BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 210 of 2020
Date of Institution : 21.09.2020
Date of Decision : 20.05.2024
Usha Rani, aged 61 years widow of Shri Manohar Lal Sukhija, resident of 126, Rania Road, Opposite ITI College, Sirsa, Tehsil and District Sirsa (Haryana).
……Complainant.
Versus.
1. Star Health and Allied Insurance Company Ltd., Branch Office: Ground Floor, Opp. Shakti Motors, Near IDBI Bank, Sirsa, Tehsil and District Sirsa, through its Branch Manager.
2. Star Health and Allied Insurance Company Ltd., Regd. Office : 1, New Tank Street, Valluyer Kottam High Road, Nungambakkam, Chennai- 600 034, through its authorized signatory.
…….Opposite Parties.
Complaint under Section 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
SH. OM PARKASH TUTEJA………..MEMBER
Present: Sh. Puneet Mittal, Advocate for the complainant.
Sh. M.K. Saini, Advocate for opposite parties.
ORDER
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred as Ops).
2. In brief, the case of complainant is that husband of complainant late Shri Manohar Lal had purchased an accident care insurance policy from ops vide policy No. P/211121/02/2018/000777 for the period 31.03.2018 to 30.03.2019 for the sum assured of Rs.49,00,000/- and paid a sum of Rs.5021/- as insurance premium for the same. The complainant was held nominee by the insured in the policy and insured completed all the terms and conditions of the policy. That husband of complainant further got renewed this policy from 31.03.2019 to 30.03.2020 with cumulative bonus of Rs.2,45,000/- and insured paid a sum of Rs.5021/- as insurance premium on 13.03.2019 and in insured details pre existing disabilities is mentioned as nil. It is further averred that insured and his wife Usha Rani i.e. complainant were also having a family health optima insurance plan vide policy number P/211121/01/2018/002672 issued by ops and valid from 21.12.2018 to 20.12.2019. That on 17.08.2019 at about 7.30 p.m., the husband of complainant met with an accident near Salarpur turn when he was coming from village Madhosinghana, District Sirsa alongwith his son in law Manish Sethi on his Honda Activa bearing registration No. HR 24U/4439. An intimation to this effect was given to the local police i.e. Police Station Sadar Sirsa on 31.03.2018 by the son of complainant namely Gaurav Sukhija about the death of insured due to the injuries suffered by him in this accident and a DDR No. 645-5C dated 26.12.2019 was also recorded by the police in this regard. That in this accident, the insured Manohar Lal suffered injuries, shock and trauma. Similarly ops were also informed about the incident vide claim intimation number CLI/2020/211121/0200020. It is further averred that after the accident, the injured Manohar Lal was taken to Delhi Spine Neuro Hospital, Sirsa where he was medically examined. His X-ray chest AP was also conducted, which suggested that his heart is normal. The insured Manohar Lal was admitted in the said hospital on 17.08.2019 at about 12.30 a.m. and remained under treatment of the doctors for the injuries suffered by him in this accident, however, he could not survive and succumbed to the injuries on 18.08.2019 at 12.40 a.m. That complainant being widow and nominee of deceased lodged her claim with the ops and submitted all the requisite documents for settlement of her claim and also completed the formalities so required from her but ops on 13.03.2020 repudiated the claim of complainant on the ground that deceased died due to cardiac arrest and not due to trauma/ accident which is totally false, wrong, against law and facts and not in consonance with the medical record. The deceased was got admitted in the above hospital as a result of accident and not for any heart ailment and doctor in death summary has opined the cause of death of the insured deceased as TBI, Concussion injury with Myocardial Infraction. The doctor in his report has further very clearly clarified that the patient was admitted in NICU with diagnosis of TBI, Concussion injury managed conservatively. He had sudden onset of chest pain for a while resulted in cardiac arrest. That it clearly suggests that prior to the accident, the deceased had no cardiac problem and he was admitted in the hospital for injuries suffered by him in this accident. It is further averred that it is pertinent to mention here that ops settled the claim against Family Health Optima Insurance Plan in favour of deceased Manohar Lal by transferring Rs.13,396/- in the account of Usha Rani on 06.12.2019 which was raised as a result of the accident, so it clearly shows that ops have made a false excuse for repudiating the claim of complainant just in order to wriggle out from its legal liability to indemnify the complainant. That complainant is legally entitled to get the amount of sum assured alongwith interest from ops. It is further averred that complainant approached the ops on many occasions and requested for settlement of her claim but ops continued put off the matter with one pretext or the other and the ops by their such act and conduct have caused deficiency in service and harassment to the complainant. Hence, this complaint seeking direction to the ops to make payment of sum assured amount i.e. Rs.49,00,000/- alongwith interest at the rate of 12% per annum from the date of death of insured till realization, to make payment of cumulative bonus of Rs.2,45,000/- alongwith interest from the date of death of insured till realization and also to pay compensation of Rs.1,00,000/- and litigation expenses.
3. On notice, ops appeared and filed written statement taking certain preliminary objections regarding locus standi, cause of action, suppression of true and material facts, complaint is hopelessly time barred and that complaint involves intricate question of law and facts, plethora of records to be introduced and number of witnesses to be examined to decide the allegations in just and fair manner, therefore, the present complaint cannot be decided in summary proceedings. On merits, it is submitted that insured availed Accident Care Insurance policy from 31.03.2018 to 30.03.2019 and got renewed the same from 31.03.2019 to 30.03.2020. The terms and conditions of the policy were explained to the insured at the time of proposing policy and same was served to him alongwith policy schedule. Moreover, it is clearly stated in the policy schedule that insurance under this policy is subject to conditions, clauses, warranties, exclusions etc. It is further submitted that preferred claim is reported in second year of policy. The nominee has submitted the claim form seeking the death benefits of insured Mr. Manohar Lal who alleged to have died due to RTA. On perusal of the claim documents, it is observed that:
* That as per statement of Nominee (wife of deceased Mr. Manohar Lal Sukhija) “In the evening of 17th August, 2019 around at 7.15 p.m., my husband was returning to Sirsa from Mallekain, Madhosinghana with my son in law Manish Sethi on Honda Activa scooty HR 24 U 4339 between the village Salarpur and village Bhambur, suddenly a cattle came in the mid of the road and scooty got unbalanced. My son in law controlled himself but my husband fell down hitting his head on road. After that there was bleeding from his nose. We took him to Delhi Neurosurgeon Hospital, Sirsa and the doctor gave him thorough check immediately with necessary reports of CT scan and Chest X-ray. At around 12.15 a.m. on 18th August, he had a Oh35 tpn and after 12.20 a.m doctor declared him dead due to cardiac arrest. He breathed his last at Delhi Neurosurgeon Hospital, Sirsa. MLC and post mortem was not done. FIR was also not registered, since there was no suspicious in foul play in accident. My husband was having health policy of Star health company and claim No. 0594576 applied for this accident and my husband was not having any other PA policy of any other Company.”
* That as per death summary, the insured was diagnosed as TBI, Concussion injury with Myocardial infarction. The insured was admitted in NICU and had sudden onset of chest pain for a while resulted in cardiac arrest. CPR was done as per protocol but could not be revived and declared dead on 18/08/2019 at 12.40 am.
* That the NCCT Scan of Head dated 17.08.2019 does not show any abnormalities in brain.
* No MLC, FIR has been lodged.
* No Post Mortem was carried out.
4. It is further submitted that from the above findings, it is observed that there is no clinical or radiological evidence of any significant Head trauma and hence trauma could not be attributed as the cause of death of insured. Moreover, there was no evidence of head injury/ trauma in NCCT report, therefore, the case of death is due to cardiac arrest not due to trauma/ accident. That as per standard terms and conditions of the policy i.e. as per clause 1 regarding Incontestability and duty of disclosure and clause 7 regarding Fraudulent Claims, the claim is not payable and claim was repudiated and same was communicated to the insured vide letter dated 13.03.2020. It is further submitted that claim against Family Health Optima Insurance Plan vide policy number P/211121/01/2018/002672 in favour of deceased Shri Manohar Lal by transferring Rs.13,396/- as per the terms and conditions of the said policy. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
5. The complainant in evidence has tendered her affidavit Ex. CW1/A, documents Ex. C1 to Ex.C14, affidavit of Sh. Manish Sethi Ex.C15, and affidavit of Sh. Gaurav Sukhija Ex.C16.
6. On the other hand, ops have tendered affidavit of Sh. Sumit Kumar Sharma as Ex. RW1/A and documents Ex.R1 to Ex.R8.
7. We have heard learned counsel for the parties and have gone through the case file.
8. From the policy schedule Ex.C1, it is evident that husband of complainant namely Sh. Manohar Lal since deceased purchased accident care individual insurance policy from ops for the sum insured amount of Rs.49,00,000/- (Rs. Forty Nine Lakhs) and the period of policy was effective from 31.03.2018 to 30.03.2019 and said policy was further got renewed for the period 31.03.2019 to 30.03.2020 as is evident from policy schedule Ex.C4. The complainant is nominee of her husband insured in the said policy. According to the complainant on 17.08.2019 her husband met with an accident and he was taken to Delhi Spine Neruo Hospital, Sirsa but he could not be survived and he succumbed to the injuries suffered by him in the accident and died on 18.08.2019 at 12.40 a.m. However, the claim lodged by complainant has been repudiated by op vide repudiation letter dated 13.03.2020 Ex.R5 on the ground that it is observed from the death summary of Delhi Spine and Neuro Hospital that the insured patient had sudden chest pain for a while which resulted in cardiac arrest. As per NCCT scan of Head report dated 17.08.2019 shows no evidence of head injury/ trauma therefore, the cause of death is due to cardiac arrest not due to trauma/ accident. The ops in their written version have also asserted that claim being fraudulent in nature has been repudiated by them as per terms and conditions of the policy. In the discharge summary Ex.C10, it is clearly mentioned that patient Manohar Lal was admitted in NICU with diagnosis of TBI, Concussion injury. Managed conservatively. He had sudden onset of chest pain for a while resulted in cardiac arrest. CPR was done as per protocol but could not be revived and declared dead on 18.08.2019. Nothing has been brought on record to show that the injuries sustained by falling from the Activa aggravated the insured’s condition that eventually led to his death. In the absence of any evidence to the contrary, the medical evidence on record is itself proof that the insured died due to a heart attack and not due to an accident. No post mortem of the deceased or policy investigation was conducted. In the absence of post mortem report indicating the nature of injuries sustained by the insured, the medical report is to be relied upon which indicates the exact cause of death as myocardial infarction. Although complainant has alleged that intimation was given to the police on 31.03.2018 by son of complainant about the death of insured due to the injuries suffered by him in the accident and a DDR dated 26.12.2019 was also recorded by the police in this regard but as per own version of complainant accident took place on 17.08.2019 then how information to the police can be given on 31.03.2018 i.e. prior to the accident. Further more, no copy of any DDR dated 26.12.2019 has been placed on file by complainant. Since no post mortem report of deceased has been conducted to know exact cause of death, therefore, it cannot be said that injuries suffered by insured were only the result of his death. Even no MLR of insured has been got conducted from Civil Hospital and there is nothing on file to show that on which part of body he suffered injuries. In an accident cover claim, the injury must be the cause of death and there has to be proximate relationship between the injury and the death. In the death summary Ex.C10, it is mentioned that there was history of LOC, headache and vomiting with nasal bleed and there is no mention of any injury on the body of the insured and from the death summary it is evident that cause of death was only due to cardiac arrest and not due to any injury caused in any accident. As such complainant is not entitled to death claim of her husband insured. In this regard we are also fortified with the observations of the Hon’ble Supreme Court in case titled as Smt. Alka Shukla Versus Life Insurance Corporation of India, CA No. 3413 of 2019 decided on 24.04.2019.
9. In view of our above discussion, we do not find any merit in the present complaint and same is hereby dismissed but with no order as to costs. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced. Member Member President,
Dated: 20.05.2024. District Consumer Disputes
Redressal Commission, Sirsa.
