Haryana

Yamunanagar

CC/690/2013

Krishna Devi W/o Sumer Chand - Complainant(s)

Versus

The Branch Manager,Life Insurance Corporation Of India - Opp.Party(s)

Arvinder Singh Chahal

22 Feb 2017

ORDER

Before the President, District Consumer Disputes Redressal Forum, Yamuna Nagar.

 

                                                                                    Complaint No. 690 of 2013.

                                                                                    Date of institution: 24.09.2013.

                                                                                    Date of decision: 22.02.2017.

Smt. Krishna Devi aged about 42 years wd/o Sumer Chand, resident of village Kotla, Sub Tehsil Sadhaura, Tehsil Bilaspur, District Yamuna Nagar

                                                                                                                         ... Complainant.

                                    Versus

1. The Branch Manager, Life Insurance Corporation of India, Netaji Subhash Chowk, Dehradun- Chandigarh Road Highway, Naraingarh-134203.
2. The Divisional Manager, Life Insurance Corporation of India Divisional Office: 489, Model Town, PB No. 106, Karnal.
3. Branch Manager, Life Insurance Corporation of India, Sector-17, HUDA, Jagadhri.

                                                                                                                          …Respondents.

BEFORE          SH. ASHOK KUMAR GARG, PRESIDENT,

                          SH. S.C.SHARMA, MEMBER.  

 

Present: Sh. Arvinder Singh Chahal, Advocate, counsel for complainant. 

               Sh. Rajiv Gupta, Advocate, for respondents.

             

ORDER            (SH. ASHOK KUMAR GARG, PRESIDENT)

 

1.                     Complainant Smt. Krishna Devi has filed the present complaint under section 12 of the Consumer Protection Act, 1986 praying therein that the respondents (hereinafter respondents will be referred as Ops) be directed to pay accidental benefit as per policy alongwith interest from the date of death of husband of the complainant till the actual payment and further to pay compensation as well as litigation expenses.

2.                     Brief facts of the present complaint, as alleged by the complainant, are that the husband of the complainant got himself insured with Ops under the policy bearing No. 177409412 which commenced from 28.04.2011 and date of maturity as 28.04.2031 and the complainant is nominee in the abovesaid policy. On 06.07.2012, in the midnight, the husband of complainant was sleeping on the roof, suddenly the rain fall was started and thereafter the husband of the complainant wake up and when he got down through ladder he fell down from the ladder and he received multiple grievous injuries. Thereafter, early in the morning on 07.07.2012, the husband of the complainant was taken to PHC Sadhaura and after giving the first aid referred to M.L. General Hospital, Yamuna Nagar and again giving some treatment and he was again referred to PGI Chandigarh on the same day with the opinion for further management and Neuro Surgeon Opinion as advised by physician on call. During the treatment in PGI, husband of the complainant had died on 12.07.2012 due to fall from ladder. The Ops have paid Rs. 51,960/- only as the basic benefit but the Ops did not pay the accidental benefit to the complainant till today regarding the death of her husband. The complainant approached to the Ops and requested to release the accidental benefits on the account of death of her husband due to fall from ladder, because it was accidental death. The complainant visited many times to the Ops but they kept on prolonging the matter on one pretext or the other. Thereafter, the complainant got served a legal notice on 03.09.2013 through her counsel by registered post to the Ops to make the payment on account of death of her husband which was duly received by the Ops but they filed an evasive reply dated 06.09.2013. Due to the deficient and negligent services rendered by the Ops, the complainant has suffered a lot of mental agony, harassment, pain and suffering. Hence, this complaint.

3.                     Upon notice, OPs appeared and filed its written statement by taking some preliminary objections such as complaint is not maintainable, no negligence or deficiency in service on the part of Ops Company; in this case, the deceased life assured Sh. Sumer Chand had taken one life insurance policy bearing No. 177409412 for a sum of Rs. 50,000/- under term and table 75-20-20 date of commencement 28.04.2011, risk commencing from 24.05.2011 @ Rs. 1940/- payable half yearly premium. Smt. Krishna Devi is the appointed nominee under the policy in question. A claim was lodged with the Ops Insurance Company on account of death of deceased life assured Sumer Chad who as per death certificate died on 12.07.2012 in village Kotla. The claim was processed and a sum of Rs. 51,960/- including sum assured and bonus has already been paid on 04.02.2013. As far as accidental claim under the policy in question is concerned, the same has been legally and justifiably denied by the Ops Insurance Company vide its letter dated 19.06.2013 as the complainant has failed to submit the legal and required documents i.e. FIR, PIR and PMR to the Ops for considering accidental claim to prove/ establish the accidental death which is required as per terms and conditions of the insurance policy. It is mandatory that the complainant has to establish nexus between injuries and resultant death, if any. The claim under the policy is subject to terms and conditions of the Insurance Policy. Hence, no further amount is payable to the complainant and on merit controverted the plea taken in the complaint and reiterated the stand taken in the preliminary objections. Lastly, prayed for dismissal of complaint.

4.                     In support of case, counsel for the complainant tendered into evidence affidavit of complainant as Annexure CX and documents such as Photo copy of receipt of premium as Annexure C-1, Photo copy of Discharge slip of M.L.General Hospital & Trauma Centre, Yamuna Nagar as Annexure C-2, Photo copy of registered AD Legal notice as Annexure C-3, Photo copy of death certificate as Annexure C-4, Photo copy of letter dated 06.09.2013 as Annexure C-5 and closed the evidence on behalf of complainant.

5.                     On the other hand, counsel for the OPs tendered into evidence affidavit of Ajay Gupta, Manager LIC of India, Karnal as Annexure RW/A and documents such as Photo copy of letter dated 19.06.2013 as Annexure R-1, Photo copy of insurance policy as Annexure R-2, Photo copy of death certificate as Annexure R-3, Photo copy of letter dated 04.02.2013 regarding payment of claim as Annexure R-4, Photo copy of letter dated 21.09.2013 as Annexure R-5, Photo copy of letter dated 06.09.2013 as Annexure R-6, Photo copy of letter dated 29.11.2012 as Annexure R-7 and closed the evidence on behalf of OPs.

6.                     We have heard the learned counsel for both the parties and have gone through the pleadings as well as documents placed on file very minutely and carefully. The counsel for the complainant reiterated the averments mentioned in the complaint and prayed for its acceptance whereas the counsel for OPs reiterated the averments made in the reply and prayed for dismissal of complaint.

7.                     It is not disputed that a claim was lodged with the Ops Insurance Company on account of death of deceased life assured Sumer Chad who as per death certificate died on 12.07.2012 in village Kotla. It is also not disputed that the claim was processed and a sum of Rs. 51,960/- including sum assured and bonus has already been paid on 04.02.2013 to the complainant.

8.                     Learned counsel for the complainant hotly argued that the genuine claim lodged by the complainant on account of death of her husband due to accident has been illegally repudiated by the OPs Insurance Company on a false and baseless ground whereas the cause of death in respect of her husband has been specifically mentioned by the Medical Officer in the discharge slip Annexure C-2 that Sh. Sumer Chand ( now deceased) fallen from Ladder and he was referred to PGI Chandigarh on 07.07.2012 and during the treatment husband of the complainant had died on 12.07.2012 in the PGI.     Lastly, prayed for acceptance of complaint.

9.                     On the other hand, learned counsel for the OPs argued at length that the OPs have paid the sum insured of Rs.51,960/- including sum assured and bonus on account of death of deceased life assured Sh. Sumer Chand whereas the complainant is not entitled for accidental claim as the complainant has failed to submit the legal and required documents i.e. FIR, PIR & PMR to the OPs Insurance Company and the claim of complainant has been rightly repudiated vide letter dated 19.06.2013 and lastly prayed for dismissal of complaint. 

10.                   After hearing both the parties, we are of the considered view that there is a deficiency in service on the part of OPs Insurance Company as from the perusal of discharge slip of the M.L. General Hospital, Yamuna Nagar Annexure C-2, it is duly evident that Sh. Sumer Chand son of Sh Mangat Ram husband of the complainant had fallen from Ladder and received head injury alongwith other injuries, frontal temporal and other serious injuries and due to that injuries he was referred to PGI Chandigarh by the doctor of General Hospital, Yamuna Nagar on the same day and during the treatment in the PGI husband of the complainant died on 12.07.2012 which is also duly evident from the copy of death certificate Annexure C-4. The plea of the OPs Insurance Company that in the absence of any FIR, PIR and PMR accidental benefits cannot be considered as no conclusive evidence co-relating to establish the accident of deceased has been submitted by the complainant is not tenable as from the perusal of discharge summary Annex. C-2 issued by M.L.General Hospital and Trauma Centre, Yamuna Nagar, it is clearly evident that deceased received multiple and serious injuries on his head and frontal temporal region alongwith other parts of the body. Moreover, it is settled law that there is no need to lodge any FIR in the cases of self-injuries suffered by the persons without any fault of other persons. It is not the case of the OPs Insurance Company that deceased Sumer Chand died due to otherwise as no such investigation report has been placed on file to controvert the version of the complainant which is duly supported by detailed affidavit of the complainant Annexure CX. When the OPs Insurance Company is paying the claim amount of Rs. 51960/- on account of death of the insured i.e. Sh. Sumer Chand then how the OPs Insurance Company can withheld the accidental benefits provided under the policy in question. Overall arguments advanced by the counsel for the OPs have no weightage and not sustainable in the eye of law whereas case of the complainant is duly proved from the documents more particularly discharge summary Annexure C-2. Hence, after going through the above noted facts and circumstances of the case, we are of the considered view that the OPs Insurance Company has wrongly and illegally withheld the accidental benefits under the policy in question which constitute the deficiency in service on the part of the OPs Insurance Company and the OPs Insurance Company is liable to pay the accidental benefits to the complainant as per terms and conditions of the insurance policy.   

11.                   Resultantly, we partly allow the complaint of complainant and direct the OPs Insurance Company to pay Rs. 50,000/- to the complainant alongwith interest at the rate of 9% per annum from the date of filing of complaint till its realization and further to pay a sum of Rs. 5000/- as compensation for mental agony harassment as well as litigation expenses. Order be complied within a period of 30 days after preparation of copy of this order failing which complainant shall be entitled to invoke the jurisdiction of this Forum as per law. Copies of this order be sent to the parties concerned free of costs as per rules. File be consigned to the record room after due compliance.

Announced: 22.02.2017.

                                                                                    (ASHOK KUMAR GARG)

                                                                                     PRESIDENT

                                                                                     D.C.D.R.F. YAMUNANAGAR

 

 

                                                                                    (S.C.SHARMA)

                                                                                     MEMBER