Order by:

Smt.Priti Malhotra, President

1.       The complainant  has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that Gursewak Singh husband of complainant (now diseased) was insured with Opposite Party vide policy bearing No.2999201790009102000 (Group Personal Accidental Policy). On 01.01.2020, Gursewak Singh met with an accident when he was going to Daudhar from Lopon with his brother Lakhwinder Singh and in the said accident, Gursewak Singh life assured suffered head injury and was admitted in H.M.C. Hospital, Ludhiana. In this regard, FIR No. 005 dated 13.01.2020 under section 279/337/338 of IPC as well as DDR no.025 dated 28.01.2020 was registered at P.S.Badhni Kalan. Due to the injuries, Gursewak Singh could not survive and died on 28.01.2020 and the post mortem of the dead body was conducted at Civil Hospital, Moga on 28.01.2020. It is averred that the complainant being the widow (nominee) of Gursewak Singh i.e. insured lodged the claim with the Opposite Party and also completed all the relevant formalities, but the Opposite Party did not pay any heed to the request of the complainant and repudiated the claim of the complainant. Thereafter, the complainant made so many visits to the office of the Opposite Party to get the death claim under the policy, but the Opposite Party refused to admit the rightful claim of the Complainant. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs.

a)       Opposite Party may be directed to pay the amount of Rs.30,00,000/- as death claim of deceased Gursewak Singh (husband of the complainant) alongwith interest @ 12% per annum till its realization.

b)      To pay an amount of Rs.50,000/- as compensation for mental tension, agony and harassment.

c)       To pay an amount of Rs.11,000/- as litigation expenses.

d)      Any other relief which this Commission deems fit and proper be granted to the complainant.

2.       Opposite Party appeared through counsel  and contested the complaint by filing  the written version taking preliminary objections therein inter alia that  the present complaint is not maintainable; the complainant has got no locus standi to file the present complaint as the complainant has failed to produce any document showing that the complainant is legal representative of Gursewak Singh. Admittedly, Gursewak Singh was insured with the Opposite Party for the period w.e.f 19.05.2019 to 18.05.2020 under the policy no.2999201790009102000 under the Group Personal Accident Insurance Policy. Averred that as per the claim, the insured met with an accident on 01.01.2020 and unfortunately died on 28.01.2020. But as per the documents submitted, the accident allegedly happened on 01.01.2020 however, FIR for the same was lodged on 13.01.2020 i.e. after delay of 13 days. Further no, intimation was given to the police after the insured was admitted to the hospital. As per the discharge summary, the deceased was admitted in HMC Hospital & Neuro Spine Trauma Centre from 01.01.2020 to 16.01.2020 and the insured was admitted with the complaint of drowsiness for 2-3 days. Nowhere in the  hospital record, it is mentioned that insured met with an accident or it is a case of RTA/ RSA. As per the statement given, the deceased was taken to home on 16.01.2020 where he unfortunately died on 28.01.2020. Moreover, the complainant has failed to provide any medical record for the period of 16.01.2020 to 28.01.2020. Further as per the Post Mortem Report, the death is caused due to septicaemia as a result of infection of liver and lungs. Averred further that the complainant has failed to produce any document which proves that the insured died on account of accidental injuries.  It is further submitted in written reply that as per the medical record submitted by the complainant herself, it is clear that the insured died a natural death and not due to any accident. The contents of the FIR which has been recorded after  a delay of almost 13 days i.e. after the date of alleged accident, by the relatives of the deceased has not been corroborated by the police. As such, it is clear that the complainant has tried to manipulate the cause of death in order to extract money from the Opposite Party. As per the terms and conditions of the policy, the policy covers death due to accident only and in the present case the insured’s unfortunate death was due to some illness and not due to any accident and therefore, the claim was repudiated vide letter dated 26.02.2021. Averred that there is no deficiency in service on the part of the Opposite Party; complicated questions of law and facts are involved in the present complaint, which requires lengthy procedure of law and evidence by way of examination in chief and cross examination and this matter requires to be relegated to the Civil Court. On merits, all other allegations made in the complaint are denied and prayer for dismissal of the complaint is made.

3.       In order to prove her case, the complainant has tendered into evidence her affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C16.

4.       On the other hand, Opposite Party also tendered into evidence affidavit of Smt.Shweta Pokhriyal Manager-Legal  Claims, HDFC Ergo General Insurance Co. Ltd. Ex.OP1 alongwith copies of documents Ex.OP2 to Ex.OP13.

5.       We have heard ld. counsel for the parties, perused the written arguments submitted on behalf of the complainant and gone through the documents placed  on record.

6.       It is admitted fact that husband of the complainant namely Gursewak Singh (now deceased) was insured with Opposite Party vide policy no.2999201790009102000 (Group Personal Accidental Policy). It is also admitted that during the policy period husband of the complainant expired. After the death of her husband complainant lodged the claim with Opposite Party, but they rejected the claim of the complainant and the said repudiation has been challenged through this complaint. It is also evident on record that FIR of the alleged accident was got registered with delay of 13 days.

7.       Ld. counsel for the complainant contended that husband of the complainant met with an accident on 01.01.2020, due to which he suffered some injuries and got admitted in HMC Hospital, Ludhiana. In this regard an FIR was got registered on 13.01.2020. However, unfortunately the husband of the complainant expired in his house, due to accidental injuries. Thereafter DDR was also filed for getting incorporation of offence u/s 304-A of IPC in the FIR earlier filed. However, the claim raised by the complainant was declined by the Opposite Party, which forces the complainant to file the present complaint.

8.       On this, the stand taken by the Opposite Party in the repudiation letter dated 26.02.2021(Ex.OP12) is that “death of the insured was non accidental in nature. The cause of death of the card holder was medical ailment, Septicemia as a result of infection of liver and lungs”. It is also submitted by ld. counsel for the Opposite Party that it is well mentioned in the repudiation letter that “as per policy special conditions 10(b) Claim for death due to accident shall be payable under any one section i.e. Accidental Death. Since the loss claimed is not covered as per above policy wording, we treat the claim as “No Claim”.

9.       To substantiate the case, the complainant has placed on record policy document Ex.C12, copy of FIR Ex.C2, copy of DDR Ex.C3, copy of post mortem report Ex.C5, copy of discharge summary Ex.C6, copy of death certificate Ex.C7. On the contrary, Opposite Party broadly have placed on record similar documents with addition i.e. few statements recorded by the investigator duly appointed by Opposite Party.

10.     In this back drop we have now to look into the genuineness of the claim and also to adjudge qua the genuineness of the repudiation of the claim as ‘no claim’. It has been alleged by the complainant that the accident of the policy holder occurred on 01.01.2020. In the record available there is a copy of FIR got registered on 13.01.2020 and it is also on record that when the death of the policy holder occurred on 28.01.2020 then a DDR for getting incorporation of offence u/s 304-A of IPC was also filed. Though, in the “claim form” also it has been so mentioned that the death of the policy holder occurred due to alleged accident, but it is apt to mention that the record available on file is contrary to this fact. We have carefully gone through the “Discharge Summary” of HMC Hospital and Neuro Spine Trauma Centre(Ex.C6 & OP5), wherein, in the “diagnosis column” it is written as under:-

“Left lateral ventricle entrapped, Diabetes Mellitus 2, HCV Positive, Deragned NR Anaemia Hypoalbuminemia”

          Also in the “column of history”, it is recorded that “Drowsiness for 2-3 days, No H/O Seizure/drug allergy” and in the “investigation column” there is reference of various tests conducted i.e. Hb, TLC, DLC, Platelet, BI Urea, Creatinine, S.Sodium, Potassium, ECG, Xray Chest, which got conducted on 01.01.2020 and it is pertinent to mention that there is also reference of “CT Head” done on 31.12.19. The result of the tests is mentioned as Left Lateral Ventriculomegaly. Further in the column Treatment & Course in hospital it is mentioned that surgery was performed and endoscopic septostomy was done. For the sake of convenience the course of treatment followed in the hospital is mentioned as under:-

Treatment & Course in hospital: Thoroughly Assessed and investigated, thereafter taken up for surgery. On 02.01.2020, underwent Endoscopic Septostomy (Ventricle hit at about 4 cm depth from dura. In CSF suspended particles present. The septum was intact. The Left Foramen of Monroe was smaller and distorted ? ventricular catheter was seen just posterior to FM. After making small fenestration in septum with bipolar probe, it was dilated sufficient to accomdate 4 mm sheath, and seen C/L choroid. Bleeding from the margin of fenestration controlled by irrigation). CSF culture grew acinatobacter lowfill and antibiotic changed according to sensitivity to Elores in high dosage. Blood sugar managed with insulin. On 07.01.20, had feed intolerance, Urea 65.0, managed with IV Fluids and Hypokalemia (S.Potassium 3.4)Correction with Syp Potklor: subsequently started tolerating feeds adequately. Had intermittent fever, tracheostomy secretions grew Pseudomonas Aeruginosa and counts were rising (TLC counts-24,000/mm so Colistin added, subsequently fever subsided. And bulge remain subsided Fever also subsided.”

Pertinent to mention here that there is no recording in the Discharge Summary that the insured/patient got admitted in the hospital in question as a Road Side Accident Patient. Thus, from the said discharge summary, it is now clear that the policy holder was not admitted in the hospital due to any road side accident, but landed up in the hospital for the cure of ailment suffered, which was diagnosed a day earlier vide CT Head been done on 31.12.2019. It also reveals that treatment/surgery was planned. Our view is duly been corroborated by post mortem report as placed on record (Ex.C5), in which, under the table Internal Examination against the column it is mentioned that “Shunt was placed in the lateral ventricle” and further in the Opinion cause of death is mentioned as under:-

“The cause of death in this case, in my opinion, is due to septicaemia as a result of infection of liver and lungs, which is antemortem and is sufficient to cause death in an ordinary course of nature.”

11.     From the discussion above, we are of the considered view that the stand taken by the Opposite Party in the repudiation letter dated 26.02.2021 (Ex.OP12) is right that the policy holder has not died due to any accidental injuries. Thus, there is no deficiency in service on the part of Opposite Party in declaring the claim of the complainant as ‘No Claim’.

12.     Sequel to the above discussion, the present complaint is hereby dismissed. Keeping in view of peculiar circumstances of the case the parties are left to bear their own costs. The pending application(s), if any also stands disposed of. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced on Open Commission