D.O.F:26/03/2023
D.O.O:21/03/2024
IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KASARAGOD
CC.70/2021
Dated this, the 21st day of March 2024
PRESENT:
SRI.KRISHNAN.K : PRESIDENT
SMT.BEENA.K.G : MEMBER
Thulasi K., aged 37 years
Widow of Rama
Kinnuval, Kudalmerkala
Permude Post, Manjeswaram Taluk.
(Adv: Manikandhan Nambiar K.) : Complainant
And
The Branch Manager
United India Insurance Company Ltd
Branch office,
Killiyamazhil Plaza Building
Majeri Road, Malapuram – 676505.
(Adv: K. Vinod Kumar) : Opposite Party
ORDER
SMT.BEENA.K.G : MEMBER
The complainant is a widow of Rama, who died as a result of a road accident. The deceased Rama has got 3 children namely, Jayalakshmi K aged 17 years, Kushal Kumar aged 16 years and Shiva Chethan, aged 10 years. This complaint is filed for and on behalf of those children also. All are residing along with the complainant at the above mentioned address. The husband of the complainant Rama met with an accident on 19/08/2019 at a place called Parmude while he was walking by the side of road, an omni van wearing registration No. KL 14-R-6816 driven by one Abdul Majeed T.M. hit the above said Rama while the van was recklessly reversed by the driver. The above said deceased Rama fell down on the road sustained grievous injuries. He was immediately taken to Carewell Hospital, Kasaragod and admitted and after treatment, discharged on 23/08/2019. The Kumbla Police registered a crime on this incident as Crime No. 321/2019 under section 278 & 337 IPC. After the discharge, the above said deceased Rama was not keeping well and died on 01/09/2019 due to the injuries sustained in the accident. Postmortem was conducted and certificate is issued. The complainant filed a claim before the opposite party through the Branch Manager, Kerala Gramin Bank, Permude Branch. The claim was repudiated and returned back to the Gramin Bank, Permude Branch through the Chief Manager. The reason for repudiation was that there was no postmortem conducted. This was fully wrong. The postmortem was done and certificates also filed along with the claim. The complainant and the children are entitled to get the insurance benefits under the scheme of PMSBY to the tune of Rs. 1,00,000/-. The opposite party wrongly and purposefully denied the claim of the complainant. The complainant has sustained mental agony and hardships due to the act of the opposite parties. Therefore, the complainant is seeking to direct opposite party to pay an amount of Rs. 1,60,000/- with interest at the rate of 10% per annum from 03/02/2020 till realization in the best interest of justice.
The opposite party filed version denying all averments in the complaint. The accident and registration of the crime 321/2019 of Kumbla Police station U/s 279/338 against the driver of the car are admitted. In addition to these sections, Sec 304 IPC along with other sections in the crime at the time of filing of the final report is unsustainable and without any basis. It is admitted that, the deceased Rama had been enrolled in the PMSBY insurance scheme through the Kerala Gramin Bank Permude branch in the capacity of account holder, that the complainant had filed a claim form through the bank and same has been repudiated. But repudiation of the claim is for valid reasons. The contention that the reasons for repudiation was no postmortem conducted is denied herewith no postmortem certificate was produced along with claim form as contented in the complaint. The further averments in the complaint to the effect that the complainant and the children are entitled for insurance benefit under the scheme of PMSBY to the tune of Rs. 1,00,000/- that the opposite party wrongly and purposefully denied the claim of the complaint and that the complainant and her children are beneficiaries of the scheme and as such their consumers as defined under the act, that the opposite party is a service provider by collecting premium and that the opposite party is liable for the unlawful trade practice and deficiency in service by wrongfully rejecting the lawful claim etc. are false and denied herewith. The opposite party respectfully submit that the coverage under the said policy is limited as per the endorsements, conditions and limitations of the policy. The documents produced by the complainant shows that the deceased Rama sustained only simple injuries like Hematoma over right leg measuring about 8cm×3cm, aberration over right hip region about 3cm×3cm, aberration over the back of right hand and left foot and outer aspect of left ankle. The wound certificate reveals that he is a Rheumatic Heart disease patient. The patient was discharged from the hospital in good condition and admittedly he died on 01/09/2019 at his residence. The cause of death is the coronary artery disease. The postmortem certificate of the deceased has not been submitted before the opposite party along with the claim. The postmortem certificate now produced along with the complaint shows that the death was due to coronary artery disease. So, the complainant may be put to strict proof of cause of death. The proximate cause of death is not the injuries sustained in the accident. The policy covers only the death due to the accident. But the death due to coronary artery disease will not come under the preview of the policy. The complainant will not come under the preview of consumer as per definition under the act. There is no deficiency of service or negligence or unfair trade practice by the opposite party. So they are not liable to pay any compensation of cost to the complainant. Hence the complaint may be dismissed with cost.
The complainant filed proof affidavit in lieu of chief examination and the documents produced are marked as Ext. A1 to A5. The opposite party cross examined the complainant as PW1. The opposite party produced 2 documents, Ext. B1 and B2. Both sides heard and documents produced. The main questions raised for consideration are,
- Whether there is any deficiency of service on the part of opposite party in rejecting the claim of the complainant?
- Whether the complainant is entitled for relief?
- If so, what is the relief?
The complainant’s husband met with a road accident on 19/08/2019, at a place called Permude, while he was walking by the side of the road. The Kumbla Police registered crime and an FIR is lodged on 19/08/2019 which is produced here and marked as Ext.A1. Ext. A2 is the final report in the above case. The above said Rama died on 01/09/2019. The postmortem certificate, Ext.A3 states the reason for the death is the treatment was not effective. The complainant was a rheumatic patient with heart issues. The inference taken by the doctor who conducted postmortem is that the treatment was not effective. The complainant submitted a claim application before opposite party and it is rejected on the ground that no postmortem was conducted and the death was not due to accident. Ext. A5 is the order of the MACT Kasaragod in O.P.(M.V.) No.155/2020.
While analyzing the materials brought before the Commission, it is true that he had admitted in Carewell Hospital after the accident and treated there till 23/08/2019. After discharge also the deceased Rama was not keeping well and he died on 01/09/2019. The deceased Rama was an account holder at the Kerala Gramin Bank, Permude Branch with account No. 40415100003021. The deceased Rama had a Prime Minister’s Insurance scheme PMSBY coverage. The opposite party was the insurer and the payment was made through Kerala Gramin Bank, Permude Branch. The complainant filed a claim before the opposite party and it is repudiated and returned back stating that no postmortem was conducted. Postmortem was conducted and certificate was also filed along with the claim application. Ext. A3 is produced. The complainant is entitled to get the insurance benefit under the PMSBY scheme to the tune of Rs. 1,00,000/-. The opposite party produced Ext. B1- wound certificate, Ext. B2 postmortem report. So the contention raised by opposite party for the denial of claim application is not sustainable as the postmortem report is produced by both parties before the Commission. While discussing about the cause of death we rely upon the postmortem report, Ext.A3, the inference taken by the doctor after postmortem is, “വാഹനാപകടത്തിൽ പരിക്ക് പറ്റി ചികിൽസ ഫലിക്കാതെ മരണപ്പെട്ടത്”.
The prayer of the complainant is Rs. 1,00,000/- (Policy benefit as per PMSBY scheme) with Rs.50,000/- for deficiency of service and cost is Rs. 10,000/-.
The complainant is entitled for the policy amount of Rs. 1,00,000/- with 9% interest from the date of complaint till realization and a compensation for deficiency in service for the repudiation of the claim, ie, Rs. 50,000 and cost of Rs. 5,000/-.
In the result, complaint is allowed, directing opposite party to pay Rs. 1,00,000/- (Rupees One lakh only) with 9% interest from the date of complaint till realization and Rs. 50,000/- (Rupees Fifty thousand only) for deficiency in service and Rs. 5,000/- (Rupees Five thousand only) as cost of litigation to the complainant within 30 days from the date of receipt of copy of this order.
Sd/- Sd/-
MEMBER PRESIDENT
Exhibits
A1 – FIR
A2 – Final report
A3 – Postmortem certificate
A4 – Copy of the letter sent by opposite party to the Chief Manager, Kerala Gramin
Bank
A5 – Order of the MACT Kasaragod
B1 – Wound certificate
B2 – Postmortem report
Witness cross-examined
PW1 – Thulasi K.
Sd/- Sd/-
MEMBER PRESIDENT
Forwarded by Order
Assistant Registrar
JJ/
