By G. Yadunadhan, President:

 

            The complainant’s case is that deceased Jatheesh none other than the husband of the complainant was a member of Kerala VyapariVyavasayi Ekopana Samithi and being a member he was covered under the Group Personal Insurance Policy No.76030142050500000335 and was covered from 20-3-06 to 19-3-07. As per the conditions of policy the risk covered were Personal Accident insurance to the members and their family members. On 17-1-06 the complainant’s husband aforementioned Jatheesh met with a road traffic accident at Calicut and he succumbed to the injuries on the same day. The aforesaid Jatheesh was driving his car and while so he lost control and hit against the wall where by he was grievously injured and died. At the time of death he was aged 34 years. As per postmortem report cause of the death was head injury. Thereafter complainant approached the opposite party for grant of insurance amount due under the policy owing to the death of the complainant’s husband. Opposite party rejected the said claim stating that unsustainable reasons. The deceased is survived by the complainant and to minor children namely Vignesh aged 5 years and Nandana aged 3 years who are the second and third complainants respectively. The said Jatheesh being fully covered by all risks arising out of accident by a valid policy is entitled for the claim amount upon his death. Opposite party repudiated the claim with unsustainable reason due to the repudiation opposite party committed deficiency of service. Therefore the opposite party is liable to pay Rs.50,000/- as compensation to the complainant and also pay the insured amount of Rs.1,00,000/-.

 

            Opposite party after serving notice and entered appearance and filed their version stating that complainant is not entitled to get any compensation or insured amount. Oppositeparty admits that the complainant approached the opposite party for the grant of insurance amount under a Group Personal Accident Insurance Policy in respect of the claim of her late husband K.K. Jatheesh. Further admits that the accident occurred on 17-10-06 while the deceased was driving the car. The liability if any of the opposite party is subject to the terms, exclusion, definition and conditions contained or endorsed in the policy issued. The deceased has obtained the policy by suppressing the material facts that he was suffering from cardiac problem before the issuance of the policy. The postmortem conducted by the Doctor clearly stated in the certificate that the opinion as to cause of death “the cardiac disease also could have contributed to cause of death”. While conducting postmortem, the heart of the deceased was sent to the department of Pathology, Medical College, Calicut and the Pathologist’s report dated 31-10-06 showed that deceased was suffering “hypertrophic cardiomyopathy with 75% atheromatous occlusion in left anterior descending artery”. The said problem of the heart resulted in a cardiac failure and deceased lost control over the vehicle resulting in the accident. Hence opposite party is not liable to satisfying the claim. Therefore the above said reason the complaint is liable to be dismissed.

 

            The only point for consideration is whether the complainant is entitled to get any relief, if so what is the relief?

 

            Complainant was examined as PW1 and Exts.A1 to A6 were marked on complainant’s side. Opposite party has not adduced any oral evidence but produced documents and marked as Ext.B1.

 

            It is admitted by the opposite party that the deceased Jatheesh had been covered by the Personal Accident Policy as per Ext.B1. Ext.A1 is also not disputed. But the reason for the death is disputed. As per ext.A1 opinion of the cause of death is high lighted by the opposite party for the purpose of escaping from liability. But it is very clear that “deceased died due to the head injury”. The second reason is the cardiac disease also could have contributed to the cause of death. But it was not detected whether deceased is having cardiac problem before the accident. It is the duty of the opposite party to verify whether deceased was having cardiac problem before the accident. That was not done in this case. More over before issuing the policy whether detailed medical investigation was done by the opposite party and if so no evidence to show that the complainant has undergone detailed medical investigation under the supervision of the opposite party. It was the failure on the part of opposite party. Any way death due to the accident is admitted by the opposite party. While perusal of ext.A5 it is a claim settlement record between the National Insurance and the complainant herein and Ext.A6 is also insurance settlement between the complainant and the LIC of India. Those documents shown regarding the death are not disputed so far. They settled the claim after the verification of the relevant documents. Therefore the dispute raised herein by the opposite party is unsustainable. Hence the complainant is entitled to get the insured amount of Rs.1,00,000/-. Therefore the opposite party is directed to pay the insured amount of Rs.1,00,000/- to the complainant without any interest or costs.

 

Pronounced in the open court this the 31st day of May 2010.

 

            SD/- PRESIDENT                   SD/- MEMBER           SD/- MEMBER

 

APPENDIX

 

Documents exhibited for the complainant:

A1. Photocopy of Post-Mortem Certificate.

A2. Copy of letter dt. 9-5-07

A3. Photocopy of F.I.R.

A4. Photocopy of letter dt. 12-10-07 sent by O.P. to the complainant.

A5. Photocopy of letter dt. 1-3-07.

A6. Photocopy of letter dt. 28-12-06 sent by L.I.C. of India.

 

Documents exhibited for the opposite party.

B1. Personal Accident Insurance Policy (Group) with conditions.

 

Witness examined for the complainant:

 

PW1. Nishitha.T.C. (Complainant)

 

Witness examined for the opposite party.

            None

 

                                                            Sd/- President

            // True Copy //

 

(Forwarded/By order)

 

 

SENIOR SUPERINTENDENT.