Order dictated by:
Sh.Anoop Sharma,Presiding Member.
- Sarabjit Kaur, complainant has brought the instant complaint under section 12 & 13 of the Consumer Protection Act on the allegations that Sahib Singh, husband of complainant No.1, father of complainants No.2 to 5 and son of complainant No. 6 was insured under Bhagat Puran Singh Sehat Bima Yojna scheme with the opposite party vide policy No. 2004362914000068. He was issued Smart Card No. 03050000162038345. On 16.2.2016 Sahib Singh met with an accident and he was taken to Guru Nanak Dev Super Speciality Hospital, Goindwal Sahib Road, Tarn Taran, where he remained admitted and died on 20.2.2016. FIR regarding the said accident was registered vide FIR No. 8/2016 at Police Station Verowal. Postmortem of the dead body of the deceased at Civil Hospital , Tarn Taran was conducted vide PMR No. 19/NSEGGAL/CHTT. Thereafter the claim was lodged with the opposite party vide claim No. 2161003249, but the opposite party illegally repudiated the said claim on the ground that the deceased was under the influence of liquor. The opposite party himself without any medical opinion took this plea only to repudiate the claim . All the documents including the post mortem report of the deceased shows that the deceased was not under the influence of liquor. Even in the FIR, the police has not mentioned that he was under influence of any liquor. The act of the opposite party in repudiating the claim of the complainant amounts to deficiency of service. The complainant has sought the following reliefs vide instant complaint:-
- The opposite party be directed to release the claim of Rs. 5,00,000/- to the complainant alongwith interest @ 12% p.a.
- Opposite party be also directed to pay compensation to the tune of Rs. 50,000/- on account of mental pain, agony and harassment suffered by him.
- Cost of litigation to the tune of Rs. 5000/- be also paid to the complainant.
Hence, this complaint.
2. Upon notice, opposite party appeared and filed written version taking certain preliminary objections therein inter alia that the claim of the complainant has already been repudiated vide letter dated 3.5.2016 stating that the deceased Sahib Singh was under the influence of liquor and as per policy, the company shall not be liable to pay any claim if the deceased had consumed liquor under the scheme of Bhagat Puran Singh Sehat Bima Yojna . However, in the said repudiation the complainant was also given period of two weeks to send any comments with respect to the said repudiation, but no reply was given by the complainant which clearly shows that the reasons stated in the repudiation letter were duly accepted by the complainant ; that the complainant has wrongly alleged that the opposite party has illegally repudiated the claim on false and flimsy ground that the deceased was under the influence of liquor , whereas there is no medical record regarding the same. However, this plea is totally wrong because there are clear documents in this regard i.e. patient record issued by Guru Nanak Dev Super Speciality Hospital from where the deceased was treated and in the said record, it has been clearly stated that “patient was drunk and riding bike” and further stated that the patient is chronic alcoholic . As such the complainant is not entitled to any compensation . On merits facts narrated in the complaint have been specifically denied and a prayer for dismissal of complaint was made .
3. In her bid to prove the case, complainant tendered into evidence her duly sworn affidavit Ex.CW1/A, copy of Smart Card issued against Bhagat Puran Singh Bima Yojna Ex.C-1, copy of FIR Ex.C-2, copy of death summary Ex.C-3, copy of postmortem report Ex.C-4, copy of death certificate of Sahib Singh Ex.C-5, copy of policy Ex.C-6, copy of repudiation letter Ex.C-7 and closed the evidence.
4. To rebut the aforesaid evidence Sh.P.N.Khanna,Adv.counsel for the opposite parties No.1 to 3 has tendered into evidence affidavit of Sh. Amit Chawla authorized signatory Ex.OP1-3/1, copy of patient record issued by Guru Nanak Dev Super Speciality Hospital Tarn Taran Ex.OP1-3/2, repudiation letter dated 3.5.2016 Ex.OP1-3/3, certified copy of Insu. Policy alongwith terms and conditions Ex.OP1-3/4 and closed the evidence on behalf of opposite parties No.1 to 3.
5. We have heard the ld. Counsel for the parties and have carefully gone through the record on the file as well as written synopsis of arguments submitted on behalf of complainant as well as opposite parties No.1 to 3.
6. Ld.counsel for the complainant has vehemently contended that Sahib Singh, husband of complainant No.1 , father of complainants No.2 to 5 and son of complainant No.6 was insured under the scheme of Bhagat Puran Singh Sehat Bima Yojna vide policy No. 2004362914000068 , copy of policy accounts for Ex. C-6 on record and smart card No. 0305000016203845 was issued to him, copy of Smart card accounts for Ex.C-1 on record. On 16.2.2016 Sahib Singh met with accident and he was taken to Guru Nanak Dev Super Speciality Hospital Goindwal Sahib Road, Tarn Taran. In this regard FIR No. 8/2016 was registered at P.S. Verowal, copy of the same is Ex.C-2 on record. Postmortem on the dead body was conducted at Civil Hospital, Tarn Taran vide PMR No. 19/NSEGGAL/CHTT. Copy of the Postmortem is Ex.C-4 on record. Thereafter the claim was lodged with the opposite party vide claim No. 2161003249 but the opposite party has wrongly and illegally repudiated the claim on false grounds that the deceased was under the influence of liquor, whereas there is no medical record regarding the same. All the documents including FIR as well as postmortem report of the deceased shows that the deceased was not under influence of any liquor.
7. But, on the other hand, ld.counsel for opposite parties No.1 to 3 has vehemently contended that the claim of the complainant has been repudiated by the opposite parties vide letter dated 3.5.2016 clearly stating that deceased Sahib Singh was under the influence of liquor while driving the vehicle . In this regard opposite parties have produced copy of patient record issued by Guru Nanak Dev Super Speciality Hospital, Tarn Taran Ex.OP1-3/2 in which it has been clearly stated that the “patient came in hospital in unconscious condition. Patient was drunk and riding bike and hit with truck and had a severe head injury. Patient is chronic alcoholic”. In this certificate, it has also been clearly mentioned that the patient was under influence of liquor. But the complainants have failed to produce these documents which are related to deceased Sahib Singh and same have been issued by the treating doctor to Sahib Singh, deceased . The complainant has also failed to prove that the abovesaid documents are not related to deceased Sahib Singh. It has further been contended that the claim of the complainant has been repudiated as per exclusion clause No. 6(b) according to which it has been clearly agreed that if the person was under the influence of liquor, the insurance company is not liable to pay any personal accident benefit under the policy in question. As such the claim of the complainant has been rightly repudiated.
8. However, from the appreciation of the facts and circumstances of the case, it becomes evident that the case of the complainants has been repudiated on the basis of medical record as well as per terms and conditions of the policy. Moreover these documents were not rebutted by the complainants. Now the question arises as to whether due to violation of the terms and conditions of policy, the complainant was entitled for grant of Insurance claim or not ? Answer to this query finds recorded in M/s. Suraj Mal Ram Niwas Oil Mills (P) Ltd-Appellant Vs. United India Insurance Co.Ltd. & another –Respondents 2010(4) RCR (Civil), wherein it has been laid down that in a contract of insurance , rights and obligations are strictly governed by the terms of the policy and no exception of relaxation can be given on the ground of equity. It has further been held in this judgement that in construing the terms of a contract of insurance, the words used therein must be given paramount importance, and it is not open for the court to add,delete or substitute any words. In this judgement it has been further held by the Hon’ble Supreme Court that where there is breach of conditions of the insurance contract by the insured, the insurance company is not liable to pay compensation in case of loss. This position of law has been further fortified in the latest judgement of Hon’ble National Commission titled as M/s. V.K. Karyana Store Vs. Oriental Insurance Co. Ltd. 2014(3) CLT page 47 wherein it has been held that it is well settled principle of law that parties are bound by terms and conditions of the insurance policy and none of the parties can seek any relief beyond those terms and conditions.
9. From the aforesaid discussion, it transpires that complainant has not been able to prove his case. As such insurance claim filed by the complainant has rightly been repudiated by the opposite party. There is no deficiency in service on the part of the opposite party.
10. Consequently, instant complaint fails and the same is ordered to be dismissed accordingly. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced in Open Forum
Dated : 16.1.2017
/R/
