O R D E R
By Sri. C.T. Sabu, President:
Fact of the case is as follows. 1st complainant is the wife of deceased Denzil Rozario. 2nd & 3rd complainants are their children. The deceased subscribed an insurance policy of Rs.5,00,000/- from the opposite party under Nagrik Suraksha Insurance Policy and another policy for Rs.30,000/- as universal health insurance covering death and injury due to an accident. The premium amount were regularly paid and the policy was in force. On 12/12/10 the deceased fell down and his neck of femur were fractured. While undergoing treatment on 21/12/10 he succumbed to death due to Multi Organ failure as well. The cause of death was accidental fall from stool and aggravation of the illness thereby. Thereafter the complainant preferred a claim for policy amount which was declined by the opposite party holding that the exact cause of death as reported by the hospital was due to Cardio respiratory arrest and chronic renal failure. Hence they denied the claim as it is beyond the scope and ambit of policy. Since the cause of death was due to the accident, the opposite party bound to settle the claim even the original bill is of Rs.98,000/- the opposite party company did not honoured the same. Since the claim denied by the opposite party, this complaint filed.
2) On receiving complaint, notice served properly to the opposite party. Opposite party appeared through counsel and filed version. The contents of version is as follows : The complaint is not maintainable. The opposite party admits the Nagrik Suraksha insurance policy in the name of Mr. Denzil Rozario for a total sum of Rs.5,00,000/- and also admits that issued universal health insurance in the name of Mr. Denzil Rozario for Rs.30,000/-. They further admit the death of Mr. Rozario as well. The death was due to cardio respiratory arrest secondary to chronic renal failure and it was mentioned as multi organ failure. The insured suppressed pre-existing disease while taking the policy. In all accidental cases post mortem should be conducted and in this case nothing so where done. As per Nagrik Suraksha Policy the opposite party’s liability attached when the insured person sustained bodily injury resulting solely and directly from accident caused by external, violent and visible means resulting in death (if sole and direct cause is accident). The proximate cause of death is not accident but pre-existing disease. Since the claim does not come under the purview of policies the opposite party repudiated the claim. They denied the cause of death as fall. They further deny the averment that the act of the insurance company is in violation of policy condition and denies valve replacement is not a disease. They genuinely repudiated the claim and prayed for a dismissal.
3) Points to be considered.
a) whether there is any deficiency of service or not ?
b) Relief and cost ?
4) From the side of complainant 1st complainant filed proof affidavit in tune with complainant. She also produced 2 documents which are marked as Ext. P1 series and Ext. P2. Ext. P1 series is the copy of Medical Bills of Denzil Rozario and Ext. P2 is the copy of Medical Report of Denzil Rozario. From the side of opposite party, filed proof affidavit and produced 3 document which are marked as Ext. R1 to R3. Ext. R1 is the Nagriksuraksha Individual Policy Schedule; Ext. R2 is the Universal Health Insurance Policy Schedule and Ext. R3 is the Death Claim of Mr. Denzil Rozario under Nagrik Suraksha Policy and UHI Policy, dtd. 28/12/2011.
Point No. 1
5) This is a case filed by the wife and children of deceased Denzil Rozario and the dispute regarding the improper repudiation of insurance claim alleging deficiency of service from the part of the opposite party insurance company. The very case of the complainant is that due to a fall, the deceased admitted in to Aswini Hospital. Thereafter, he undergone some treatment, at last due to multiple organ failure, the patient succumbed to death. The sole reason lead to the death was due to a fall and the same is an accidental fall. At this juncture the only evidence leading to the fact is Ext. P2 Medical report. Wherein it has been clearly stated that the patient was admitted there on 12/12/10 with history of fall-fractural neck of femur (Right). Now the diagnosis clearly states that “fall from height, fracture NOF resulting in pulmonary edema, renal failure and multi organ failure. Police was not informed as no foul play was suspected. Now Ext. P2 is very clear that the cause of admission and the diagnosis was fall from height. Moreover, Ext. P2 further shows that fracture NOF resulting in pulmonary edema multi organ failure. Hence the case of the complainant stands proved to the extent that the result including the death was caused to fall from height. As per order in IA, the Medical superintendent filed an affidavit to the effect that the treatment records are not seen and every endeavor for finding out the same were failed. Hence it is only to be concluded that the case of the complainant stands proved especially when no contra evidence has been brought up before the commission by the opposite party. Now opposite party produced Ext. R1 Nagrik Suraksha individual policy schedule in the name of deceased Denzil Rozario. The attached portion forming part of the policy states that the ‘insurance under this policy subject to conditions, clauses, warrantees, endorsement. Nil’. So Ext. R1 probalise the case of the complainant. Moreover the exclusion stated in the Ext. R2 policy reads that existing disability and death caused directly or indirectly or contributed to by or traceable to any such disability leads to exclusion of payment. Now the entries in Ext. P2 nowhere concluded that the death was due to any such pre-existing disabilities. Moreover, the death was due to sudden body cardia. No attempt has also been made by the opposite party to establish that the cause of death was due to a pre-existing disability, rather they raised a lone contention to the effect that multi organ failure. Hence at no stretch of imagination it can be stated that the death was due to a pre-existing disability especially when Ext. P2 reads that the multi organ failure resulted fall from height.
6) Now Ext. R3 needs close look. It has been stated that ‘final diagnosis’ mentioned as multi organ failure. “As per treatment records insured declared death due to cardio respiratory arrest secondary to chronic renal failure. Surprisingly the first part of diagnosis as shown in Ext. P2 seen absent and no where in the counter as well as in evidence of the opposite party the first part of diagnosis resulted to the death is absent and no explanation what so ever has been put forth before the Commission by the opposite party for such absence. So it is to be prudently believed that the allegation is only intended to improperly defeat the claim of the complainant and Ext. R3 is bad to that extent as well. Thus the improper repudiation of the insurance claim is a clear case of deficiency of service warranting interference of this Commission. From the above discussion as a whole the commission is inclined to allow this complaint.
In the result, the complaint is allowed and hereby directing the opposite party to pay the insurance claim sum insured as personal accident section 80% amounting to Rs.4,00,000/- (Rupees Four lakh only) and hospitalisation section amounting to Rs.98,000/- (Rupees Ninety eight thousand only) with 12% interest from the date of death till realisation within one month from the date of receiving the copy of this order. The opposite parties further directed to pay cost of Rs.5,000/- (Rupees Five thousand only) to the complainant.
Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Commission this the 27th day of August 2020.
Sd/- Sd/- Sd/-
Sreeja S Dr. K. Radhakrishnan Nair C.T. Sabu
Member Member President
Appendix
Complainant’s Exhibits :
Ext. P1 series copy of Medical Bills of Denzil Rozario
Ext. P2 copy of Medical Report of Denzil Rozario.
Opposite party’s Exhibits :
Ext. R1 Nagriksuraksha Individual Policy Schedule
Ext. R2 Universal Health Insurance Policy Schedule
Ext. R3 Death Claim of Mr. Denzil Rozario under Nagrik Suraksha Policy
and UHI Policy, dtd. 28/12/2011.
Id/-
President
