OP No.1 to 3.

6. We have heard the learned counsel for the respective parties and also gone through the case file very minutely.

7. After hearing the argument and from scrutiny of the case file, it has become clear that the factum in regard to purchase of personal accidental claim insurance policy by deceased Pritam Singh, father of the complainant is not denied and further it is also admitted fact that the complainant submitted a personal accidental claim which was considered by the OP and then repudiated the claim of the complainant, vide letter dated 18.01.2016 Ex.C11, whereby the reason for repudiation is only that the personal accidental policy covers “injury/disability/death caused by an accident due to visible external means which in this case is not proved by way of supporting documents submitted by complainant and on the basis of above and medical opinion obtained from our TPA, the death of the patient is due to prolonged illness and not due to any accident, hence your claims stands repudiated. In order to fortify the aforesaid letter for repudiation of the claim, the OP has made a reliance upon the discharge summary report of DMC Hospital, Jalandhar and copy of the same is available on the file Ex.O3, wherein the previous ailment of the deceased Pritam Singh has been mentioned and as per summary discharge slip, the deceased remained admitted in the DMC Hospital, Jalandhar from 07.02.2015 to 12.02.2015 and further the OP has examined two witnesses i.e. Mohit Chawla Assistant Manager, whose affidavit is Ex.O1 and then Gurwinder Kaur, Deputy Manager, whose affidavit is Ex.O2 and Gurwinder Kaur in his affidavit categorically stated that when the deceased had a dead foot due to gangrene and he was advised by his doctor, vide Ex.O3 to be moved only on wheel chair how could he be shown in the complaint as walking on stick before fall, this story of the complainant is remain un-answered and further deposed that there was no visible injury proved by the complainant on the head of the complainant and even the MRI as well as post mortem report not produced, regarding that the OP has brought on the file a letter Ex.O4, whereby they demanded some documents and in response to letter Ex.O4, the reply of the complainant is also proved on the file Ex.O5 and it is alleged by the OP that due to the above reason, the claim of the complainant is rightly repudiated.

8. The complainant alleged that he has supplied all the documents, vide letter Ex.C17, Ex.C18 and Ex.C19, except post mortem report and MRI Report, these documents have been demanded by the OP, vide letter Ex.C14, Ex.C15, Ex.C16 but the OP was informed that the deceased died not due to any violative act rather he died due to fell from the stair cases and this is a natural accident and no postmortem and FIR is required. So for the MRI is concerned, the counsel for the complainant stated that they have never received the copy of the MRI Report but we find that the OP itself appointed as Investigation Officer, who conducted investigation and submitted a report Ex.C7, which is very important to decide the case in hand. In the said report Ex.C7, the Investigation Officer categorically recorded under the heading of analysis and final opinion, it is categorically mentioned that the accident has generally taken place on 20.03.2015, in which accidentally the insured slipped in the stairs of his house near the main door while he was decending the stairs to go up to the car as he was to go to for his routine medical check up and further reported that police has not been informed and further reported that the post mortem of deceased has not been conducted because there is no criminal act/police involved and further reported that the death certificate is enclosed and gives his opinion in the report and categorically mentioned that the death of the insured is purely accidental in nature. So, it is clearly established from the report of the Investigation Officer that the death of the deceased Pritam Singh was caused due to accident by way of falling from the stair cases and this report is not given by the person of the complainant rather the said investigator is appointed by the OP itself. Further, we like to take assistance from the summary discharge report of both the hospital, where the deceased Pritam Singh was remained admitted prior to his death. Firstly, after accident, he was brought to Doaba Hospital and summary discharge report of the Doaba Hospital is Ex.C21, wherein he remained admitted from 20.03.2015 to 27.03.2015 and under the heading of diagnose, it is categorically mentioned that head injury and further report of the second hospital i.e. Global Hospital is Ex.C3, wherein under the heading of diagnose, it is categorically mentioned that head injury. From both the medical report, itself corroborated the version of the complainant that the deceased Pritam Singh falls from the stair cases and got head injury and this factor is very well corroborated by both the hospital by stating that there is a head injury and the query of the OP that there is no visible head injury proved by the complainant is answered in the manner that there might be internal injury and which is mentioned by the doctor, who is the expert of his profession and if any X-Ray is not conducted then it is not the fault of the complainant because it is required to the doctor for the purpose of treatment, if the concerned doctor considered necessary then he must get the X-Ray of the head of the deceased. So, for the concern of non production of post mortem report and MRI, no doubt the complainant has alleged that he has not received a MRI report from the hospital and secondly as per the version of the OP, the complainant alleged the same has been drain out alongwith the assets of the deceased Pritam Singh and at the time of ossification ceremony, somewhat we are not concerned with the MRI because if the MRI is not produced before the OP, is not sufficient to discard the claim of the complainant because the OP has itself appointed an Investigation Officer, whose report is available on the file Ex.C7, wherein in para No.5, the Investigation Officer categorically submitted that they have collected the copy of the hospital record of the previous ailment of the insurer and further in para No.11, he stated that he visited the Doaba Hospital, Jalandhar, if the Investigation Officer of the OP was able to get the medical report of the deceased Pritam Singh in regard to previous ailment then why the Investigation Officer did not demand the copy of the MRI from the hospital. So, we find that the OP is making a pretext just to decline the legal right of the complainant for getting an insurance claim. Further, if we gone through the term and condition of the insurance policy, which is placed on file by the complainant, which is Ex.C4 and in the opening para of the said term and condition, itself clear that when insured sustain any bodily injury resulting solely and directly from accident caused by external violent and visible means then the company shall pay to the insured or his legal personal representative as the case may be the sum or sums hereinafter set fourth, that is to say the insured amount. So, it is clear in the term and condition that any injury caused by external violent and visible means. So, it is clearly established that the external injury caused on the head of the deceased Pritam Singh, which is corroborated by both the hospital. So, the version of the OP that the complainant is failed to establish that there is any external head injury caused on the person of the deceased Pritam Singh but we find that these factum are very well established and in order to get more strength to our above observation, we like to refer a pronouncement of Hon'ble National Commission, cited in 2015(2) CLT, title Geeta Devi Vs. United India Insurance Co. Ltd., wherein his Lordship held as under:-

"Insurance Claim, death caused by accidental fall, held, in case of death caused by accidental fall, the question of reporting to the police and conducting a panchnama does not arise, the post mortem was not done as the death of the insured was not construed to be a suspicious one, repudiating the claim on the ground that the claimant had not sent the documents, which were not relevant to the nature of death, is totally unjustifiable."

9. On the same point, we further like to refer an another pronouncement of the Punjab State Consumer Disputes Redressal Commission, Chandigarh, cited in 2010 CPJ 272, title "New India Assurance Company Ltd Vs. Kiran Agnihotri", wherein his Lordship held as under:-

"Cause of death was fall from bed, same covered under definition of accident, accidental death proved, repudiation of claim not justified.”

10. So, in view of the above detailed discussion, we find that the insurance claim of the complainant is wrongly, illegally repudiated by the OPs. Further, we also considered the submission of the OPs that the deceased Pritam Singh died not due to head injury rather he died due to old ailments, which are proved by the OP by bringing on the file copy of the summary discharge of DMC Hospital, Jalandhar, we find that the said ailment was treated by the doctor much prior to the date of death and as such the said ailment does not relate to the cause of death in any manner. So, accordingly this plea of the OP is not tenable and even the plea taken by the OP that the deceased Pritam Singh could not walk due to gangrene and infection in the foot, no doubt this factum has been indicated in the summary discharge report Ex.O3, but it is not mentioned in the report that due to that infection of the foot, the deceased was not able to walk and moreover if the deceased was using the Wheelchair but that cannot be used on the stair cases while he descending from stair cases he has to come by his foot. So from all angles, the version of the OP is not established rather the case set up by the complainant is very well established and therefore the complainant is entitled for the claim.

11. In the light of above detailed discussion, the complaint of the complainant is partly accepted and OPs are directed to pay personal accidental insurance claim of Rs.10,00,000/- and thereon cumulative bonus of Rs.5,00,000/-, in total Rs.15,00,000/- to the complainant with interest @ 9% per annum from the date of filing the complaint till realization and further OPs are directed to pay a compensation for mentally and physically harassment to the complainant, to the tune of Rs.25,000/- and litigation expenses of Rs.5000/-. The entire compliance be made within one month from the date of receipt of the copy of order. Complaint could not be decided within stipulated time frame due to rush of work.

12. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated Parminder Sharma Karnail Singh

13.09.2017 Member President