DISTRICT CONSUMER DISPUTES REDRESSAL FORUM PALAKKAD

Dated this the 12^th  day of February 2013

Present : Smt.Seena H, President

            : Smt. Preetha.G. Nair, Member

            : Smt. Bhanumathi.A.K, Member           Date of filing: 27/07/2012

(C.C.No.141/2012)

Sindhu,

W/o.Late Radhakrishnan,

Mandhirad Veetil,

Kuzhalmannam,

Palakkad                                             -       Complainant

(By Adv.Subramanian) 

V/s

1.State of Kerala,

   Rep.by District collector,

   Palakkad    

   (By District Govt.Pleader)  

2.Senior Divisional Manager,

   National Insurance Co.Ltd.,

   Vazhuthacaud,

   Thiruvananthapuram    

  (By Adv.P.K.Devadas)  

3.Manager,

   National Insurance Co.Ltd.

   Palakkad

  (By Adv.P.K.Devadas)                                  -        Opposite parties

O R D E R

By Smt.PREETHA G NAIR, MEMBER

Complainant is the legal heir of deceased Radhakrishnan. The deceased Radhakrishnan was a teacher in B.M.A.J.B. School. On 25/02/2009 due to snake bite he was admitted in the District Hospital, from there he was taken to Jubilee Mission Hospital and on 28/02/2009 he died. The 1^st opposite party introduced Insurance  Scheme for the State Govt.Employees and Teachers including part time contingent employees.  The complainant’s husband Radhakrishnan paid Rs.50/- as per capital annual premium for policy of Rs.7 lakhs. After  the death of Radhakrishnan the complainant filed a claim petition before the 2^nd opposite party. On 12/05/2010 the 2^nd opposite party rejected the claim petition stating that the delay was caused in filing the claim petition. Subsequently  a letter was sent to the Principal Secretary, Financial Department and on 2/6/11 a reply was sent to reject the claim petition. The opposite parties are liable to pay the claim amount  to the complainant. The opposite parties had rejected the claim petition without stating sufficient reasons. The act of opposite parties amounts to deficiency  in service and unfair trade practice. Hence, the complainant prays an order directing the opposite parties to pay Rs.7 lakhs as the claim amount with 12% interest and cost of the proceedings.

Opposite parties filed version stating  the following contentions. 1^st opposite party stated that on 1/1/2008 onwards they had conducted a group personal accident insurance scheme through opposite parties 2 & 3 for an amount of 7 lakhs as the yearly premium amount is Rs.50/-. Thereafter the group personal accident insurance policy issued to the aided school teacher and non teachers with conditions on 25/8/07. The husband of the complainant was a teacher in aided school. As per the Govt.order dated 29/05/07 the conditions is that the notice of death issued within 30 days to maximum 45 days to District Office of the Insurance company. Thereafter the Insurance Company will be  taken the process of claim. If the company had not acted as per law, the appeal will be preferred to the Govt.Secretary, within 60 days. The appeal to the order of Govt.will be filed to the Insurance Ombudsman. In the present case the complainant has not filed any appeal as per the order.  The claim amount will be paid by the 2^nd and 3^rd opposite parties. The 1^st opposite party has not liable to pay any amount. Hence, the 1^st opposite party prayed that dismiss the complaint.

2^nd and 3^rd opposite parties stated that they had not admitted that the complainant’s husband was paying Rs.50/- annually and  a valid policy for Rs.7 lakhs is in existence. The claim has been lodged long after the time limit stipulated in the policy and as per the Govt.order dated 29/05/2007 without any acceptable explanation for such inordinate delay which is a violation of the terms and conditions. The application of nominee was submitted to 2^nd opposite party by the Headmaster BMAJB School with a covering letter dated 31/12/09 only. The Assistant Educational Officer has submitted the claim application to 2^nd opposite party with a covering letter dated 21/01/2010 only. And the 2^nd opposite party has rightly informed the Assistant Educational Officer through a letter dated 12/05/2010 regretting the inability to consider the claim at that belated stage in the light of the violation. The complainant has also admitted that she has thereafter an application was forwarded to the Principal Secretary, Finance Department who has also rejected it.

Rule 11 of the scheme deals with the procedure for claiming compensation. Rule 12 deals with the procedure in case of rejection of claim which says that if the claims rejected the aggrieved party has to make a complaint with necessary documents to the Principal Secretary, Finance Department. Govt. of Kerala within sixty days of the rejection of the compensation  by the company. The Principal Secretary should forward a copy of the same to the company and request the company to settle the matter. If it is not possible to arrive at a consensus the case to be left to the decision of the Insurance Ombudsman. The decision of the Insurance Ombudsman shall be final.  The complainant has to approach the right Forum for redressal. There was no unfair trade practice on the part of opposite parties.

In the additional version 2^nd and 3^rd opposite parties stated that the claim has been repudiated due to the inordinate delay in filing the claim form and connected document. The first condition attached to the policy says that upon the happening of the any event which may give rise to a claim under the policy written notice with all particulars must be given to the company immediately. In case of death, written notice also for the death must unless reasonable cause is shown be given before internment cremation and in any case within one calendar month after the death etc.

The second condition is that proof satisfactory to the company shall be furnished of all matters upon which a claim is based. In the event of the death to make a postmortem examination of the body of injured person. Such evidence as the company may from  time to time require shall be furnished and a post mortem report, if necessary be furnished within the space of fourteen days after demand in writing. Hence, the 2^nd and 3^rd opposite parties prayed that dismiss the complaint with costs.

Complainant and 2^nd and 3^rd opposite parties filed their affidavits. 1^st opposite party has not filed any affidavit and documents. Ext.A1 to A11 marked on the side of complainant. Ext.B1 & B2 marked on the side of 2^nd and 3^rd opposite parties. Complainant and 2^nd and 3^rd opposite parties filed argument notes.

Issues to be considered are

1.    Whether the complaint is maintainable ?

2.    Whether there is any deficiency in service on the part of opposite parties   ?

3.     If so, what is the relief and cost ?

Issue No.1  

We perused relevant documents  on record. According to the opposite parties  the complaint is not maintainable. Section 2(1)(o) of the Consumer Protection Act states that insurance is coming under the definition of service. According to the complainant, the opposite parties liable to pay the claim  amount. Complainant stated that the husband of the complainant was paying Rs.50/- annually and availed policy for Rs.7 lakhs is in existence. As per Ext.A10 shows that in the name of the husband of the complainant has deducted an amount of Rs.50/- by the Head Mistress of the School to the scheme of Group Personal Accident Insurance. Section 3 of the Consumer Protection Act shows that Act not in derogation of any other law. The provisions of this Act shall be in addition to and not in derogation of the provisions of any other law for the time being in force.  So the complaint is maintainable under the Consumer Protection Act. Hence the 1^st issue answered in favour of the complainant.

Issue 2 & 3

As per Ext.A10 & A11 the husband of the complainant has paid the premium amount of Rs.50/- in the year 2008 and the complainant is the nominee of the deceased Radhakrishnan. The opposite parties had not raised objection to marking of Ext.A10 and Ext.A11. In Ext.A4 the death certificate shows that Radhakrishnan.N died on 28/2/09 on the place of Jubilee Mission Medical College Hospital, Thrissur. Ext.A3 shows that Dr.John.A.G. stated that Mr.Radhakrishnan had been admitted on 25/02/2009 with snake bite and expired on 28/02/2009. Postmortem  was not done as patient expired following snake bite. The doctor has not examined as a witness.

The main contention raised by the opposite parties that the complainant has not acted as per the Rule 11 and 12 of the Scheme. Moreover 2^nd and 3^rd opposite parties stated that the claim petition filed by the complainant was belated. The complainant stated that her husband died on 28/2/2009 and she could not file the claim petition before the concerned authority due to the death ceremonies.

In Ext.B1 page 3 clause 4 mentioned that the insured shall have to pay an annual premium of Rs.50/- inclusive of service tax, the insured sum of Rs.Seven Lakhs. In clause 6(1) on commencement of this scheme, the Principal Secretary to Government in Finance Department shall apply to the company for a single policy covering all Government employees and teachers as members under the Scheme entitling each member to an accident benefit of the sum not exceeding Rs.Seven lakh. Every Government employee and teacher shall compulsorily be a member under the scheme.

In clause 11 mentioned the procedure for claiming compensation,  clause 12 mentioned the procedure in case of rejection of claim. But the opposite parties had not produced evidence to show that Ext.B1 given to the husband of the complainant. On the available evidence, we considered that  the husband of the complainant availed the insurance policy for an amount of Rs.7 lakhs from the opposite parties and the policy is in existence at the time of the death. According to 2^nd and 3^rd opposite parties the claim petition  was submitted by the Assistant Education Officer only on 21/01/10 i.e. after 11 months of the death of the person. According to opposite parties the claim application is highly belated and a clear case of violation of the terms and conditions in the Govt.Order and policy. Further 2^nd and 3^rd opposite parties stated that the postmortem was not done. But in Ext.A3 Dr.John stated that the husband of the complainant had been admitted on 25/2/2009 with snake bite and expired on 28/2/2009. Postmortem was not done as patient expired following snake bite. No contradictory evidence produced by the opposite parties.

On the available evidence, the husband of the complainant has a valid insurance coverage at the time of death. The opposite parties had not produced evidence to show that the terms and conditions given to the deceased Radhakrishnan.

In the above discussions we are of the view that there is deficiency in service on the part of 2^nd and 3^rd opposite parties.  1^st opposite party is exonerated from liability.

In the result complaint allowed. We direct the opposite parties 2 & 3 jointly and severally liable to pay the complainant an amount of Rs.7 lakhs with 8% interest from the date of repudiation of claim to the date of receipt of order and pay Rs.1,000/- as cost of the proceedings. The ordered amount shall be paid only after the receipt of legal heirship certificate and consent letter of the   legal heirs authorizing the complainant to receive the amount.

Order shall be complied within two weeks from the date of receipt of legalheirship certificate and consent letter, failing which the complainant is entitled for 9% interest per annum for the whole amount from the date of order, till realization.

Pronounced in the open court on this the 12^th day of February 2013.

   Sd/-

Seena H

President

    Sd/-

Preetha G Nair

Member

    Sd/-

Bhanumathi.A.K.

Member

APPENDIX

Exhibits marked on the side of the complainant

Ext.A1  –  Photocopy of Claim Petition  

Ext.A2  –  Certificate issued by Jubilee Mission Hospital   dt.7/3/2009

Ext.A3  –  Certificate issued by Jubilee Mission Hospital   dt.29/5/2009  

Ext.A4  – Death Certificate issued by Thrissur Corporation.    

Ext.A5  – Photocopy of letter dated 12/5/10 sent by Insurance Company to the

             complainant.  

Ext.A6  – Copy of letter dated 28/4/11 sent to Principal Secretary, Finance

              Dept. By the complainant

Ext.A7  – Reply letter dated 2/6/11 sent by Principal Secretary, Finance

              Dept. To the complainant

Ext.A8  – Legalheirship certificate  

Ext.A9  – Copy of letter issued by Superintendent, Dist.Hospital to the

             complainant.    

Ext.A10  –   Copy of list of employees in Form 11 for GPAI  Scheme

Ext.A11  –   Copy of GPAI nomination Form 1  

Exhibits marked on the side of the opposite party

Ext.B1 – Copy of Govt.OrderNo221/07/Fin dated 29/5/07

Ext.B2 – Certified copy of insurance policy along with terms and conditions.

Cost

Rs.1,000/- allowed as cost of the proceedings.