This C.C. is coming on before us for hearing in the presence of Sri. B. Gangadhar, Advocate for complainant and of Sri G Hareender Reddy, Advocate for opposite party No.1 and of Sri G. Seetarama Rao, Advocate for opposite party No.2; upon perusing the material papers on record; upon hearing arguments, and having stood over for consideration, this Forum passed the following:-
O R D E R
(Per Smt.V.Vijaya Rekha, Member)
1. This complaint is filed under section 12(1) of the Consumer Protection Act, 1986.
The brief facts of the complaint are that the complainant is the son of deceased, Bajjuri Pullamma. During her life time, she joined as a member in Road Safety Club of opposite party No.1 and obtained two certificates of insurance vide Nos. SC3/HD000009117 & SC3/HD000009127 from the opposite parties to cover under group personal accident policy bearing No.500500/42/03/A200124, by collecting Rs.1800/- per each certificate towards premium, which is valid from 29-11-2004 to 28-11-2005 and as per the policy coverage, in case of death of the policy holder, the opposite parties are liable to pay Rs.2,00,000/- under each certificate. On 24-01-2005, the deceased/policyholder was bitten by a snake, while she was sleeping in her house, due to which, she died on 24-04-2005 and lodged a complaint before the police concerned and issued F.I.R. The Doctors of Govt. Hospital, Penuballi conducted postmortem and issued report. As per P.M.E. report the cause of death was due to shock due to septicemia due to cellulites due to snake bite and after investigation, the police filed final report by stating that the deceased was accidentally died on 24-04-2005 due to snake bite and after the death, information was given to the opposite parties by submitting the claim form along with original documents and after making many rounds the opposite parties appointed an investigator and even after investigation, the claim was not settled by the opposite parties and vexed with the attitude of the opposite parties the complainant approached the insurance ombudsman, after hearing both parties, the insurance ombudsman dismissed the complaint on 01-03-2007 without following the scientific manner, as such the complainant knocked the doors of Consumer Forum by seeking redressal and sought an amount of Rs.4,00,000/- towards insured amount together with interest @24% p.a under G.P.A. policies and Rs.1,00,00/- towards damages and costs.
2. Along with the complaint, the complainant filed his affidavit and also filed the following documents, which were marked as Exhibits:
A1:- Membership Certificate, issued by opposite party No.1, in the
name of deceased Pullamma.
A2:- Certificate of Insurance bearing No.SC3/HD000009127
under GPA Policy bearing No.500500/42/03/8200124.
A3:- Certificate of Insurance bearing No.SC3/HD000009117
under GPA Policy bearing No.500500/42/03/8200124.
A4:- Attested copy of FIR dated 24-04-2005.
A5:- Attested copy of inquest
A6:- PME Report
A7:- Order copy of insurance ombudsman
A8:- Attested copy of Final report dated 04-08-2005.
3. On receipt of notice, the opposite parties appeared through their counsels and filed counters by denying the averments made in the complaint.
4. In the counter, the opposite party No.1 submitted that they issued membership certificates in the name of mother of the complainant and the opposite party No.2 issued GPA Master Policy bearing No. 500500/42/03/8200124, commencing from 29-11-2004 to 28-11-2005 and submitted that the opposite party No.1 is only the issuer of membership certificates under the program of Road Safety Club and as such there is no liability to pay the insured amount on the part of them, the opposite party No.2 is the insurance company, who issued the insurance policies, is only having the liability to pay the insured amount. Further submitted that there is no deficiency on the part of them and as such prayed to dismiss the complaint with exemplary costs.
5. In the counter, the opposite party No.2 admitted the issuance of policies by collecting the premium from deceased Bajjuri Pullamma and denied the other allegations regarding the cause of death as mentioned in the complaint and submitted that there was negligence on the part of the deceased in taking treatment, soon after she was bitten by a snake and the death of the deceased occurred only due to other intervening reasons, which were specifically excluded under the policy and as such the claim is rejected by the insurance ombudsman, as the complainant failed to produce any record of initial treatment, which she had taken and the complainant produced only two bills for initial treatment before the insurance ombudsman, but it did not contain any information regarding the treatment of anti-venom administration, as such the claim was rejected by the insurance ombudsman. The opposite party No.2 further submitted that the snakebite was not the sole and direct cause of death and the postmortem report also did not speak about the sole and direct cause of death and there is no liability on the part of them as per the excluded conditions of policies, issued to the deceased and prayed to dismiss the complaint.
6. The opposite party No.2 also filed additional counter by submitting that they came to know that the deceased obtained two other GPA Policies from different companies by suppressing the material facts with malafied intension as such prayed to dismiss the complaint.
7. In addition to the averments as mentioned in the complaint, the complainant filed written arguments and submitted that the complainant did not receive any amounts either from the Oriental Insurance Company or from the New India Insurance Company as contended by the opposite party No.2 and also mentioned that the opposite party No.2 did not file any proof with regard to the receiving of amounts from the above said companies. . In support of cause of death, the complainant filed news, published in Daily News papers and also filed a decision, delivered by Rajasthan State Commission.
8. The opposite party No.2 also filed written arguments almost all the same averments as mentioned in its counters and also filed a decision of the Hon’ble Apex Court.
9. Along with a petition the opposite party No.2 filed the following documents, which were marked as Exhibits:
Ex.B1:- GPA Policy, bearing No.500500/42/03/8200124, issued by
opposite party No.2
Ex.B2:- Membership certificate, issued by opposite party No.1
Ex.B3:- Order of insurance ombudsman
Ex.B4:- Copy of Insurance Policy, issued by Oriental Insurance
Company Ltd.
Ex.B5:- Copy of Insurance Policy, issued by New India Insurance
Company Ltd.
10. In view of the above submissions made by the parties, the point that arose for consideration is whether the complainant is entitled to the relief as prayed for?
11. As seen from the above mentioned averments there is no dispute regarding the issuance of two membership certificate bearing Nos. SC3/HD000009117 & SC3/HD000009127 in favour of the deceased, Pullamma by collecting Rs.3600/- i.e. Rs.1800/- per each certificate and it is also an admitted fact that the opposite party No.2 issued GPA Policies in the name of opposite party No.1 by collecting the premium as mentioned supra, from the deceased through opposite party No.1 and it is the case of the complainant that his mother/policy holder died due to snakebite and claimed the opposite parties for insured amount. The opposite parties neither paid the insured amount nor repudiated the claim under GPA Policies, issued in the name of deceased. On the other hand, the opposite party No.2 resisted the case of the complainant by denying that the death was not solely and directly due to snakebite. The death occurred only due to other intervening reasons, which are specifically excluded under the policies. Having perused the material papers on record, it is clear that the mother of the complainant died due to snakebite, which leads to septicemia-cellulites-shock and it lead to death of the deceased. The opposite party No.2 also taken a plea that there was negligence on the part of the deceased in taking proper treatment for diabetes immediately after snakebite, due to which death was occurred but in support of its contention the opposite party No.2 did not place any medical record. In general, cellulites may be formed not only due to lack of treatment but also develop due to different reasons, such as age, immunity and maintainability of hygienic conditions of such person. As such the contention raised by the opposite party No.2 is not sustainable. After having perused the material papers on record the cause of death is clearly mentioned in Exs. A4 – A6 & A8. As per Exs.A4 & A5 the deceased Pullamma bitten by a snake, when she was slept in her house at night hours on 24-01-2005 and initially she has taken local treatment, but there was no improvement and as such she was shifted to Govt. Hospital, Penuballi on 28-01-2005 and after taking treatment, she shifted to her house as she was not doing well and continued the medication at home and on 24-04-2005, she died at 7.00AM. Ex.A6 is the post mortem report, wherein clearly mentioned that the cause of death was due to shock due to septicemia due to cellulites due to snakebite and as per the final report, which is marked as Ex.A8, it is a case of accidental death due to snakebite and Ex.A8 also speaks the same facts regarding the cause of death.
12. As per the contentions of opposite party No.2, the deceased had obtained two GPA Policies from different companies in addition to the policies, issued by them i.e. one policy from Oriental Insurance Company and another policy from New India Insurance Company, valid from 06-11-2004 to 05-11-2005 and 13-01-2005 to 12-01-2006 respectively and suppressed the same for wrongful gain and also contended that the complainant might have claimed the sum insured from those companies and having suppressed the material facts, the complainant claimed against the opposite party No.2 only. As such there is no sole liability on the part of them. But failed to file any terms and conditions to that effect and moreover if the complainant claimed against the opposite party No.2 by suppressing those material facts, the opposite party No.2 has to prove the same and the burden lies on them only and it is the case of the complainant that the opposite parties neither settled nor repudiated his claim and after making many representations for settlement, the complainant approached the insurance ombudsman. Instead of settling the claim, the insurance ombudsman dismissed the complaint, which is against the principles of natural justice and as such the complainant knocked the doors of Consumer Forum for redressal. But as per the opposite party No.2, the insurance ombudsman rightly rejected the claim, therefore the present complaint is not maintainable and as such there is no liability to pay the insured amounts under the policies issued by them. But we are of the opinion that the jurisdiction of insurance ombudsman is advisory in nature and it is binding on the insurance company but not on the complainant. Insurance ombudsman is not a court, whose order is deemed to be a decree, passed by a court of competent jurisdiction. As such rejection of claim by ombudsman is not binding on the complainant and it is against the principles of natural justice.
13. In view of the above discussion, we are of the opinion that the attitude of the opposite party No.2 in settling the claim of the complainant, unfair and amounts to deficiency of service and as such the point is answered accordingly in favour of the complainant.
14. In the result, the C.C is allowed, directing the opposite party No.2 to pay Rs.4,00,000/- to the complainant under GPA Policy bearing No. 500500/42/03/A200124 together with interest @9% per annum from the date of complaint i.e. from 20-08-2007. Further directed to pay Rs.1000/- towards litigation costs. The complaint against opposite party No.1 is dismissed.
Typed to my dictation, Corrected and pronounced by us, in this Forum on this 23rd day of April, 2010.
President Member Member
District Consumers Forum, Khammam
APPENDIX OF EVIDENCE
Witnesses examined for complainant
-None-
Witnesses examined for opposite parties:
-None-
Exhibits marked for Complainant:
A1:- Membership Certificate, issued by opposite party No.1, in the
name of deceased Pullamma.
A2:- Certificate of Insurance bearing No.SC3/HD000009127
under GPA Policy bearing No.500500/42/03/8200124.
A3:- Certificate of Insurance bearing No.SC3/HD000009117
under GPA Policy bearing No.500500/42/03/8200124.
A4:- Attested copy of FIR dated 24-04-2005.
A5:- Attested copy of inquest
A6:- PME Report
A7:- Order copy of insurance ombudsman
A8:- Attested copy of Final report dated 04-08-2005.
Exhibits marked for opposite party No.2:
Ex.B1:- GPA Policy, bearing No.500500/42/03/8200124, issued by
opposite party No.2
Ex.B2:- Membership certificate, issued by opposite party No.1
Ex.B3:- Order of insurance ombudsman
Ex.B4:- Copy of Insurance Policy, issued by Oriental Insurance
Company Ltd.
Ex.B5:- Copy of Insurance Policy, issued by New India Insurance
Company Ltd.
President Member Member
District Consumers Forum Khammam
