D.O.F:16/12/2017
D.O.O:30/11/2021
IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD
CC.No.243/2017
Dated this, the 30th day of November 2021
PRESENT:
SRI.KRISHNAN.K :PRESIDENT
SRI.RADHAKRISHNAN NAIR.M : MEMBER
SMT.BEENA.K.G : MEMBER
Mr. K. Gurudath Prabhu, aged 49 years.
S/o Late Sadananda Prabhu.
“ Sadananda”, Behind S.A.Temple,
Mattadagudde, Hosbettu, Post : Complainant
Manjeshwara. 671323
Kasaragod District
(Adv: A. Balakrishnan Nair)
And
The Manager,
United India Insurance Company Ltd,
Opp – Popular Building, K.S. Rao Road, : Opposite Parties
Mangalore – 575001
(Adv: C. Damodaran)
ORDER
SRI.RADHAKRISHNAN NAIR.M : MEMBER
The instant complaint is filed by the complainant under section 12 of the Consumer Protection Act, 1986 (as amended)
The facts of the case in brief is that the complainant and his wife Mrs. Shrimathi Shanbogue @ Akshatha Prabhu obtained Uni Home Care Policy as per Policy No.070801/46/10/90/000 of the Opposite Party for the period 12-10 -2010 to 11-10-2030 for the RC framed house No MP IX / 569 of the complainant . The Opposite Party issued the insurance policy to the complainant stipulating certain conditions. As per the conditions both the insured were given personal accident benefits as per the Section 2 of the Policy to the tune of Rs 6,50,000/-.
The complainant's wife Mrs Shrimathi shanbogue @ Akshatha Prabhu met with an accident on 24-01-2015 at Manjeswara, while the driver of the KSRTC bus , in which she was travelling to Mangalore, suddenly applied brake and she fell down through the front door and sustained grievous injuries on head and chest. She was taken to KMC Hospital, Mangalore and undergone surgery. After discharge, She was under treatment but subsequently her condition became worse and on 24 - 01-2016 she started to vomiting and fell unconscious . Immediately she was taken to KMC Hospital Manglore and doctors tried their level best to rescue her but she was declared to be dead on the same day. The cause of death was respiratory failure, which was due to road accident co-pulmonary arterial Hypertension and bronchial asthma. Complainant's wife was hale and healthy before accident and she was working as a college at Manglore. She did not have any Co - morbidity. The complainant informed the Opposite Party about the accidental death of his wife and submitted the claim form for insurance benefit but the Opposite Party repudiated the claim stating that death was not due to any accident. The action of Opposite Party is unfair trade practice and service deficiency. Hence this complaint is filed with a prayer to give direction to the Opposite Party to pay Rs.6,50,000/- towards accident claim along with damages and costs.
The Opposite Party’s entered appearance and filed written statement. As per the version of Opposite Party, the complaint is false, frivolus, vexatious, and not maintainable on law or facts.
The Opposite Party admitted the issuance of a Policy as mentioned in the complaint. It is also admitted that the wife of the complainant met with an accident and she was treated from 24.06.2015 to 28.06.2015. Since her death was after 7 months after the accident it cannot be attributed to the accident. The cause of death was Type - II Respiratory failure, Bronchial Asthma, Co pulmunale with PAH and the claim was rightly repudiated. Only accidental death attracts policy liability. Post mortem Report/Death certificate only can be accepted as satisfactory proof for cause of death. Also, the claim was filed in delay. The complainant submitted the claim on 7.11 .2016, after nearly 1 year, before Canara Bank, who availed policy for complainant being their account holder. The delay in filing disentitle the claim. There is no service deficiency on the part of the Opposite Party and no mental agony caused to the complainant. The complaint is Iiable to be dismissed.
The complaint filed proof affidavit in lieu of chief examination and marked documents Ext A1 to A7. Ext. A 1 is the certified copy of Discharge Summery issued by KMC Hospital Manglore, Ext. A 2 is the Wound certificate, Ext. A3 is the prescription issued by Dr. Narasimha Pai, Ext. A4 is the copy of Insurance Policy, Ext.A5 is the repudiation letter issued by the Opposite Party, Ext. A6 is the CC of the deposition of Dr. Muralidhara Pai, the PW 2 in OP (MV) No.218/2018. Ext. A7 is the CC of the deposition of another witness Dr. Padmanabha Kamath in OP(MV) No.218/2018.
The complainant is cross - examined as PW 1.
The Opposite Party didn't adduced any oral evidence. They produced certain documents which are marked as Ext B1 to B8. The Document Ext. B 1 is the Personal Accident Insurance Claimant's Statement., Ext. B 2 is the Death Summary, Ext. B3 is the Uni home care policy, Ext. B4 is the copy of the extract of Attendance Register of the Institution where the Complainant's wife worked . Ext. B5 is the CC of the document X1(Patient Record) on the file OP(MV)No. 218/2018, Ext. B6 is the CC of the deposition of the complainant in OP(MV)No. 218/2018, the Ext. B7 is a Letter issued by Dr. BH Krishna Moorthy Rao, Ext. B8 is the CC of the Award in OP(MV)No. 218/2018.
Based on the pleadings and evidence adduced by the rival partice in this case the following issues are raised for consideration in this case.
1. Whether the complainant's wife sustained bodily injury in an accident during the Policy Period?
2. Whether the above accident be the sole direct cause of complainant's wife's death?
3. Whether the complaint is entitled for any amount towards insurance benefit?
4. Whether there is any service deficiency on the part of the Opposite Party?
5. If so, what is the relief and costs?
ISSUE No:1
Here there is no dispute as regards to the issue that whether the complainant's wife sustained bodily injury in an accident during the Policy Period. The complainant states that his wife Smt. Akshatha Prabhu @Shrimathi Shanbogue met with an accident on 24-01-2015 at Manjeswara, while the driver of the KSRTC bus in which she was travelling to MangIore suddenly applied break and she fell down through the front door and sustained grievous injuries on head and chest. She was taken to KMC Hospital, Manglore and undergone surgery. The Opposite Party admitted in their version that the wife of the complainant met with an accident and she was treated from 24.06.2015 to 28.06.2015.
But as regards to the issue, whether the above accident be the sole direct cause of complainant's wife's death, there is dispute .The complainant argue that after the discharge from Hospital , she was under treatment but subsequently her condition became worse and on 24 - 01-2016, she started to vomiting and fell unconscious . Immediately she was taken to KMC Hospital Manglore and doctors tried their level best to rescue her but she was declared to be dead on the same day. The cause of death was respiratory failure which vas due to road accident co-pulmonary arterial Hypertension and bronchial asthma. Complainant's wife was hale and healthy before accident and she was working in a college at Manglore. She did not have any Co - morbidity. She had no ailments before the accident. The Opposite Party strongly disputes this argument and submits that since her death was after 7 months of the accident it cannot be attributed to the accident. The cause of death was Type - II Respiratory failure, Bronchial Asthma, Corpulmunale with PAH and the claim was rightly repudiated . Only accidental death attracts policy liability. Post mortem Report/Death certificate only can be accepted as satisfactory proof for cause of death.
To prove the claim the complainant produced Ext. A1 to A7 document. The Ext. A3, the Wound certificate would show that Smt: Akshatha Prabhu sustained a head injury.
As per the argument of the complainant, as per CT Scan report fluid discharge was detected. The complainant also produced 2 documents, Ext. A6, which is the CC of the deposition of Dr. Muralidhara Pai, the PW 2 in OP(MV) No.218/2018 and Ext. A7, which is the CC of the deposition of another witness Dr. Padmanabha Kamath in OP(MV) No.218/2018. It is seen deposed by Dr. Muralidhara pai that on 24.06.2015, Akshatha Prabhu was brought to his hospital and during investigation using CT scan he noticed right subdural haematoma and frontal contusion. It is also seen deposed by Dr. Muralidhara pai that by medication she was improved and consequently discharged on 28.62015. It is also deposed by the Dr. Muralidhara Pai that the infection that can cause from ear to nose is unlikeIy to go to Iungs unIess there is aspiration or fulminant infection. The doctor also seen deposed that the patient can develop aspiration if she had fits and it can result in secondary complication of aspiration pneumonia , which can result in poor out come . But at the time of discharge no neurological deficit was detected and in follow up consultation she was found better. The document Ext. A 5 , the Death Summary would show that the cause of death is Type II Respiratory failure, Bronchial Asthma, Corpulmonale with PAH. In the Document Ext. A 7 , which is the CC of the deposition of another witness Dr. Padmanabha Kamath in OP(MV) No.218/2018, it is seen deposed by Dr. Padmanabha Kamath that he cannot say whether the death was due to complication of the accident. It was Dr. Padmanabha Kamath, who issued the Ext A7, and he is seen deposed that he issued the certificate showing the cause of death. Hence there is no reliable evidence to show that Smt. Akshatha Prabhu had any post accident complications which resulted in her death.
As regards to the issue, whether the complaint is entitled for any amount towards insurance benefit, the document Ext. A4 is the copy of Insurance Policy. The page 7 of the document would show that "SECTION - II PERSONAL ACCIDENT: Subject to the terms, exclusions, definitions, and conditions contained herein or endorsed or otherwise expressed here on the company will pay the insured as here in after mentioned. If at any time during the currency of this policy the insured's borrower shall sustain bodily injury resulting solely and directly from accident caused by external violent and visible means, then the company shall pay to the insured or the borrower's legal personal representatives as the case may be, the sum here in set forth, that is to say. If such injury shall with in 12 calendar months of its occurrence be the sole and direct cause of the death of the insured's borrower, the capital sum insured stated in the schedule here to ".
So it is clear that its occurrence, that is, the accident be the sole and direct cause of the death of the insured's borrower. Here the insurer is the Canara Bank and the insurance policy is made available by the bank for the security of its account holders/borrowers. Here, no post mortem is conducted and therefore no post mortem report. The complainant didn't produced the death certificate also. The sole document available to show the cause of death is death Summary produced and marked by Opposite Party. Ext.B2 is the Death Summary, which shows that the death is due to "Type II Respiratory Failure, Bronchial Asthma, Corpulmunale with PAH.” The complainant could not establish any direct or indirect connection to the death of Smt. Akshatha Prabhu with the accident occurred 7 months prior to the death.
So considering the circumstances and available evidence in this case, this commission is of the view that the death of Smt. Akshatha Prabhu, the complainant's wife is not due to RTA accident and therefore the complainant is not entitled for insurance benefit.
Therefore the repudiation cannot be held as against law. Hence there is no service deficiency or un fair trade practice on the part of the Opposite Party and the complainant is not entitled to the relief prayed for in this case.
In the result the complaint is dismissed with no costs.
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Exhibits
A1- Discharge Summary
A2-Wound Certificate
A3-Prescription
A4- copy of Insurance policy
A5- Repudiation letter
A6- Deposition of Pw2 OP (MV) No: 218/218
A7- Chief examination of Dr. Padmanabha Kamath
B1- Personal Accident insurance claimant’s statement.
B2- Death summary
B3- Uni home care policy
B4- Attendance Register
B5- Patient Record
B6-Deposition of the complainant in OP(MV) No 218/2018
B7- Letter issued by Dr. BH Krishna Moorthy Rao
B8- CC of the Award in OP (MV)
Witness Examined
Pw1- Gurudath Prabhu
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Forwarded by Order
Senior Superintendent
Ps/
