DATE OF DISPOSAL: 09.10.2023
PER: SRI SATISH KUMAR PANIGRAHI, PRESIDENT:
The fact of the case in brief is that the complainant has filed this Consumer complaint Under Section 35 of the Consumer Protection Act, 2019 alleging deficiency in service against the Opposite Parties (in short O.Ps.) and for redressal of her grievance before this Commission.
2. The complainant’s husband namely Kailash Bhatta aged about 30 years worked as a labour in a factory at Vijayawada. On 24.06.2009 at 19:30 hours he died on accident due to fall of earth cakes at the worksite of the fly over bridge over the Railway Tack near a Milk factory at Vijayawada under it town police station wherein the earth fell over on her husband who was the worker Kailash Bhatta when he was working along with some others at the work sport. He was removed from the earth in the pit and immediately shifted to GGH Hospital where the Medical officer examined and declared dead as per report of the Police station. Her husband commenced a LIC Policy in Aska Life Insurance Corporation of India Branch at ASKA under Life Insurance Corporation of India, Division Office , Berhampur on 28th January 2005 vide his policy No. 571581172 which has double accidental de3ath benefit accordingly he pays the premium regularly and sum assured was Rs.55,000/- of the policy bond. After getting report from the Medical and police station she submitted for his husband’s death certificate in Vijayawada Municipality and she obtained his husband’s death certificate from the competent authority. As per rule and resolution of LIC of India she submitted application with all necessary papers in original to the Branch Manager LIC of India at Aska branch under Berhampur LIC Division office to release death benefits as per provision of the policy bond. The LIC of India Aska Branch after getting the death certificate and original policy bond rereleased only the premium money and said orally after submitting of certified copy from the Vijayawada court of her husband’s death on accident then further amount i.e. accidental death benefit will be released. Since the date he is frequently moving Vijayawada Police Station and Court premises. But meanwhile more about 12 years elapsed he could not get success. Because of police has not filed the case in the Hon’ble court. The complainant had prayed to the Hon’ble High Court of A.P. seeking a direction to release all the benefits of the policy of her husband. She has no other way except to approach this Commission to direct the O.P. to settle the accidental death benefits in the best interest of justice.
3. The Opposite Parties filed written version/written argument through their advocates. It is stated that the husband of the complainant namely late Kailash Bhatta availed the L.I.C. of India Policy No. 571581172 dated 28.01.2005 with additional benefit of accidental death agreeing to pay half yearly premium of Rs.1572.00 under plan No.14 for a term of 18 years for a sum of assured Rs.55,000.00. The life assured who was said to be working as a labourer in a factory at Vijayawada (AP) reported to have died on dated 24.06.2009. The nominee under the said policy submitting the death certificate of the policy holder filed her death claim. In due course the death claim was settled and the nominee under the policy was paid the death benefits amounting to Rs.66,880.00 vide cheque No. 767857 dated 30.12.2009. The complainant in her petition has admitted to have encashed the said sum. Admittedly the policy holder Kailash Bhatta died and on production of his death certificate the Life Insurance Corporation of India settled the death claim in favour of the nominee as per rule but unfortunately the complainant who is the nominee under the policy in question as yet could not produce any authentic document or evidence in support of her claim that the policy holder died out of an accident though she has mentioned in her complaint. Her husband Kailash Bhatta was working as a labour in factory at Vijayawada (AP) met with an accident on dated 24.06.2009and he died on account of earth cake fall on him at work site of the fly over bridges over a railway track near a milk factory at Vijayawada (AP) under II Town police Station. He was said to have taken to hospital where the medical officer declared him dead. The papers and documents submitted by the complainant in this Hon’ble Court are not relevant material evidence to say that the death of the deceased policy holder is on account of an accident. Instead of filing this case before the DCDRC Ganjam after 12 years of the death incident the complainant should have filed a case in proper court of law where she could have led evidence of eye witnesses or police personals who conducted the panchanama of dead body of the person or the doctor who conducted the autopsy/post-mortem of the body or the employer of the deceased to establish that the deceased policy holder died out of an accident. The accident/death of the policy holder was reported to have taken place on dated 24.06.2009 and the case is filed in the year 2021. The reason for 12 years delay in filing case has not been properly explained in the plaint. The case is barred by limitation and there is no cause of action the case is liable to be dismissed in limine.
4. On the date of hearing both parties are present. We heard argument from both sides at length. We perused the complaint petition, written version, written argument and materials available in the case record.
The insured of the policy no.:571581172 purchased the policy under plan-14 for term of 18 years from the LIC of India from Aska Branch under Division Office, Berhampur on 28th January 2005 which was inclusive of ‘double accidental death benefits’ and accordingly, the insured has deposited premium for the Sum Assured Rs.55,000/-.
The complainant in support of the complaint has adduced the evidences and submitted relevant documents relating to the accidental death of the insured. The complainant obtained the Final Report of the Case Diary. Part.I – Cr. No.:228/2009, II Town PS, Vijawada City and Post Mortem Report vide P.M.No.:640/2009, Dated: 26.06.2009 (Police Station:280 II Town, Cr. No.:228/2009) of Department of Forensic Medicine, Government General Hospital, Siddhartha Medical College, Vijayawada.
When the nominee/complainant claimed the death claim under the policy no.:571581172, the op has paid death benefits only amounting of Rs.65308/- out of Rs.66,880/- by deducting premium for one month bearing cheque no:767857/Dated:30.12.2009. But the op did not consider the claim for the double accidental death benefits due to not submission of the proper documents by the complainant/nominee.
By objecting the complaint of the complainant, the op has submitted in its Written Version, Evidence and Written Argument that, the word ‘accident’ is defined as something that happens unexpectedly. In this case the accident resulting death or the death is the cause of accident need to be taken as two incidents and not one. Contradicting the query, the complainant has described the incident in his complaint at para 4 that, ‘earth cake fell down over the insured. He was removed from the earth in the pit and immediately shifted to GGH hospital where the medical officer examined and declared dead as per report of the police station at page 9/10 of Final Report: CD dated:17.03.2011 in Cr. No.:228/2009 of II Town Ps, Vijayawada city. By dropping the further action in this case, the police authority concluded it as ‘Thus it is an accidental death due to fall of earth from over the ground into the pit where deceased was working and there is no foul play or suspicion about the death of the deceased’.
Further the complainant produced Post Mortem Report vide PM No.:640/2009 Dated:26.06.2009 related to Cr. No.:228/2009 – ‘died in hospital about 24-30 hrs prior to PMT. The PMT taken place at 1.45pm on 26.06.2009. The cause of death ‘died due to multiple injuries only’. On analysis of the PMT, it discloses that, the insured was died in between 7.45am and 1.45pm on 25.06.2009 at hospital after shifting from the spot on 24.06.2009.And further it can be confirmed from the PMT that, the injuries can be sustained only in the case of the accidents and the PMT also discloses that, the body was covered with mud.’
In support of his complaint, the complainant has also corroborated the FIR no.:228/2009, Dated:25.06.2009, Time:10.30hrs of Ps:Vijayawada II Town Ps: - wherein the informant reported that, ‘The deceased Kilas Bhatt working at flyover bridge accidentally debris fell over on the deceased with as a result he sustained fatal injuries and died on the way to the GGH Vijayawada.’
From all the reports mentioned supra, only one word was confirmed that, the cause of death of the insured was only due to the accident, nothing else.’It is apparent from the above documents that, the insured was died due to multiple injuries in his body and the same was caused due to fell down of debris/earth cake over the insured. The incident itself defines that, it was an accident which was happened suddenly or unexpectedly but not preplanned.
Further, the law is well settled in 2023 (3) CPR 58 (NC) that, ‘An insurance policy is a contract of insurance which as to be read as it is without any additions or other interpretations’. In the instant case, the insured was died due to accident only and the accident is the cause of death. Therefore, the doubt of op regarding – ‘death is the cause of accident’ is ruled out. And the meaning of the accident in the present case is only one i.e., accident resulting death. Hence the nominee/complainant is entitled to receive the double accidental death benefits under the policy no.:571581172. So the op should not be interpreted the terms and conditions of the policy otherwise.
The complaint has been filed by the complainant on 08.09.2021 as per order in WP no.:13946/2021, dated:20.07.2021 of Hon’ble Andhrapradesh High Court. So there was no delay in filling of the present case by the complainant and it is within time limitation of 2 years as per the Act, 1986. The instant case has been filed in accordance to the Order dtd: 20.07.2021 in WP No.:13946/2021 of the Hon’ble Andhrapradesh High Court.
The law is well settled in catena of cases that, the insurer cannot reject the claim in mechanically and technically and cannot deprive the beneficiary to get the benefits as per contract of insurance. The Hon’ble National Commission rightly observed in 2023 (3) CPR 66 (NC) that, “A contract of insurance between the concerned parties is on the principle of ‘Uberima Fides’ i.e., absolute good faith on part of both the contracting sides.” If the insurer is not providing all the benefits as per contract to the beneficiary it will be treated as breach of contract.
Further, the op has not settled the double accidental death benefits when the complainant/nominee submitted the death claim form with all original policy documents for first time on wanting of the authentic documents or evidence in support of the claim that the policy holder died out of an accident. When the same has been submitted by the complainant after 12 years of struggling and issued legal notices under Sec.80 of the CPC to the op frequently, the op being service provider should rendered the service by allowing the double accidental death benefits under the said policy instead of paid deaf ear and close eyes on the genuine claims zipped the mouth by interpreting the contract of insurance technical and mechanical way. And unfortunately, violating the terms and conditions of the said contract of insurance in policy no:571581172 the op intentionally, mechanically and technically not paid the double accidental death benefits as per policy term-14/pterm-18. It is tantamount to deficiency in services and unfair trade practices under the Consumer Protection Act, 1986.
The judgment on which the op has relied upon is not applicable to the present case. The main issue in present case whether the nominee is entitled to receive the additional death benefits as per insurance of contract. So the op is failed to prove its stand in the present case.
Once the op has accepted the death of insured is true and correct it should be the duty of the op to provide all the benefits at the time of settlement of the SA to the nominee instead of raising question of cause of death. It should have duty of the op to assist the helpless and poor widow nominee/complainant by considering her economic conditions to get all the additional accidental death benefits after submission of the death claim form. The IRDA laid down the clear regulations that, ‘after receiving the documents the claim should be settled in 30 days if it is non-early claim and natural death and no investigation is required. The instant case is coming under non-early claim and the death claim fulfills all the terms mentioned supra but it was not settled within 30 days.For deficient services of the op, the complainant being economically weaker person, suffered from uncountable physical, mental and financial harassments for last more than 14 years to get rights of the insured for which purpose, the policy was issued. Being nominee, the complainant is entitled to get all the double additional death benefits along with the adequate compensation and litigation cost in the present case.
But in the instant case, the op has taken steps negatively and against the principle of natural justice. It should not be made moto of the LIC of India. In the instant case, we inclined to appreciate the Ld. Counsel Sri Sudhir Kumar Pattnaik who has taken the task to his hand in very difficult time of the complainant and struggled to get rid of and further he helped the poor widow nominee of the policy holder to get justice by struggling for more than 14 years.
In our considered view and relying upon the principle of law laid down by SC of India in CA No.: 4071/2022 - Gurmel Singh v Branch Manager, National Insurance Co. Ltd the complaint is allowed against the op no.3 and dismissed against the op no. 1 & 2. The op no.3 is directed to pay additional accidental death benefits as per policy no:571581172 to the complainant together with interest @ 16% pa from the date of submission of the First death claim form by the nominee/complainant. Further the op is directed to pay exemplary cost of Rs.1,00,000/- to the complainant. It is directed to op no.3 to comply the order within 45 days from the date of receipt of this order failing which the complainant is at liberty to recover all the dues and costs from the op at the rate of 18% pa by invoking the statutory provisions of the consumer protection act, 2019.
Further, it is directed to the Zonal Manager, East Central Zonal Office of LIC of India, Bihar to make necessary inquiry and take disciplinary action against the erring officials of OP no.3. However, while making payment of compensation and cost to the complainant by the OP no.3, the ZM of LIC of India is at liberty to fix the accountability on erring official who was responsible for causing and rendering such deficient services to the complainant. The Sr. Divisional Manager of LIC of India Divisional Office, Berhampur shall pay first the awarded amount to the complainant and the same may be recovered from salary of such erring employees of OP no.3. And it is also directed to the LIC of India to render appropriate and cordial services by maintaining the State-of-the-Art services to the consumers’ especially to the widow nominee of the Ganjam districts.
The case is disposed of accordingly.
The Judgment be uploaded on the www.confonet.nic.in for the perusal of the parties.
A certified copy of this Judgment be provided to all the parties free of cost as mandated by the Consumer Protection Act, 2019. A copy of this order be also sent to the Secretary, State Consumer Disputes Redressal Commission, Odisha, Cuttack for information.
The file is to be consigned to the record room along with a copy of this Judgment.
Pronounced on 09.10.2023.
