Heard learned counsel for both sides on V.C.
2. Here is an appeal filed u/s 15 of the erstwhile Consumer Protection Act, 1986 (hereinafter called the ‘Act’). Parties to this appeal shall be referred to with reference to their respective status before the District Forum.
3. The factual matrix leading to the case of the complainant is that her husband Jitendriya Senapati had purchased “Janasurakhya policy with accident benefit” vide policy No.586249840 commencing on 28.11.2005 for sum assured of Rs.50,000/-. Complainant alleged inter alia while life assured was sitting on the chair, he fell down on the ground and he became unconscious. Thereafter, he was shifted to District Headquarters Hospital, Bhadrak, then to Aditya CARE Hospital, Bhubaneswar and Kalinga Hospital Ltd., Bhubaneswar but succumbed to injury on 17.4.2013. where after the complainant made claim. OP after scrutiny of documents debited a sum of Rs. 63,141/- to the account of the complainant through RTGS. Complainant alleged that as the accident benefit required under the policy has not been given to the complainant, and he was forced to write letters on 17.9.2013 and 20.12.2013 for disbursement of such amount but the respondent rejected the request for which the complaint was filed.
4. OPS filed written version admitting that the husband of the complainant is a beneficiary under the policy and after the complainant filed the documents, they have considered the same and made payment of Rs.63,141/- to the account of the complainant who is admittedly the nominee of the deceased. It is further stated in the written version that the accidental benefit of the deceased is not payable as the deceased has not died due to accident. Therefore, there is no deficiency of service on their part.
6. Learned District Forum after hearing both parties passed the following impugned order:-
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In the result, complaint is allowed on contest against the OPs. The OPs are directed to disburse the accidental benefit of Rs.50,000/- along with interest @9% per annum till its realization from the date of disbursement of death claim of the life assured i.e. 06.09.2013 within a period of 30 days of receipt of this order to the complainant. We further direct the OPs to pay litigation cost of Rs.1,000/- to the complainant within the aforesaid stipulated period.”
7. Learned counsel for the appellants submitted that the learned District Forum has committed error in law by not considering the written version filed by the OPs with proper perspective. According to him the life assured although insured for the accidental benefit, but the death of the assured did not come within the purview of ‘accident’. He submitted that learned District Forum has not followed the policy bond where it is specifically addressed that such type of cases are not covered under “accidental injury”. Therefore, he submitted that the learned District Forum ought to have followed the policy condition to peruse the definition of ‘accident’ so that the complainant is only entitled the amount which is already paid through RTGS mode. He further submitted that the impugned order being illegal and improper to be set aside by allowing the appeal.
8. Learned counsel for the respondent submitted that the life assured while sitting on the chair suddenly fell down on the ground and as such got head injury and became unconscious. He was shifted to Hospital at various places and finally succumbed to injury. Therefore, the death was fully covered under the “accident” because of head injury. He submitted that the learned District Forum appropriately passed the impugned order. He also drew attention to the policy bond where the policy bond does not deny such type of case. So he supports the impugned order.
9. Considered the submission of learned counsel for both sides and perused the DFR including the impugned order.
10. It is well settled in law that the complainant is to prove the deficiency of service on the part of the OPs.
11. It is admitted fact that the policy holder has got the policy having purchased the same from the OPs under “Janarakshya Policy with accident benefit”. It is also admitted fact that the policy holder has fallen from the chair and sustained head injury on his head and he was being treated at different hospitals and finally at Kalinga Hospital, Bhubaneswar, he died. The documents filed by the District Headquarters Hospital, Aditya CARE Hospital and Kalinga Hospital are clearly to show that the death of the insured occurred due to head injury. The death summary of Deputy Medical Officer, Kalinga Hospital Ltd, Bhubaneswar is as follows:-
“xxx xxx xxx
Patient was fell down while sitting on chair followed by vomiting & became unconscious due to head injury. Patient primarily treated at DHQ, Bhadrak & Aditya Care Hospital, Bhubaneswar & referred here. Patient was admitted to Kalinga Hospital on 15.04.13 with GCS-3 Pupils 4mm non reacting, BP was not recordable was kept on ventilator support. Fresh frozen plasma was transfused on 15.04.13. EVD was done. Random doner platelet was transfused on 16.04.13. But patient was deeply comatose with GCS-3. Pupils fixed bilaterally. On ventilator. No doll’s eye phenomenon. On 17.04.13 at 12.00 pm patient had bradycardia f/b cardiac asystole. ECG flat on monitor. In spite of all resuscitative measurers vitals of the patient could not be revived and was declared clinically dead at 12.25 pm on 17.04.13.”
12. The aforesaid report is clear to show that the insured after fall from chair became unconscious due to head injury and finally died on 17.4.2013. It is admitted fact that the OPs have made detail investigations and paid Rs.63,141/- towards the death benefit but refused to pay the accidental benefit. Both the learned counsel drew attention of the Commission to Clause 10(b) of the policy which is as follows:-
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10(b) Death of the Life Assured – To pay an additional sum equal to the sum assured under this policy, if the Life Assured shall sustain any bodily injury resulting solely and directly from the accident, caused by outward violent and visible means and such injury shall within 180 days of its occurrence solely, directly and independently of all other causes result in the death of the Life Assured. However, such additional sum payable in respect of this policy shall not exceed Rs.25,00,000/-.
The Corporation shall not be liable to pay the additional sum referred in (a) or (b) above, if the disability or the death of the Life Assured shall:
- be caused by intentional self injury, attempted suicide, insanity or immorality or whist the Life Assured is under the influence of intoxicating liquor, drug or narcotic or
- take place as a result of accident while the Life Assured is engaged in aviation or aeronautics in any capacity other than that of a fare-paying, part paying or non-paying passenger in any aircraft which is authorized by the relevant regulations to carry such passengers and flying between established aeronautics, the Life Assured having at that time no duties on board the aircraft or requiring descent therefrom, or
- be caused by injuries resulting from riots, civil commotion, rebellion, war (whether war be declared or not), invasion, hunting, mountaineering, steeple chasing or racing of any kind or
- result from the Life Assured committing any breach f law; or
- arise from employment of the Life Assured in the armed forces or military service of any country at war (whether war be declared or not).”
13. The aforesaid condition of the policy having been given the in-depth study show on what basis the accident benefit can be awarded and cannot be awarded. Learned Counsel for the appellant drew attention to the first part of this clause and argued that the injury must have been caused by outward violent and visible means and such injury shall within 180 days of its occurrence must lead to death directly. Therefore, the specific clauses as stated above are clear to show that where the accident cannot be computed.
14. In the instant case, since the insured while sitting on the chair fell down on the ground and got head injury and surface undoubtedly a hard surface, the injury is accidental and none of the clauses (i) to (v) of 10(b) attracts such type of incident so as to deny such benefit to the complainant. On the other hand, interpreting this clause this Commission is of the view that none of the clause (i) to (v) of 10(b) attracts the case of the insured to deny the benefit. Therefore, he is covered under clause 10(b) to get the accidental benefit which is additional benefit to the policy in question. Hence, conclusion arrived by the learned District Forum cannot be said as illegal or improper. Hence, this Commission having agreed to the finding of the learned District Forum confirmed the same. As such the appeal sans merit and stands dismissed. No cost.
DFR be sent back forthwith.
Supply free copy of this order to the respective parties. The copy of this order be downloaded from Confonet or Website of this Commission to treat same as copy supplied from this Commission.