DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016.
Case No. 1155/07
The Director,
BSC – C&C Joint Venture,
Plot No. 70, Sector-32,
Gurgaon – 122 001 (Haryana) -Complainant
Vs
The Manager
SBI Life Insurance Co. Ltd.
3rd Floor, Bank of Baroda Building
16 Sansad Marg, New Delhi - 110001 -Opposite Party
Date of Institution: 31.10.2007 Date of Order: 27.07.2016
Coram:
N.K. Goel, President
Naina Bakshi, Member
S.S. Fonia, Member
O R D E R
Brief facts of the case are that the complainant negotiated for a comprehensive all risks life insurance cover for its 684 permanent employees working in foreign country, Afghanistan with the OP and that the complainant never negotiated for any policy containing any exclusion clause or any other clause limiting the risk of insurance of the employees of the complainant working in foreign country; that the complainant obtained OP’s Master Policy No. 82001510407 known as Super Suraksha Policy covering all types of risks like death due to any diseases, accident – like road accident, drowning, electrocution, snake bite, unprovoked murder and death of natural/unnatural causes; that late Sh. Madan Lal, Cook, was one of the life assured under the policy in question and was insured for Rs. 5 Lacs; that he fell sick in Afghanistan on 28.7.2006 and was admitted to Site First – Aid –Station at around 8.00 p.m. on 29.7.2006 and he was in senses and he must have narrated the history of his illness to the attending doctor but the same is not available; that he was shifted to the Hospital in Kabul (Afghanistan) on 31.7.2006 and finally to AIIMS, New Delhi on 2.8.2006 where he died on 3.8.2006 due to Cardiac Arrest. It is stated that there is no definite evidence with any hospital in Afghanistan/Kabul/AIIMS, New Delhi where Sh. Madan Lal was treated for consuming illicit liquor and only in the AIIMS report, it is mentioned “Suspected case of Poisoning, ? Methanol Poisoning”. It is stated that in the Postmortem report, the department of Forensic Medicine and Toxicology, AIIMS, New Delhi bearing No. 1092/06 dated 24.8.2006 it is mentioned in Column No. J : “Opinion : The cause of death to the best of my knowledge and belief in this case is kept pending till the receival of viscera report”; that brief history as per the Inquest papers including FIR/DD etc. of AIIMS, New Delhi states, “ALLEGED L/O CONSUMPTION OF SOME ILLICIT LIQUOR IN AFGHANISTAN ACCORDINGLY ADMITTED TO AIIMS IN UNCONSCIOUS STATE ON 2/8/2006 AT 1.49 MORN. WHERE HE DIED ON 3/8/06 AT 7.45”; that the AIIMS, New Delhi in Postmortem report dated 24.9.2006 (sic) further states that Sh. Madan Lal probably had died due to methanol poisoning but there is no final report. It is stated that death claim papers of late Sh. Madan Lal were submitted with the OP on 8.9.2006 for payment of claim amount but the OP rejected the claim by rejection letter No. OPS/06/CL/D/33124 dated 15.9.2006 on the following grounds:
- “As per the master policy conditions, no claim for death benefit will be admissible if the death of the member is due to any Breach of Law
- As per the reports available with us, the death of Late Madan Lal occurred due to consumption of illicit liquor in Afghanistan
As the consumption of liquor in the State of Afghanistan is against law, the member had consumed illicit liquor, which shall be considered as Breach of law. Hence, we express our inability to settle the aforesaid claim.”
It is stated that the claim has been rejected by the OP in view of condition in schedule No. IV, General conditions, clause No. 4- Exclusions which states:
“No claim for Death Benefit will be admissible if the death of the member working in Afghanistan and who have died in Afghanistan due to the following reasons:
- was caused by injuries resulting from war and civil commotion; war, invasion, hostilities (whether war be declared or not), civil war, rebellion, revolution or taking part in a riot or civil commotion,
- any breach of law,
- Criminal acts: taking part in a criminal act,
- Death due to terrorism activities (Endogenous & Exogenous).”
It is stated that the claim of Sh. Madan Lal was rejected on the basis of presumption that he had consumed illicit liquor in Afghanistan which cannot amount to direct evidence, hence, this exclusion clause was not applicable in his case. OP was, accordingly, served with a legal notice dated 8.12.2006 which was replied by the OP vide letter dated 2.3.2007 wherein the OP changed its stand and instead of sticking to their old exclusion clause No. 4 under which the claim was rejected, they rejected the claim under clause 3 of the policy in question which reads “The Company shall cover only death claims of those members of the policyholder working in Afghanistan on projects which are due to natural causes”. The company reiterates and submits that the member Late Sh. Madan Lal died due to unknown poisoning and the same cannot be construed as a natural death. Hence, by pleading that OP itself is not sure as to under which clause the OP should reject the death claim of Sh. Madan Lal, the complainant has filed the present complaint for issuing following directions to the OP:
“It is, therefore, most respectfully prayed that this Hon’ble Forum may most graciously be pleased to direct the respondent, SBI Insurance Company Ltd, 3rd Floor, Bank of Baroda Building, 16, Sansad Marg, New Delhi-110001 to make the payment of death claim of late Sh. Madan Lal to the tune of Rs. 5,00,000/- (Rupees Five Lakhs) with interest @ 18% per annum from the date of filing of the claim with the above named respondent, i.e.08.09.2006 to date of the realisation of the claim together with the litigation charges as this Hon’ble Forum deems fit and proper and Rs. 50,000/- for pain and agony suffered by the dependents of late Sh. Madan Lal on account of rejection of his death claim by the respondent.”
In the written statement, OP has admitted that Sh. Madan Lal, the Life Assured was covered for Rs. 5 Lakhs and he was working as a Cook in Afghanistan. It is, however, stated that he was taken to Site First – Aid – Station, Lashkargah site, Afghanistan on 28.7.2006 due to acute alcoholic intoxication and as per the report of Dr. Chandra M Arora, Safety – Cum- Medical officer, Lashkargah Site, Afghanistan Late Madan Lal had consumed country made liquor and his physical examination revealed that “Skin was hot and flushed, pale and sweating, deep reflexes were exaggerated with bilateral extensor planters, pupils dilated, breathing was not strenuous, odour of alcohol and distended lower abdomen due to urine in the urinary bladder” and that he was advised to be shifted to Kabul or India and that thereafter he was reported to have been shifted to a hospital in Kabul on 31.7.2006 and to AIIMS, New Delhi on 2.8.2006 where he died on 3.8.2006. According to the OP, the death summary report given by AIIMS, New Delhi clearly mentions that Late Madan Lal had consumed illicit liquor in Afghanistan and was admitted in Kabul in a critical condition. Life Assured was shifted to AIIMS in Comatose state and his MRI brain showed T2 hyperintenstics in both basal ganglia with methanol poisoning. It is stated that consumption of liquor in the State of Afghanistan is against law and as late Madan Lal had consumed liquor, he had committed a breach of Law and that he had died due to methanol poisoning, which was a result of breach of law and, hence, the complainant’s claim stood excluded by the terms of the policy which is mentioned in Schedule IV, point 4, Exclusions; that as per the terms and conditions of the policy (general condition no. 3 of Schedule IV) of Master Policy, the Company shall cover only death claims of those members of the policy holder working in Afghanistan on projects which are due to natural causes but late Madan Lal died due to poisoning which cannot be construed as a natural death. The repudiation of claim of the complainant has been justified. Hence, it is prayed that the complaint be dismissed.
In the replication, it is admitted that Dr. Chandra M Arora, M.B.B.S., Dc. C.H. (Pediatrics) attended the ailing Sh. Madan Lal but it is stated that since he was only a Child Specialist and was posted in the site hospital to attend and provide First Aid to the employees of the complainant company only, he was not medically competent to attend to the type of illness of Sh. Madan Lal and hence his report with regard to type of illness stated to be suffered by the deceased with regard to consumption of alcohol cannot be acted upon.
We must say here at once that in the complaint the case of the complainant is that the name of the attending doctor in Site First – Aid – Station Hospital on 29.7.2006 was not available and that the history of illness given by the attending doctor was not appearing in the hospital record but, however, in the replication the complainant has admitted about the report of Dr. Chandra M Arora as disclosed in the written statement by the OP.
The complainant has filed affidavit of Sh. Sanjay Gupta, Director who has relied on documents Ex. CW1/1 to Ex. CW1/7. It appears that no evidence has been filed on behalf of the OP.
Written arguments have been filed on behalf of both the parties.
We have heard the arguments of the counsel for the parties and have carefully gone through the record.
The only question which arises for our consideration is, whether it has been proved on the record that late Sh. Madan Lal while working as a cook in Afghanistan had breached the law of that country and, if so, the breach of law was the cause of his death?
In the complaint, the complainant has shown ignorance about the preparation of report by the doctor at Site First – Aid – Station Hospital on 29.7.2006 when the deceased was examined. It is only when in the written statement the OP disclosed that the report at Site First – Aid – Station Hospital, Afghanistan was prepared by one Dr. Chandra M Arora, Safety-cum-Medical Officer and in that report the doctor had written that late Sh. Madan Lal had consumed country made liquor that in the replication the complainant has stated that Dr. Chandra M Arora was only a Child Specialist and he was posted in the Site First – Aid- Station Hospital to attend and provide the first aid and hence not medically competent to attend to the type of illness of Sh. Madan Lal. The type of illness with which late Sh. Madan Lal had suffered in Afghanistan has not been disclosed by the complainant. Therefore, it has to be accepted that late Sh. Madan Lal had been got admitted in Site First – Aid – Station Hospital, Afghanistan with the history of consumption of acute alcoholic contents and he was under an acute alcoholic intoxication. Any how, he was ultimately brought to AIIMS, New Delhi and admitted there.
He died on 3.8.2006. Post Mortem examination on his death was conducted. The copy of the Post Mortem report is Ex. CW1/3. The cause of his death was kept pending till the receipt of viscera report. It appears that the viscera report has not been received so far. The complainant has filed a copy of the reply obtained under the RTI Act and bearing ref. No. FMT/RTI/I/2016 dated 12.2.16 received from the Department of Forensic Medicine, AIIMS, New Delhi wherein it has been reported that the AIIMS has not received the viscera report from the police. Thus, the AIIMS, New Delhi has not given any final report from August 2006 till date for any reason.
It is an admitted fact that consumption of liquor in Afghanistan was not allowed or was banned or prohibited at the relevant time. That must have been an offence under the law of Afghanistan. Late Sh. Madan Lal had consumed illicit liquor on 28.7.2006. Ultimately, he died in AIIMS, New Delhi on 3.8.2006 due to cardiac arrest. Thus, he died after six days of consumption of liquor. His immediate cause of death was cardiac arrest. Therefore, we are of the considered opinion that even though late Sh. Madan Lal had consumed illicit liquor in breach of the Afghanistan’s Law, however, his immediate cause of death was not consumption of liquor. On the other hand, his immediate cause of death was cardiac arrest. Therefore, we hold that the repudiation of the claim in question by the OP by taking recourse to clause 4 or clause 3 of the General conditions in Schedule IV of the policy in question was not at all justified.
It is an admitted fact that late Sh. Madan Lal was insured for an amount of Rs. 5 Lacs. Therefore, his legal representatives became entitled to recover Rs. 5 Lacs from the OP on his death. Therefore, we hold that the OP committed deficiency in service while repudiating the claim in question of the complainant.
However, at the same time we hold that it is not the complainant who is entitled to receive the said amount on behalf of the LRs of late Sh. Madan Lal. It is not the case of the complainant that the complainant has paid the said amount of Rs. 5 Lacs to the LRs of late Sh. Madan Lal. Accordingly, we direct the OP to pay the amount of Rs. 5 Lacs to the LRs of late Sh. Madan Lal.
The complainant company shall provide the names of the LRs of late Sh. Madan Lal to the OP and the OP shall first verify the genuineness of the identify of the LRs and in case the OP is not able to establish the identity of LRs of late Sh. Madan Lal, the OP shall be at liberty to file an application in this regard before this forum and this Forum shall decide about the LRs of late Sh. Madan Lal. Award of interest, if any, on the amount of Rs. 5 Lacs is kept pending till the decision of the names of the LRs of late Sh. Madan Lal by the OP or by this forum.
Complaint stands disposed off accordingly.
Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.
(S.S. FONIA) (NAINA BAKSHI) (N. K. GOEL) MEMBER MEMBER PRESIDENT
Announced on 27.07.2016
Case No. 1155/07
27.07.2016
Present – None.
Vide our separate order of even date pronounced, the complaint is allowed. The OP is directed to pay the amount of Rs. 5 Lacs to the LRs of late Sh. Madan Lal. The complainant company shall provide the names of the LRs of late Sh. Madan Lal to the OP and the OP shall first verify the genuineness of the identify of the LRs and in case the OP is not able to establish the identity of late Sh. Madan Lal, the OP shall be at liberty to file an application in this regard before this forum and this Forum shall decide about the LRs of late Sh. Madan Lal. Award of interest, if any, on the amount of Rs. 5 Lacs is kept pending till the decision of the names of the LRs of late Sh. Madan Lal by the OP or by this forum. Complaint stands disposed off accordingly. Let the file be consigned to record room.
(S.S. FONIA) (NAINA BAKSHI) (N. K. GOEL) MEMBER MEMBER PRESIDENT
