DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

C.C. No. 188/2019

QUORUM:

Order By: Shri S.S. Malhotra (President)

JUDGMENT

By this order the Commission shall dispose off the present complaint filed by the Complainant against OP w.r.t. deficiency in service in not giving death benefit of his wife despite there being a valid policy.

1. Brief facts as stated by the complainant in the complaint are that the husband is the policy holder as well as nominee and beneficiary of the policy of Smt. Rajni Sharma his wife, since deceased and she had purchased a ‘Group Credit Secure Policy’ with master policy bearing No.0235000085 w.e.f. 30.08.2017  to 29.08.2022 for insurance value (IDV) of Rs.16,13,390/- from the OP and she was pregnant at the time of having that policy however on 16.09.2017 she gave birth to male child which was a normal delivery at Govt. Hospital Sanjay Nagar, Ghaziabad and at the same day the complainant felt certain complications on account of excess bleeding and she was admitted to GTB Hospital Shahdara at 05:25 AM but she expired at 07:00 AM same day and the cause of death as declared by Doctor was P2L2 with PPH with severe Anemia and cardio respiratory arrest and the death was due to loss of excess blood at the time of delivery.  The complainant thereafter approached the OP for insurance of his wife who died on account of an accident, as his wife was comprehensively insured with OP but OP vide letter dated 22.02.2018  rejected the claim by referring /relying clause 2(i) i.e. accident Accidental death, which defines that specific exclusion applicable to this section 2 is and it is further said that in addition to the general exclusion listed in this policy this coverage shall not cover loss caused directly and indirectly, wholly or partly by medical or surgical treatment except as necessary solely and directly as a result of accident. It is further stated that there was another exclusion clause cited by the OP i.e. any critical illness or covered disease / illness / sickness of which signs or symptoms first occur prior to or within 90 days following the policy issue date or the last commencement date whichever is earlier  and in this matter it is stated that the date of inception of the policy is 29.08.2017 and date of illness of the wife of complainant is 16.09.2016  i.e. within 90 days and therefore the claim was rejected.  Complainant further submitted that his wife has died on account of accident as accident means an unfortunate incident that happens unexpectedly and unintentionally, typically results in damage or injury and in view of this definition, the death of his wife at the time of delivery is covered under an accidental death as it was an accident.  As per report of doctors the cause of death or disease was due to severe anemia and cardio respiratory arrest which was unexpected and unintentional damage and therefore the complainant is entitled to claim the relief and as far as second ground of rejection is concerned the same is also stated to be bad in the eyes of law as there was no signs or symptoms occurred by the diseased at the time of purchasing the policy and she was pregnant for about 8 months when the policy was taken and this fact was also known to the OP and therefore they have issued the policy despite this knowledge, and therefore does not come within the rejection clause/ exclusion clause and since complainant has not been  the benefit of the insurance, he has filed the present complaint thereby seeking direction to OP to reimburse of Rs.16,13,390/- to the complainant with compensation of Rs.50,000/- and any other relief which this Commission may deems fit.
2. The OP has filed the reply taking preliminary submission that the complaint is totally devoid of any merits and is not tenable as he has lodged the claim under accidental death and critical illness benefit of this policy and since this was neither the case of accidental death nor is a case of critical illness, the claim was rejected and this illness was not covered under the policy and as per the death certificate of the deceased issued by GTB Hospital Shahdara the cause of death was P2L2 with PPH with severe Anemia with cardio respiratory arrest and this cause of death does not fall under the purview of the accidental death and is simply an illness/ sickness. Further, since the death has happened within 90 days of the inception of the policy the OP falls within the exclusion clause therefore claim is not maintainable and even otherwise the death of the insured does not fulfill the eligibility conditions and falls within the general exclusion of the policy and therefore the claim of the complainant was rightfully rejected and OP is not deficient in providing the services.
3.  As far as merits are concerned, taking the policy, paying the premium, lodging the death claim benefits and rejection thereof is not disputed and it is submitted that cause of the death of the deceased neither falls within the category of critical illness nor same falls within the terms and conditions of the policy and therefore it was rightfully rejected and it is prayed that complaint of the complainant be dismissed.
4. Complainant has filed the Rejoinder thereby denying the contents of the written statement and reaffirming and reiterating the contents of the complaint and it is submitted that the repudiation was wrongly done as the death claim of his wife does not fall within the general exclusion of the policy as alleged and it is prayed that complaint of the complainant be allowed.
5. Complainant has filed his own evidence whereas OP has filed evidence of Sh. Amit Chawla AVP Legal Claims and both the parties have reaffirmed and reiterated the contents of their respective pleadings.
6. Both the parties have also filed their written arguments.
7. The Commission has heard the arguments and perused the record.
8. The whole endeavour/contention of the complainant is that since his wife has died in the hospital on account of excess bleeding it be treated as an accident  and since the accident is covered the claim be granted.  On the other hand the contention of the OP is two fold i.e. No.1 it is not an accident as the hospital authority has not given any opinion that it was an accidental death and since, the complainant has died on account of excess bleeding after the delivery of child and therefore it was neither a critical illness which was covered in the policy nor it was covered as an accidental death and therefore the claim was rightfully rejected, and, secondly the insurance company has relied upon the general exclusion clause which inter alia states that if anything happens within the period of 90 days of inception of the policy then claim would not be paid.
9. Keeping in view both these contentions now coming to the word ‘accident’. It is referred as accident per se may not include any accident by a motor or motorized vehicle but it can be any type of accident.  Therefore the next issue which would be whether a person who died on account of excess bleeding after delivery of a child can be termed as an accident. This issue could have been better appreciated if the post mortem of the insured could have been done and the exact cause of death could have been ascertained.  Admittedly the post mortem of the insured has not been done and therefore there is no expert opinion before the  Commission that what exactly was the cause of death.  On the face of it death has been caused on account of some medical exigencies and intricacies which developed at the time of delivery of the child and which  could not be confirmed / ascertained by the hospital where she was firstly admitted and when she was referred to GTB Hospital at about 05:15 AM.  As per complaint she could not survive on account of excessive blood loss.  Therefore this incident can, by no stretch imagination be termed as accident. Simultaneously,  coming to the next aspect that the death has taken place within 90 days from the date of inception of policy is concerned the contention of the complainant is that the wife of the complainant was pregnant when the policy was taken and this fact was well within the knowledge of the OP and if this condition could have been brought to the notice of the complainant at that time or if the medical test of the complainant’s wife had been done by the insurance agent/OP  then they may not insured the complainant but since they have insured the wife of the complainant, despite having knowledge that she was on the family way at the time of inception of the policy this exclusion clause does not apply. The Commission has perused the record and there is no document placed on record by the complainant that the complainant or his wife has ever communicated by way of any letter  to the OP that the wife of the complainant is on family way. Not only this, no document has been placed on record w.r.t. continuous follow up of the treatment of the wife of complainant w.r.t explaining the complications, if any in the process of her being on family way. There is no medical reports available as to why the excessive bleeding happened.  It could have ascertained if the previous chain of facts /health treatment and follow up documents would have been filed by the complainant this matter would have been understood in a better way.  If the previous follow up/check-ups of the complainant’s wife could have been brought on record and would have been proved by way of medical evidence, on the Commission’s file the contention of complainant could have been appreciated.  Therefore neither these documents are filed on record nor there is any letter which may show that wife of the complainant was on family way was brought to the knowledge of the OP. 

Therefore this contention of complainant also is not well found. Keeping in view the facts and circumstances of the present case, the Commission is of the opinion that complainant has not been able to prove deficiency on the part of OP nor he is able to prove that the insured died on account of some accident or insured is not covered within the exclusion clause.  The complaint case is therefore dismissed.          

Copy of the order be supplied / sent to the parties free of cost as per rules.

File be consigned to Record Room. 

Announced on 21.05.2024