Haryana

Ambala

CC/95/2022

Diler Singh - Complainant(s)

Versus

SBI General Insurance Co Ltd - Opp.Party(s)

Sunny Sharma

15 Jan 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

Complaint case no.	:	95 of 2022
Date of Institution	:	17.03.2022
Date of decision	:	23.01.2024

Diler Singh aged 38 years son of Sh. Balwindar Singh husband of late Sukhvinder Kaur Resident of House No.16, Heera Nagar, Ghel Road, Patti Rangran, Ambala City, Haryana.

          ……. Complainant

                                                Versus

1. SBI General Insurance Company Ltd., Corporate and Registered Office at: 'Natraj 101, 201, 301, Junction of Western Express Highway and Andheri-Kurla Road, Andheri(East), Mumbai- 400069, India through its General Manager.
2. State Bank of India, Ghel Road branch, Near S A Jain College, Ambala City through its Branch Manager.

                                                                                   ….…. Opposite Parties.

Before:        Smt. Neena Sandhu, President.

                     Smt. Ruby Sharma, Member,

          Shri Vinod Kumar Sharma, Member.           

 

Present:       Shri Sunny Sharma, Advocate, counsel for the complainant.

                     Shri R.K.Vig, Advocate, counsel for the OP No.1

                   Shri Satinder Garg, Advocate, counsel for the OP No.2.

Order:        Smt. Neena Sandhu, President.

                   Complainant has filed this complaint under Section 35 of the Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them to pay the insurance claim amount of Rs.10,00,000/-, to the complainant being the husband and nominee of Late Sukhvinder Kaur on account of her death on 8-12-2020 and further to pay Rs.50,000/- as compensation for mental agony and harassment or grant any other relief, which this Hon’ble Commission may deems fit.

2.             Brief facts of the case are that the complainant was married to Late Mrs. Sukhvinder Kaur on 5-02-2012 and since then they were residing at the above mentioned house No.16, Heera Nagar, Ghel Road, Patti Rangran, Ambala City. The OPs are Public Limited Companies, who are carrying Banking as well as Insurance business. The wife of the complainant Late Mrs. Sukhvinder Kaur was having a Saving Account bearing No. 65260291124 at the branch of OP No.2. Late Smt. Sukhvinder Kaur was persuaded by the officials of OP No.2 to purchase a SBI General's Personal Accident Insurance Policy bearing Master Policy No. 17888968, Certificate No. 106050059. The above policy was purchased on 11-6-2020 valid from 11-6- 2020 to 10-6-2021. The premium was also paid on the same date. The nominee in the Insurance Policy was the complainant Mr. Diler Singh, who is the husband of Late Mrs. Sukhvinder Kaur. The sum insured in the above policy was Rs.10,00,000/-. Before or at the time of purchasing the above policy and till her death, Late Smt. Sukhvinder Kaur was not at all suffering from any pre- existing disability, condition, or any complication arising from it. On 8-12-2020 Late Smt. Sukhvinder Kaur at about 8 O' clock in the morning while being at her house and while doing kitchen work, accidently fell on the ground due to slipping of foot, due to which she suffered an internal injury in her head and became unconscious. The complainant immediately took his wife to the Civil Hospital, Ambala and treatment was given to her at the emergency ward of the Hospital but unfortunately Sukhvinder Kaur succumbed to injury. An MRI of the Sukhvinder Kaur was also conducted in order to reveal actual cause of death. After the death of Late Smt. Sukhvinder Kaur, the complainant after performing the last rites as well as rituals of her deceased wife approached the OPs and submitted the insurance claim being a nominee under the above policy along with all the necessary proofs and documents regarding the entitlement and release of accident insurance claim of Rs. 10,00,000/- to him, as it is quite clear from the medical records, discharge cards, MRI that the death of Late Smt. Sukhvinder Kaur was the result of head injury due to accidental fall on the ground. The complainant made several oral as well as written requests to the OPs, to release the claim amount but they lingered on the matter and  ultimately rejected the claim of the complainant on the flimsy, illegal and arbitrary ground vide Whatsapp message dated 25.09.2021. Hence, the present complaint.
3.           Upon notice, OP No.1 appeared and filed written version wherein it raised preliminary objections to the effect that the complaint is not maintainable as insured died due to illness and subject policy was personal accident insurance policy only etc. On merits, while admitting factual matrix of the case with regard to the fact of issuance of the insurance policy in question, in favour of the insured and that the death of insured occurred during subsistence of the policy in question,  it has been stated that  the complainant informed OP No. 1 regarding the death of Smt. Sukhvinder Kaur, which took place on 08.12.2020. OP No. 1 consequent upon the said information, investigated the matter from approved IRDA Investigator, who in his report dated 08.03.2021 mentioned that in the absence of documentary proof (PMR & Police report) on cause of death, thus unable to ascertain the genuineness of the claim. Complainant is clarifying that his wife was pregnant & he was in great sorrow therefore he denied for PMR. The husband of the insured also signed claim form in which he specifically mentioned that her wife had fallen in the bathroom at home. Insured family has not got done her PMR as they refused for PMR & they also mentioned it in hospital record & in their written statement also they did not inform to the Police. There is lack of any conclusive documentary evidence, which could establish the exact cause of death of the insured. Medical records received from Civil Hospital, Ambala confirms admission of insured for transient ischemic attack with seizures & also states that insured was 2 months pregnant and the said documents does not establish any evidence of grievous injury sustained before death or any grievous accidental trauma over body, which could have led to death of insured. However, there is lack of any conclusive documentary evidence like police reports, DDR, FIR, PMR or diagnostic reports, which could prove the claimed cause of death. Doctor in his report submitted that "This 25 Years old lady is admitted to the hospital with deviation of angle of mouth transitley today morning following fall on the ground. History of clinching of tooth, frothing from mouth and jerky in left" which is clearly a sign of seizures. Thus, the claim was not maintainable as per clause of the "terms and conditions of the subject policy i.e. Personal Accident Insurance Policy which stated that coverage is limited to death on account of accident only. Death of insured due to accidental injuries has been not established from available documents and as such, death due to medical illness/natural cause is not covered under the Policy; thus the claim is repudiated vide letter dated 31.03.2021 as death due to natural causes/medical illness was beyond the ambit of terms and conditions of the subject policy. Rest of the averments of the complainant were denied by OP No.1 and prayed for dismissal of the present complaint with heavy costs.
4.           Upon notice, OP No.2 appeared and filed written version wherein it raised preliminary objections to the effect that this complaint is not maintainable; the matter involved in the complaint is a complicated one which requires recording of voluminous evidence and decision on intricate questions of law and facts, which are beyond the purview of this Commission; this Commission has no jurisdiction to try or entertain the present complaint; the present complaint is baseless and a flagrant abuse of the process of law to harass and extract money from the OPs; the complainant is not a consumer etc. On merits, it has been stated that the claim of insurance did not lie against OP No.2 as it has no concern with the same and is concerned only with banking facilities. SBI is a state entity established under a central enactment and not a public limited company. No official of the branch is authorized to sell or even to suggest regarding any such life insurance policy to any customer and the averments regarding such persuasion are blatantly false. Rest of the averments of the complainant were denied by OP No.2 and prayed for dismissal of the present complaint with exemplary costs
5.           Learned counsel for the complainant tendered affidavit of complainant as Annexure CA alongwith documents as Annexure C-1 to C-19 and closed the evidence on behalf of complainant.  On the other hand, learned counsel for the OP No.1 tendered affidavit of Jitendra Dhabhai, Authorized Signatory of OP No.1-Company-SBI General Insurance Company Limited, 46 Pusa Road, 3^rd Floor, Karol Bagh, Opposite Metro Pillar No.129, New Delhi and affidavit of Mamta Rana, Auto Investigators, # 32, Onyxe Paraiso Apartments, Patiala Road, Zirakpur as Annexure OP-1/A and OP1/B respectively alongwith documents Annexure OP-1/1 to OP-1/21 and closed the evidence on behalf of OP No.1. Learned counsel for the OP No.2 tendered affidavit of Ravinder Kumar Khanduja, Special Associate of OP No.2-State Bank of India, S.A.Jain College Branch, Ambala City as Annexure OP-2/A and closed the evidence on behalf of OP No.2.
6.           We have heard the learned counsel for the complainant and the learned counsel for the OPs No.1 and 2 and have also carefully gone through the case file.
7.           Learned counsel for the complainant submitted that the deceased life assured (hereinafter referred as ‘DLA’) had taken the Personal Accident Insurance, which provides compensation in the event of injuries, disability or death caused solely by violent, accidental, external and visible events. It is different from life insurance and medical and health insurance. DLA had died during the subsistence of the policy in question, as such, OPs No.1 and 2 were under legal obligation to pay the claim amount under the policy in question i.e. Rs.10 lacs but the claim was not paid by them and was rejected on flimsy grounds, which act amounts to deficiency in providing service, negligence and adoption of unfair trade practice on their part. 
8.           On the contrary, the learned counsel for the OP No.1 submitted that since the complainant failed to provide any documentary/medical evidence to prove that the death of the insured occurred because of any accident or it was accidental in nature, and on the other hand, she first suffered seizure which resulted in her death as such, the claim filed by the complainant was rightly rejected, strictly as per conditions of the insurance policy, for which it cannot be held liable for deficiency in providing service or guilty of adoption of unfair trade practice.
9.           Learned counsel for OP no.2 submitted that OP No.2 has no concern with the dispute in question as OP No.2 is providing the banking facilities only.  
10.           The moot question which arises in this case is as to whether, OP No.1 was justified in not paying the claim amount to the complainant or not? A bare perusal of written version filed by OP No.1 reveals that the main stand taken by it in its defence to justify the stand of not paying the claim amount to the complainant is that since the complainant has failed to prove that the death of his insured wife was accidental in nature, whereas, from the medical record it appears that it was a natural death because the insured was suffered from seizure as a result of which she fell down and died after suffering injuries, as such, the claim was rightly rejected. 
11.           In our considered opinion, for coming to any conclusion of this case, we have to refer the relevant condition  of the policy, Annexure C-3, which reads as under:-

“…..Coverage is limited to death on account of accident only….”

 

12.           Bare perusal of abovesaid condition clearly says that claim was payable only in case the death of insured took place due to accident only. However, in the present case, in the medical record i.e OPD Card dated 08.12.2020, Annexure C-5; Initial Assessment Sheet, Annexure C-6 and also discharge card, Annexure C-11  issued by the District Civil Hospital, Ambala, it has been clearly mentioned that “C/o Deviation of angle of mouth to left following fall on ground. History of clinching of tooth, frothing from mouth and jerky in left. In the document Annexure C-4, against the column Procedure it has been written as “Seizure”. From the said documents it can easily be culled out that the DLA first got seizure attack resulting into fall on the ground and ultimately she died. 
13.           A similar question, as to whether, if a patient/insured dies due to fall  after suffering heart attack or any other disease, will amount to his/her death as accident or accidental in nature under the insurance policy, fell for determination before the Hon’ble Supreme Court of India in  Civil Appeal No. 3413 of 2019 (Arising out of SLP (C) No. 32335 of 2016) Smt. Alka Shukla Versus Life Insurance Corporation of India, decided on April 24, 2019, wherein, it was held that in order to sustain a claim under the accident/accidental benefit cover, it must be established that the assured has sustained a bodily injury which resulted solely and directly from the accident and that there must, in other words exist a proximate causal relationship between the accident and the bodily injury. The Supreme Court gave findings in favour of the insurance company by holding as under:-

 

• 10 .  The plain reading of the policy is to be accepted as our guide. Under the policy, in order for the complainant to prove her claim, she must show direct and positive  proof that the accident of the assured falling from his motorcycle caused bodily injury by external/outward, violent and visible means. The complainant will have to prove that the accident and the injuries sustained as a result were a direct or proximate cause of her husband’s death.

 

• …xxxxxxxxxxxxxxxxxxxxx....

 

12 In the present case, there is no evidence to show that any bodily injuries were suffered due to the fall from the motorcycle or that they led to the assured suffering a heart attack. There is no evidence to show that the accident took place as a result of any outward, violent and visible means. The assured died as a result of a heart attack which was not attributable to the accident.

 

14.           Recently, the Hon’ble Supreme Court in 2023 LiveLaw (SC) 90 ( NATIONAL INSURANCE COMPANY LTD. versus THE CHIEF ELECTORAL OFFICER & ORS.)  held that even death occurred by sunstroke cannot be said to accident and therefore claim is not payable by the insurance company. Relevant part of the said order is reproduced hereunder:-

“……..Insurance Law - Accidental death - Death due to sun stroke during election duty will not come under the scope of the clause "death only resulting solely and directly from accident caused by external violent and any other visible means"- proximate causal relationship between the accident and the body injury is a necessity- plain reading of the clauses is the guiding principle to interpret insurance contracts…”

 

15.           Since, in the present case also, admittedly the death of the insured occurred, was not a direct cause of accident but she first got seizure attack followed by fall and the complainant has failed to prove that the said seizure was having any direct proximate cause of any accident, therefore, in our considered opinion, OP No.1 could not be held deficient or guilty of unfair trade practice, by rejecting the claim of the complainant. 
16.           In view of peculiar facts and circumstances of this case, it is held that because the complainant has failed to prove his case, therefore, no relief can be given to him. Resultantly, this complaint stands dismissed with no order as to cost. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

 

Announced:- 23.01.2024

 

(Vinod Kumar Sharma)	(Ruby Sharma)	(Neena Sandhu)
Member	Member	President