DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

PATIALA.

                                      Complaint No. CC/15/164 of 4.8.2015

                                      Decided on: 10.3.2016        

Harpal Singh @ Haripal Singh son of Sh.Bhagwan Singh resident of village Dandrala Kharoud, P.O.Dakaunda, Tehsil Nabha, District Patiala Ph.No.98146-50989.

                                                                   …………...Complainant

                                      Versus

1.      TATA AIG General Insurance Company Ltd., 15^th Floor, Peninsula Business Park, Tower-A, G.K.Marg, Lower Parel, Mumbai, through its M.D.

2.      TATA AIG General Insurance Company Ltd., Branch office at Ist Floor, S.C.O. 18-19, Leela Bhawan Market, Patiala through its branch manager.

                                                                   …………….Ops

                                      Complaint under Section 12 of the

                                      Consumer Protection Act.

                                      QUORUM

                                      Sh. A.P.S.Rajput, President

                                      Smt.Neelam Gupta, Member

                                      Smt.Sonia Bansal,Member

Present:

For the complainant:       Sh.Deepak Badhwar , Advocate

For Ops:                           Sh.D.P.S.Anand, Advocate

                                         ORDER

A.P.S.Rajput, PRESIDENT

1. The Complainant, Harpal Singh @ Haripal Singh s/o Bhagwan Singh R/o Village Dandrala Kharoud, P.O.Dakaunda, Tehsil Nabha, District Patiala, has filed this complaint against the Opposite Parties (hereinafter referred to as the OPs) under Sections 11 to  14 of the Consumer Protection Act. The brief facts of the complaint are as under:
2. It is stated by the complainant that on 5.3.2014 he and his late wife Mrs.Jaswant Kaur took an insurance policy No.0200371489 for the sum  of Rs. 25,00,000/- covering the risk of death and other medical expenses. The complainant Harpal Singh was the nominee of late Mrs.Jaswant Kaur. An amount of Rs.9927/-was paid as premium of the policy.
3. It is alleged by the complainant that on 26.6.2014 when he came to his house he was shocked on seeing Jaswant Kaur, in injured condition fallen  on the floor.  Immediately he called the doctor through his son Harjot Singh and the doctor after having checked up Jaswant Kaur declared her dead.
4. After cremation of Jaswant Kaur , a death claim was lodged with the Ops in July,2014. An investigation team to investigate the matter was sent by the Ops.The complainant submitted all the documents regarding his claim to the investigating team.
5. It is alleged by the complainant that in the month of January 2015, he received a letter from the Ops stating that the Ops are not in a position to consider the claim. Again in the month of March,2015 a letter was received by the complainant from the Ops demanding some documents relating to death of Jaswant Kaur, which were again sent by the complainant. It is alleged by the complainant that the Ops vide their letter dated 7 April,2015, stated that they are unable to pay anything relating to the claim to the complainant.
6. On 8.7.2015 the complainant got sent a legal notice upon the Ops but till today neither any reply of the legal notice has been received nor any amount is paid by the Ops. Thus on account of deficiency of service on the part of the Ops the complainant prayed for a direction to the Ops  to pay the amount of Rs.12,50,000/- the sum insured , an amount of Rs.2,00,000/- on account of mental and physical harassment and also Rs.50,000/- on account of unfair trade practice on the part of the Ops.
7. On notice the Ops appeared and filed their written version having admitted that an Accident Shield Policy No.0200371489 in favour of Sh.Haripal Singh covering the risk of accidental death of Rs.25lacs and his spouse Smt.Jaswant Kaur covering  50%  of the insured amount on account of accidental death, permanent total disability and permanent partial disability for the period 5.3.2014 to 4.3.2017 was issued. It is stated that the policy also provides education benefit for an amount of Rs.1,00,000/-.It is also admitted that the complainant registered one claim vide  No.748891 on 9.8.2014 on the death of his wife,Mrs.Jaswant Kaur.It is alleged by the Ops that the claim of the complainant was denied  on 18.12.2014 as death was due to fever is not covered under the terms and conditions of the policy. The complainant registered another claim No.760941 with the OPs. Finally vide letter dated 31.12.2014 with respect to claim No.748891,the complainant was informed that the death due to sickness is not covered under the policy and the Ops are unable to consider the claim. It is stated that the Ops demanded various documents from the complainant but the complainant failed to supply the documents and the Ops were left with no option but to repudiate the claim of the complainant on 7.4.2015.All other averments made in the complaint have also been denied and it is prayed to dismiss the complaint.
8. In order to prove his case, the complainant tendered in evidence Ex.CA his sworn affidavit, Ex.CB the sworn affidavit of Harjot Singh, Ex.CC, the sworn affidavit of Dr.Dharampal Sharma, Ex.CD, the sworn affidavit of Bhagwan Singh,Ex.CE, the sworn affidavit of Sh.Ajaib Singh alongwith the documents Exs.C1 to C14 and his counsel closed the evidence.
9. On the other hand, on behalf of the Ops their counsel tendered in evidence Ex.RA, the sworn affidavit of Mohd.Azhar Wasi, Ex.RB the sworn affidavit of Anoop Bist, alongwith the documents Ex.R1 to R11 and closed the evidence.
10. The complainant filed the written arguments. We have examined the same, heard the learned counsel for the parties and gone through the evidence on record.
11. The ld. counsel for the complainant has submitted that the OPs have repudiated the claim of the complainant in an arbitrary manner.The ld. counsel also submitted that it is evident from the statement sworn by the Doctor i.e Ex.C-3, statement of  Bharwan Singh, Nambadar i.e Ex.C-4, statement of Ajaib Singh, Sarpanch i.e Ex.C-E that the deceased wife of the complainant died due to sudden fall and injury sustained on the head. The ld. counsel stated that the investigator in his investigation report has also stated at Sr.No.11 that on inquiries made from village people and neighbourers it had been informed by them that the deceased died due to sudden fall on the floor, thus it is covered under the accidental clause. The ld. counsel also pleaded that the documents demanded as mentioned in Ex.C6, i.e. Post Mortem Report, FIR, Medical Record could not be provided as the deceased was found dead on the floor and this was confirmed by the doctor. The ld. counsel argued that it is clearly established from the evidence lead by the complainant that the OPs have committed deficiency of services by repudiating the claim in an arbitrary manner. The ld. counsel relied upon the following case laws; National Insurance Company Limited, Gurgaon V.Ravi Dutt Sharma (P&H) 2011(4)PLR 154: 2011(3)R.C.R.(Civil)631; wherein it has been observed in para no.2, “I have my doubts whether the Insurance Company can act as a super investigator once the complaint was lodged with the police about the theft. The responsibility to investigate or to ascertain the cause of theft or whether it was there or not would really be that of the police. Merely because there was a delay on the part of the insured to inform the petitioner-company would not be a reason enough to decline or repudiate the claim.Lok Adalat has rightly appreciated this aspect and has negated the plea raised by the petitioner Insurance Company on the ground that the respondent-insured had immediately informed the police about the theft and hence the delay would be immaterial in such cases. The Insurance Companies, in my view, are not acting fairly in all such matters after charging huge premium. Intention is always to repudiate the claim on one ground or the other.The condition of the Insurance agreements are so minutely printed that person gets hardly any time to go through such conditions to make it legally binding in any appropriate manner”.The other case relied upon by the ld. Counsel for the complainant is titled   New India Insurance Company Ltd. vs.State of Haryana (N.C.D.R.C.) 2008(2) C.P.J.(N.C.)371, wherein it has been observed in paras no.4,5 and 6 as;  “The insured’s family consists of three children and wife who are his dependents. This is a group insurance policy taken by the Government of Haryana. The petitioner cannot discount and reject the reports and statements made by the Government Hospital authorities and also the Gram Panchayat and other Government authorities without any evidence to the contrary.Further, to cast doubt regarding the death of the insured that there is a fraud or misrepresentation of material facts without evidence brought by them to that effect and still coming for revision before us and continuously drag the poor members of the deceased into repeated litigation is unjustified.”

5. “If the petitioner Insurance Company feels that the Government authorities are not following correct rules while giving documents pertaining to death as given in this case, then they should deal with the Government authorities directly and rectify the same instead of harassing the family members of the deceased. Feasibility and viability of offering such Group Insurance Policies should be gone into before offering the same to the consumers and not after collecting the premium and concluding the contract by giving the policy. Continuous litigation tactics adopted by the petitioner on flimsy grounds should be discouraged.”

6. “In the present case, there is no evidence to show that there is fraud and misrepresentation of material facts regarding death of the insured and unjustified to interfere with the well-reasoned order of the State Commission. Revision petition is dismissed”.

12. On the other hand, the ld.counsel has stated that the Ops had repudiated the claim of the complainant as per terms and conditions of the policy i.e “Part D - Coverage of policy states as under:-
13.  

Section – Accidental Death

We will pay the principal sum shown in the policy schedule if the injury to you results in loss of life.

Part-A-General definitions of the policy states:-

13. Injury- means accidental physical bodily harm excluding illness or disease solely and directly caused by external, violent, visible and evident means which is verified and certified by a medical practitioner/physician” .The ld. counsel further stated that the claim of the complainant was denied, as death was due to fever and the same is not covered under the terms and conditions of the policy. The complainant registered another claim No.760941 with the OPs. Finally vide letter dated 31.12.2014 with respect to claim No.748891,the complainant was informed that the death due to sickness is not covered under the policy and the Ops are unable to consider the claim. He stated that the Ops demanded various documents from the complainant but the complainant failed to supply the documents and the Ops were left with no other option but to repudiate the claim. The ld. counsel pleaded that there are contradictory statements with regard to the claim, as initially the complainant informed the OPs that the deceased wife of the complainant died due to sickness and later on cooked up a story of death due to head injury. He also pleaded that, it is evident from the investigation report i.e Ex.R-1, that the complainant has misrepresented and played fraud upon the OPs, in order to claim the insurance payment worth Rs.25, 00,000/-(Twenty Five lakhs).The ld. counsel argued that in the present case voluminous evidence is required as the complainant has not been able to rebut the report of the investigator i.e Ex.R-1  The ld. counsel further argued that in the present case there are complicated questions of law involved and this Forum can only adjudicate in a summary manner. The ld. counsel also relied upon the latest case law in the case of Oriental Insurance Co.Ltd. Versus Varinder Singh & others 2015(3)CLT 340 decided by Hon’ble National Consumer Disputes Redressal Commission, New Delhi, wherein it has been held in para no.9, “On reading of the above, it is clear that death of the insured was reported to the police at Chowki Varpal and on the request of the family members of the deceased Amarjeet Singh, SDM waived conducting of post mortem on the dead body. In order to succeed in the insurance claim, the complainants were required to prove that Amarjeet Singh had died as a consequence of accidental fall from the stairs.The claimants have failed to lead cogent evidence to discharge the aforesaid onus of proof. Instead, they have not even cared to summon and prove the report lodged at Police Post Varpal, which obviously would have contained first hand information about cause of death of Amarjeet Singh. Even the family of the deceased requested the SDM to waive the post mortem on the body of the deceased which could have established the cause of death. From this it is evident that claimants have failed to produce the best evidence i.e. report made at the Police Post Varpal  and also the claimants by getting the waiver of post mortem have ensured the exact  cause of death of Amarjeet Singh is not scientifically established. As the complainants have failed to produce the best evidence and by their own effort ensured that post mortem on the dead body of the insured is not conducted, we are inclined to draw an  adverse presumption against them. Thus, it can be safely inferred that the story of death of Amarjeet Singh due to accidental fall is false and there is truth in the statement of witness Kirpal Singh and Amrik Singh made to the investigator that Amarjeet Singh died because of heart attack”.

13.    After hearing the Ld. Counsel for the parties and going through the pleadings and evidence produced by them and oral as well as written submissions, we find force in the submission made by the ld. counsel for the OPs that the complainant has not been able to rebut the investigation report i.e Ex.R-1. The complainant has also failed to lead cogent evidence to discharge the aforesaid onus of proof  and we are of the opinion for doing the same, it will require voluminous evidence alongwith detailed cross examination and examination-in chief, in the absence of the same, the present complaint cannot be adjudicated upon by this Forum,as this Forum can only adjudicate upon the cases in a summary manner. The Hon’ble State Commission,Punjab in a case Savitri Devi Vs Guru Ram Dass Jee International Airport,2015(3) CLT 415(PB) has observed  that “ where the matter cannot be  adjudicated without recording elaborate evidence involving cross-examination of witnesses, the complainant be directed to approach competent civil court to seek redressal of her grievance”.

14.    Accordingly in view of our aforementioned discussion and the judgment, in our view, we feel that in the present case also elaborate evidence involving cross-examination of witnesses is required for proper adjudication of the case. Thus we would not like to go into the merits of the case . Hence the present complaint is disposed of with  liberty to the complainant to approach the appropriate Court of law  and may be entitled to the benefit of the observations of the Supreme Court inLaxmi Engineering Works Vs. P.S.G. Industrial Institute II(1995) CPJ 1 (SC)  for the purpose of exclusion of time spent before this Forum. Parties to bear the cost. 

Pronounced

Dated:10.3.2016

               Sonia Bansal           Neelam Gupta                        A.P.S.Rajput

        Member                 Member                                  President