DISTRICT CONSUMER DISPUTES REDRESSAL FORUM;BHADRAK
………………..
C.D.Case No.32 of 2014
Smt.Gitanjali Senapati, aged about 44 years
W/o: Late Rabindra Kumar Senapati
At/PO: Saragadia, PS/Dist:Bhadrak
………………….Complainant
(Vrs.)
1. The Branch Manager,
The Oriental Insurance Co.Ltd.,
Bhadrak Branch
At: By-Pass(R.C.Behera Market Complex)
PO/PS/Dist:Bhadrak
2. The Divisional Manager,
The Oriental Insurance Co.Ltd.,
Divisional Office, 1st Floor, Shiva Hospital,
In front of F.M.College,
At/PO/PS/Dist:Balasore-756001
…………………….Opp.Parties
Order No.11 dt.30.07.2014:
The Complainant who is the nominee of the policy holder late Rabindra Kumar Senapati has filed this case alleging deficiency in service on the part of the O.Ps and claiming the insured sum of Rs.3,00,000/- along with compensation from the O.Ps due to accidental death of her husband.
In nut-shell the case of the Complainant is that her husband Rabindra Kumar Senapati had obtained a “Nagarika Surakshya Policy” bearing No.345701/48/2013/612 for the period from 31.07.2012 to midnight of 30.07.2016 from O.P.No.1 for the amount of Rs.3,00,000/- covering the risk of death/permanent total disability, loss of limbs and permanent partial disability including reimbursement of hospitalization expenses. On 08.11.2012 at about 6.00 AM, the deceased husband of Complainant while coming down the stairs of his house, fell down as his foot slipped and became unconscious and thereafter died on 08.11.2012 at District Headquarters Hospital, Bhadrak. The said accident was reported to Bhadrak Town Police Station and information was given to O.Ps about the death of the policy holder Rabindra Kumar Senapati. Complainant lodged claim before the O.Ps for disbursement of the policy amount along with required documents. Thereafter, O.Ps appointed Investigator to investigate the incident. After long lapse of time, the O.P.No.1 repudiated the claim of the Complainant on 12.03.2014 on the ground of non-submission of viscera report as the postmortem report is silent about the cause of accidental death. According to Complainant when the Final Report submitted by the Police has been accepted by the Competent Court of law and the collection of Viscera Report was the duty of the Investigator, repudiation of claim by O.Ps amounts to deficiency in service.
O.Ps in their written version submitted that on 26.11.2012 the Complainant submitted the claim Form duly filled in and signed by her along with copy of FIR with promise to submit the post mortem report, final investigation report and death certificate. On receiving the claim Form the O.P.No.1 appointed an investigator Sri Tushar Kanta Das, Advocate on the self same day to investigate the death claim of the deceased Rabindra Kumar Senapati. The deputed investigator submitted the certified copy of the order sheet, first information report, final report, Inquest report, Dead Body challan and Postmortem report in connection with UD GR No.391/2012 of SDM, Bhadrak on 05.11.2013. On perusal of the aforesaid documents, the O.P.No.1 found that the doctor has not opined the cause of death for which the O.P.No.1 sent the claim file to O.P.No.2 for necessary advice. On perusal of claim file the O.P.No.2 found that the doctor who conducted P.M. Examination found that there is an abrasion injury over the web space of third and fourth toe of left foot and old scar mark over Rt. Temporal area with old fracture piece of bone of 2” radius found over Rt. temporal area with fibrous union and after post mortem examination he could not opine the cause of death. As such, he preserved the viscera in common salt and directed the police to send the same to SFSL, Bhubaneswar for chemical examination and opinion and accordingly the investigating officer sought permission from the Hon’ble SDM, Bhadrak to send the preserved viscera to SFSL, Rasulgarh, Bhubaneswar. After receiving the order from the Hon’ble SDM, Bhadrak the Investigating Officer sent the viscera to SFSL, Bhubaneswar through escort party for chemical exanimation to ascertain the cause of death and prior to receipt of the chemical examination report, Police has submitted the Final report. As there is no positive evidence/material submitted by the Complainant that the death of the deceased Rabindra Kumar Senapati has occurred due to accidental bodily injury solely and directly caused by external, violent and visible means for which the O.P.No.2 repudiated the claim of the Complainant.
We have heard the Ld.Counsels appearing on both sides and perused the documents available on record. Admittedly, the deceased Rabindra Kumar Senapati had obtained a “Nagarika Surakshya Policy” bearing No.345701/48/2013/612 for the period from 31.07.2012 to midnight of 30.07.2016 from O.P.No.1 for the amount of Rs.3,00,000/- on payment of insurance premium of Rs.775/-, covering the risk of death/permanent total disability, loss of limbs and permanent partial disability including reimbursement of hospitalization expenses. On 08.11.2012 at early morning the insured Rabindra Kumar Senapati, who was Homeopathic doctor by profession, while returning from the roof of building, his foot slipped and he fell down on the stair and became unconscious. Immediately, the life assured was shifted to District Headquarters Hospital, Bhadrak where he was declared dead by the Doctor. The death of the life assured was intimated to the Insurance Company and FIR was lodged in Bhadrak Town Police Station. The dead body was sent for Postmortem examination. Complainant filed Claim Form with relevant documents before the O.Ps. on 26.11.2012. On receiving the Claim Form, O.P.No.1 appointed Investigator to investigate the death claim of the deceased Rabindra Kumar Senapati. Subsequently, the O.Ps repudiated the claim of the Complainant on 12.03.2014 on the ground of non-submission of Viscera report as the Postmortem report is silent about the cause of death due to accident.
Ld.Counsel for the Complainant at the time of hearing submitted that when the postmortem has been conducted by the Public Servant in due discharge of their duty and the Ld.SDM, Bhadrak has accepted the Final Form submitted by Police stating that the insured died due to injury from accidental fall from stair case, repudiation of claim on flimsy ground amounts to deficiency in service by the O.Ps. He further stated that the LIC of India has also released the Accidental Benefit to the Complainant against Policy Nos.587369445 and 595836045 of the deceased Rabindra Kumar Senapati basing on certified copy of Final Court verdict, duly attested with seal by any Class-I Officer of LIC. He relied on a decision of the Hon’ble National Commission reported in CPR-2013(4), Page-563 in the case of Life Insurance Corporation of India, Through Assistant Secretary, Northern Zonal Office- Petitioner Vs. N.Shanker Reddy-Respondent, where in it has been held by the Hon’ble National Commission that to prove death by accident either Police report or hospital records confirming death as accidental are to be produced. So when the Police report reveals death of insured was due to injury from accidental fall stair and there is no suspicion of foul play and F.R. is accepted by the Ld.SDM, Bhadrak in U.D.G.R.No.391 of 2012, insistence for Viscera is a move put forth by the Insurance Company to defeat the genuine claim of the widow. Ld.Counsel appearing for the O.Ps on the other hand relying on a decision of the Hon’ble National Commission reported in 2014(2) CPR 546(NC) in the case of Smt. Resham Devi- Petitioner Vs. New India Assurance Co.ltd., through its Manager & Anr.-Respondents, submitted that benefits under accidental Policy are available only when an accident is caused by external violent and visible means. As the Postmortem report is silent about the cause of death, repudiation of claim is justified due to non-submission of viscera report by the Complainant.
While going through the Final Report No.78 of 2012 in U.D.G.R.Case No. 391 of 2012 we found that the IIC, Bhadrak Town PS in his report has stated that “every day deceased Rabindra Kumar Senapati was attending Yoga and was moving in the roof of the building 10-15 minutes. On 08.11.2012 after completion of Yoga he went to roof. After half an hour while returning from the roof, the leg was slipped and he fell down on the stair case on back and received waist pain and became unconscious. Immediately he was brought to DHH, Bhadrak where he was expired. The dead body was sent to PM examination. Local enquiry reveals that deceased Rabindra Ku.Senapati was a Homeopathic doctor and was suffering from high blood pressure. On 8.11.12 while he was returning from the rope of building his steps was slipped due to rain and accidentally fell on the stair case on back sided received severe pain on his waist. He was regularly practicing Yoga for his pressure. Due to unconscious he was brought to DHH, Bhadrak where he was expired. I took charge on the enquiry from ASI N.Ch.Biswal, received PM report from Dr.A.Mishra who opined the final opinion could not be given and viscera preserved for C.E. Sent requisition to SDM,Bhadrak who passed an order to sent exhibits to SFSC, Bhubaneswar and accordingly, I despatched viscera to S.F.S.C., Bhubaneswar through escort party. During enquiry, no adverse came to notice about the death of deceased from any angle so far. From the above facts and circumstances I submitted F.R. declaring the cause of death of the deceased might be due to injuries resulting from accidental fall from stair case and there is no suspicion of any foul play. If any adverse report will come to notice in future, the case will be reopened”. The Doctor who conducted PM examination found there is an abrasion over web space of 3rd and 4th toe of left foot old scar mark over Rt. Temporal area with old fracture piece of bone of 2” radius found over Rt. temporal area with fibrous union and after post mortem examination he could not opine the cause of death for which he preserved viscera and directed the Police to send the same to SFSL, Bhubaneswar. Exclusion clause No.4 of the Policy provides that insurance company shall not pay compensation in respect of injury as a direct consequence of committing or attempting suicide, intentional self-injury or under the influence of intoxicating liquor of drugs. Neither the Police, investigator appointed by Insurance Company nor the doctor who conducted PM examination has given adverse report on the above points. As has been held by the Hon’ble National Commission in the case of Life Insurance Corporation of India, Through Assistant Secretary, Northern Zonal Office- Petitioner Vs. N.Shanker Reddy-Respondent, reported in CPR-2013(4), Page-563 that to prove death by accident either Police report or hospital records confirming death as accidental are to be produced and the Complainant has produced the Police Report which has been accepted by the Ld.SDM,Bhadrak on 30.07.2013 in U.D.G.R.Case No.391/12 and LIC basing on the said order of the Ld.SDM,Bhadrak has released the accidental benefit of the life assured Rabindra Kumar Senapati to Complainant, repudiation of claim by OPs without proper application of mind and insistence of viscera report from the Complainant amounts to deficiency in service. Further, what prevented the O.Ps to collect the viscera report by the engaged Investigator in this case if the Complainant who is a widow could not submit the same. On perusal of the decision cited by the O.Ps in the case of Smt. Resham Devi- Petitioner Vs. New India Assurance Co.ltd., through its Manager & Anr.-Respondents, we found in that case neither any injury report nor was postmortem report submitted by the Petitioner. So the decision cited by O.Ps is not applicable to the present case. Apart from the above in the Policy prospect filed by Complainant reveals that final claim along with hospital receipted bills/cash memos, FIR-if any, claim form and list of documents as listed in the claim Form etc. should be submitted to the Company’s policy issuing office within 14 days of discharge from the Hospital. Nowhere has it been mentioned in the policy prospect to submit viscera report except FIR-if any. Insurance Regulatory and Development Authority (Protection of Policyholders’ Interests) Regulations, 2002(IRDA) stipulate the Turnaround Times (TAT) for various services that an insurance company has to render to a consumer. In case of General Insurance Company offer of settlement/rejection of Claim after receiving first/addendum survey report is 30 days. So we completely agree with the submission made by the Ld.Counsel for Complainant that Insistence for Viscera is a move put forth by the Insurance Company to defeat the genuine claim of the widow. There is no escape from the conclusion that the deceased Rabindra Kumar Senapati had sustained bodily injury as per Police Report which has been accepted by the Ld.SDM, Bhadrak on 30.07.2013 in U.D.G.R.Case No.391/12 and repudiation of genuine claim by O.Ps is a clear case of deficiency in service. Accordingly, it is ordered:
O R D E R
In the result, the Complainant is allowed in part on contest against the O.Ps 1 & 2. The O.Ps directed to pay the payable insurance claim under the policy No. 345701/48/2013/612 to the complainant with interest @ 9% p.a. with effect from 26.02.2013 i.e. after 3 months receipt of claim Form from the Complainant till final payment is made along with litigation cost of Rs.1000/- within a period of 30 days of receipt of this order.
