Haryana

StateCommission

A/881/2017

CHOLAMANDALAM MS GEN.INSURANCE CO. - Complainant(s)

Versus

SANTOSH DEVI - Opp.Party(s)

PUNIT JAIN

04 Sep 2017

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeal No  :      881 of 2017

Date of Institution:      25.07.2017

Date of Decision :      04.09.2017

 

1.      Cholamandalam MS General Insurance Company Limited through its authorised signatory, Plot No.06, 1^st Floor, Pusa Road, Karol Bagh near Metro Pillar No.81 New Delhi.

Local Address: SCO 2463-2464, Sector 22, Chandigarh.

2.      Cholamandlam MS General Insurance Company Limited Registered and Head Office D Floor, Dare House 2 NSC Road, Chennai through its authorised signatory.

                                      Appellants-Opposite Parties

Versus

 

Smt. Santosh Devi wife of late Tara Chand, Resident of Village Bhairampur Bharangi, Tehsil Bawal, District Rewari.

                                      Respondent-Complainant

 

CORAM:             Hon’ble Mr. Justice Nawab Singh, President.

                             Mr. Balbir Singh, Judicial Member.

                                                                                                         

Argued by:          Shri Punit Jain, Advocate for appellants.

 

                                                   O R D E R

 

BALBIR SINGH, JUDICIAL MEMBER

 

        This appeal has been preferred against the order dated May 26^th, 2017 passed by District Consumer Disputes Redressal Forum, Rewari (for short ‘the District Forum’) in Consumer Complaint No.382 of 2012.

2.                Tara Chand s/o Sh. Shiv Lal-husband of complainant-Santosh Devi (respondent herein), Resident of Village Bhairampur Bharangi, Tehsil Bawal, District Rewari, during his life time was provided Group Hospital Master Insurance Policy bearing No.90007106-000-00 on October 21^st, 2011 by Cholamandalam MS General Insurance Company Limited (for short ‘the Insurance Company’)-Opposite Parties (appellants herein) regarding the period from October 21^st, 2011 to October 21^st, 2014. The sum assured on account of death by accident was mentioned as Rs.4,70,000/- and regarding medi-claim on account of accident is mentioned as Rs.3.00 lacs, in the insurance policy.

3.                On November 07^th, 2011 the insured Tara Chand climbed up a Neem tree and started cutting branch of the tree. Tara Chand could not maintain his balance and he fell down on the ground and sustained multiple grievous injuries on his body. There was bleeding from the mouth and ears of the insured. Soon after, Tara Chand succumbed to the injuries suffered by him on the same day. At the time of death of her husband, the complainant was not having any knowledge regarding insurance policy as the same was kept by the insured (since deceased) in his office. The complainant being an illiterate lady could not inform the police regarding death of her husband and dead body of her husband was consigned to flames without conducting post mortem examination. When the complainant came to know regarding insurance policy, she submitted her insurance claim on February 23^rd, 2012 before the Insurance Company along with death certificate and other necessary documents along with the certificate issued by Village Gram Panchayat and duly attested affidavits of the complainant and few other villagers. The insurance claim of the complainant was repudiated by the insurance company on the ground that no F.I.R. was lodged and Post Mortem examination was also not got conducted after death of Tara Chand. The complainant filed complaint under Section 12 of the Consumer Protection Act, 1986 before the District Forum with a prayer to direct the opposite parties to make payment of the total sum assured with interest and compensation.

4.                The Opposite Parties in their written version have taken plea that the complaint is not maintainable in the present form and that the complainant is not a consumer as defined under the Consumer Protection Act. The opposite parties have taken plea that after death of Tara Chand, neither matter was reported to the police nor post mortem examination of the deceased was conducted. The insurance policy covers the risk of insured only if the insured died an accidental death. In these circumstances, it cannot be presumed that it was a case of accidental death and as it could not be proved that it was an accidental death, the complainant is not entitled to receive any amount as compensation. Moreover, information was given to the insurance company also after more than a period of about 2½ months. The opposite parties have prayed that the complaint filed by the complainant be dismissed.

5.                Both the parties adduced evidence in support of their respective claims before the District Forum.

6.                After hearing arguments, vide impugned order dated May 26^th, 2017, the complaint filed by the complainant was allowed directing the opposite parties No.1 and 2 to pay the accidental death benefit of Rs.4,70,000/- with interest at the rate of 9% per annum from the date of decision of the case and to pay an amount of Rs.10,000/- as compensation.

7.                Aggrieved with the impugned order dated May 26^th, 2017, the opposite parties have filed the instant appeal bearing No.881 of 2017 with a prayer to set aside the impugned order and to dismiss the complaint filed by the complainant.

8.                We have heard learned counsel for the appellants and perused the case file.

9.                From the pleadings and evidence on the file there appears to be no controversy of any type that Tara Chand insured died on November 07^th, 2011. It is also admitted fact that Tara Chand (deceased)-husband of the complainant was provided insurance policy regarding the period from October 21^st, 2011 to October 21^st, 2014. In case of accidental death, the sum assured is mentioned in the insurance policy as Rs.4,70,000/- and in case of accidental injuries, the sum assured is mentioned as Rs.3.00 lacs. The claim of the complainant has been repudiated on the ground that neither the matter was reported to the Police nor Post Mortem examination on the dead body of the deceased Tara Chand was got conducted. In this case, regarding date, month and year of death of Tara Chand, there is no controversy of any type. The complainant is required to prove that Tara Chand climbed up on a Neem tree and while cutting branch of the tree, he lost balance and fell down on the ground and died on account of the injuries sustained by him. The complainant is required to prove that it is a case of accidental death.

10.              In our view, much discussion is not needed. Legally and technically, findings can be safely given that it was an accidental death. The complainant has been able to prove that the complainant fell down from Neem tree, sustained injuries and thereafter succumbed to the injuries.  Version of the complainant in this regard finds support from a duly attested affidavit of Village Sarpanch (Exhibit CW-1/6) and duly attested affidavits of other villagers Exhibits CW-2/A, CW-3/A and CW-4/A. Village Sarpanch as well as few other villagers made statements (Exhibits CW-1/6 to CW-1/9) before the investigator of the insurance company-opposite parties stating that Tara Chand died an accidental death as he had fallen from a Neem tree.

11.              Keeping in mind the peculiar facts and circumstances of the case, affidavits of Village Sarpanch and few other persons mentioned above, findings can be safely given that Tara Chand died by falling from a Neem tree and he succumbed to the injuries suffered by him. The opposite parties could not adduce any evidence to rebut the evidence adduced by the complainant. In these circumstances, we feel the version of the complainant should be believed that it was an accidental death.

12.              In our view, the insurance claim of the complainant should not be repudiated merely because the matter was not reported to the police and as no Post Mortem examination was conducted. In order to prove death or the cause of death in each and every case, Post Mortem examination report is not necessary. In this case, there is no different version of the opposite parties mentioning that there was any other cause of death of Tara Chand. The complainant is an illiterate lady and she has mentioned in her complaint that she was not aware of the insurance policy also. As she was perturbed due to death of her husband, matter was not reported to the police. In our view, the matter might have not been reported to the police because the accident did not take place due to fault of any other person. Tara Chand himself had climbed up a Neem tree; he could not maintain his balance and died after he fell down on the ground and sustained some serious injuries on his body. The complainant might have not thought it proper to inform the police as any other person was not responsible for death of deceased Tara Chand. Keeping in mind all these circumstances, there is no reason to disbelieve the version of the complainant, Village Sarpanch and other villagers as mentioned in their duly attested affidavits. Resultantly, findings are given that it was an accidental death and complainant’s claim is covered under the insurance policy.

13.              So far as the plea taken by the Insurance Company that there was delay in giving intimation to the Insurance Company, the same is not acceptable because the complainant was not aware about the insurance policy taken by her husband Tara Chand.  Even otherwise, the Insurance Regulatory Development Authority (IRDA), which control and regulates the Insurance Companies, issued direction not to reject the genuine claims simply because of delay in registration of FIR and intimation to the Insurance Company. In the instructions of the IRDA it was also mentioned that claims shall be intimated to the insurer with prescribed documents within a specified number of days is necessary for insurers for effecting various post claim activities like investigation, loss assessment provisioning, claim settlement etc.  However, this condition should not prevent settlement of genuine claims, particularly when there is delay in intimation or in submission of documents due to unavoidable circumstances.  The insurer’s decision to reject a claim shall be based on sound logic and valid grounds.  Support to this view can be taken from the case law cited as Bharti Axa General Insurance Company Limited vs. Ms. Monu Yadav and another, 2014(4) PLR 861, decided by Hon’ble Punjab and Haryana High Court, Chandigarh.  As per facts of that case, the delay in lodging claim with the Insurance Company was of 54 days. The findings in that case were also given in favour of the claimants on the basis of the guidelines issued by IRDA.  The Insurance Companies were advised that they must not repudiate such claims on the ground of delay especially when the Police have been promptly informed in this regard.

14.              It is very clear from the circular that the insurance company cannot repudiate the bonafide claims on technical grounds like delay in intimation and submission of some required documents. The decision of insurers’ to reject a claim of the claimant should be based on sound logic and valid grounds. The limitation clause does not work in isolation and is not absolute. One needs to see the merits and good spirit of the clause, without compromising on bad claims. Rejection of claims on purely procedural grounds in a mechanical fashion will result in policy holders losing confidence in the insurance industry, giving rise to excessive litigation. It has been further advised in the above said letter that the insurers must not repudiate such claims unless and until the reasons of delay are specifically ascertained, recorded.     What is the spirit of Insurance Policy should be kept in mind by the officials dealing with the genuine claims of the sufferers and the same should not be rejected on methodological grounds in a mechanical manner. The tendency of Insurance Companies in rejecting genuine claims is the reason of increasing litigation between the insurers and the insured/their legal heirs.  In this case the repudiation of complainant’s claim was contrary to the instructions issued by the IRDA, mentioned above. No other point was raised during the course of arguments. 

15.              As per discussions above in detail, we feel that it is not a fit case to issue notice to the respondent-complainant.  Learned counsel for the appellants-opposite parties have not been able to convince this Commission that there is need of more discussion after notice to the respondent-complainant for decision of this appeal. With these findings, we find no illegality and invalidity in the impugned order dated May 26^th, 2017 passed by the learned District Forum. Resultantly, findings of the learned District Forum stand affirmed and the appeal stands dismissed in limini.

16.              The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the complainant-respondent against proper receipt and identification in accordance with rules, after expiry of period of appeal/revision, if any.

 

Announced: 04.09.2017

(Balbir Singh) Judicial Member

(Nawab Singh) President

 

CL