By. Sri. P. Raveendran, Member:-
Brief of the Complaint:- The complainant's husband Sri. Sivadasan who is a milk producer and the opposite party No.3 procured milk from him. On 09.10.2009 Sri. Sivadasan expired from Kannur Medical College Super specialty Hospital with history of fall from a height while he was collecting leafs from a jackfruit tree for his cattle's. Due to fall he suffered with grievous injuries including fracture of C 5 Vertebrae and qruadriparasis. While Mr. Sivadasan was alive he joined in a Ksheera Karshaka Kshema Nidhi through opposite party No.1 for an amount of Rs.50,000/-. After the death of Sri. Sivadasan his wife the applicant herein submitted a claim form for getting the insurance amount with necessary medical certificates from opposite parties No.1 to 3 through proper channel. So the applicant sent a lawyer notice to opposite parties No.1 to 3 on 04.06.2011. In the reply notice the opposite parties contended that the claim form along with medical certificates sent to opposite party No.4 and the opposite party No.4 repudiated the claim stating that “cardiac arrest not payable”. The act of the opposite parties are deficiency of service and unfair trade practice. Hence it is prayed, to give direction to opposite parties to pay an amount of Rs.50,000/- towards Kshema Nidhi with 12% interest from 09.01.2010 onwards and award Rs.20,000/- towards compensation and to grand cost of this complaint.
2. The opposite parties appeared and filed their version. Opposite party No.1 contended that Ksheera Karshaka Insurace Scheme is a joint venture of Kerala Dairy Farmers Welfare Fund Board and United India Insurance Company. According to MOU sent by Kerala Dairy Farmers Welfare Fund Board and United India Insurance Company the insurance policy covers death due to accident/permanent total disablement due to accident (Rs.50,000/-). In the case of the complainant the company rejected the claim stating that “Cardiac Arrest Not Payable”. The claim has to be settled by the United India Insurance Company. The application of the complainant relating to accident claim for her late husband Sri. Sivadasan was forwarded from opposite party No.1's office to opposite party No.4's office for settling the claim. But the insurance company has rejected the claim stating that “Cardiac Arrest Not Payable”. The MOU signed between Kerala Dairy Farmers Welfare Fund Board and United India Insurance Company clearly states that it has an insurance coverage of Rs.50,000/- for death due to accident. The respondent No.1,2 and 3 are not liable to pay the loss incurred to the complainant since the claim is to be settled by the United India Insurance Company ( Opposite Party No.4). The field level officers, District Nodal Officer of the Dairy Department were fully convinced of the death of Sri. Sivadasan due to accident and had forwarded the application of the complainant with their recommendations to Kerala Dairy Farmers Welfare Fund Board. The Board after scrutiny of the application and on enquiry with the department officials was convinced that the death due to accident and forwarded the application to the opposite party No.4. The company has rejected the claim stating technical reasons. The MOU signed between Kerala Dairy Farmers Welfare Fund Board and opposite party No.4 clearly states that it has an insurance coverage of Rs.50,000/- for death/total disability due to accident. The decision of the company in this case cannot be accepted.
3. The 2nd opposite party is the District Nodal Officer of the Kerala Dairy Farmers Welfare Fund. In the version of opposite party No.2 it is stated that the 2nd opposite party is only entitled to forward the application to Chief Executive Officer who is the person authorized to forward the claim to the opposite party No.4. Opposite party No.4 is the authority to process, finalize and disburse the claim. This opposite party had forwarded application of the complainant on 18.02.2010 to the opposite party No.1. There was no delay in forwarding the application of the complainant to opposite party No.1. The claim has to be settled by the opposite party No.4. Hence there is no deficiency of service on the part of opposite party No.2. Hence it is prayed to exonerate this opposite party.
4. Opposite party No.3 appeared and filed their version. In the version he stated that the Ksheera Kshema Insurance Scheme is a project constituted by the Kerala Dairy Farmers Welfare Fund Board. The insurance amount has to be paid by the 4th opposite party. This opposite party has forwarded the entire documents to the higher authorities which was given by the complainant. This opposite party has no connection with the processing of the claim, sanction of claim amount or disbursement of claim amount to the complainant. This opposite party is not liable to pay any amount to the complainant in connection with the Ksheera Karshaka Kshema Nidhi. Hence it is prayed to dismiss the complaint with compensatory cost to the opposite party No.3.
5. The opposite party No.4 appeared and filed their version. In the version the opposite party admitted that 3706 dependants of the members of Kerala Dairy Farmers Welfare Fund Board were insured with this opposite party from 29.05.2009 to 28.05.2010. The risk covered is death due to accident etc. In this case Mr. Sivadasan. M.B died on 09.10.2009 due to Cardio respiratory arrest. Hence as per the terms and conditions of the policy this opposite party is not liable to pay any amount as prayed for. The Cardio respiratory arrest is not covered as per the policy. Only after conducting the postmortem the actual cause of death can be ascertained. The claim arising death due to cardiac arrest is not payable. It is not an accident it is a natural disease. The opposite party is not bound to pay Rs.20,000/- as compensation. Hence it is prayed that to dismiss the complaint with the cost of this opposite party.
6. On considering the complaint and versions the following points are to be considered:-
1. Whether there is any deficiency in service on the part of opposite parties?
2. Relief and Cost.
7. Point No.1 :- To prove the complainant's case she has filed her chief affidavit. She is also produced Exts.A1 to A6 documents. In the chief affidavit she stated as stated in the complaint. To prove opposite parties case opposite party No.4 was examined as OPW1 and Exts.B1 to B2 documents are also marked. Dr. Sujith, Consultant Neurologist and Movement disorder Specialist in Kannur Medical Colleage is examined as court witness No.1 and X1 series are also marked.
8. The Insurance of the deceased Sivadasan is not denied by opposite parties. The contentions of opposite party No.1 to 3 are that there is no deficiency of service on their part. They have submitted claim form along with medical documents to opposite party No.4. Opposite party No.4 has to scrutinize and sanction the claim. In the version of opposite party No.4 it is admitted that Sri. Sivadasan. M.B died on 09.10.2009 due to Cardiac respiratory arrest. Hence as per the terms and conditions of the policy he is not liable to pay any amount to the complainant. We do not know how opposite party No.4 come to such a conclusion. Dr. Sujith the doctor who treated the deceased in super specialty Medical Collage, Kannur was examined as CW1 he admitted that he is issued Ext.A6 Certificate. In Ext.A6 he clearly mentioned that the cause of death was cardio respiratory arrest secondary to fall from height and its complications. In the chief examination also he clearly stated that in the case of this petition cardio respiratory arrest happened to cardiac arrest. Cardiac arrest and Cardio respiratory arrest are different. In his final opinion the death was due to cardio respiratory arrest secondary to fall from height. At the time of cross examination of opposite party No.4 he stated that he does not know the difference between the cardiac arrest and cardio respiratory arrest since he is not a doctor. He further stated that the company has medical team. No evidence is adduced before this Forum to rebut the evidence adduced by CW1. Doctor is the opt person to say the cause of death. In his opinion the death is due to cardio respiratory arrest secondary to fall from height. The case of the complainant is that Mr. Sivadasn fall from a tree height while he was collecting food materials from a jackfruit tree for his cattle's. The evidence of complainant corroborate with the evidence of CW1. So the death happened due to an accident. In our opinion the death is happened due to accident ie fall from a tree height and consequents to its injuries. So the repudiation of the claim form submitted by the complainant is a deficiency of service on the part of opposite party No.4. Point No.1 is decided accordingly.
9. There is no deficiency of service on the part of opposite parties No.1 to 3. Since they have done their job without delay.
10. Point No.2 :- The complainant is entitled to get Rs.50,000/- from opposite party No.4 with 10% interest from 29.08.2011 till the payment is made. She is also entitled to get Rs.3,000/- as cost and compensation.
In the result the complaint is party allowed. The opposite party No.4 is directed to pay an amount of Rs.50,000/- ( Rupees Fifty Thousand Only) with 10% interest from 29.08.2011 till the payment is made. The opposite party No.4 is also directed to pay Rs.3,000/- (Rupees Three Thousand Only) as cost and compensation to the complainant. This Order is to be complied by the opposite party No.4 within 30 days from the date of receipt of this Order.
Pronounced in Open Forum on this the day of 30th March 2012.
Date of Filing:29.08.2011.
