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. At that time he joined in the insurance policy with opposite party No.2 through opposite parties No.1 and 3. While so Sri. Sivadasan fall from a tree height while he was collecting food materials from jackfruit tree for his cattle's and suffered with grievous injuries including fracture of C5 Vertebrae and qruadriparasis. While he was undergoing treatment at Kannur Medical College Super Speciality Hospital he died on 09.10.2009. After his death the complainant's wife of the late Sivadasan, submitted a claim form but she has not received the claim amount ie Rs.2,00,000/- from opposite parties. That is deficiency in service on the party of the opposite parties. Hence it is prayed to give direction to opposite parties to pay an amount of Rs.2,00,000/- with 12% interest from 09.01.2010 onwards and direct to pay an amount of Rs.50,000/- as compensation and to grand the cost of this petition.
2. The opposite parties appeared and filed their version. In the version of opposite party No.1 the opposite party denied all the allegations and the averments in the complaint. He admitted that this opposite party submitted insurance claim application submitted by the complainant to the opposite party No.3 along with other documents and opposite party No.3 submitted the application to opposite party No.2 on 11.12.2009 for consideration. Hence there is no deficiency in service on the part of opposite party No.1. Hence it is prayed to dismiss the complaint with cost.
3. Opposite party No.2 filed version and additional version. In the version of opposite party No.2 they admits that the opposite party has issued a Group Personal Accident Insurance Policy to opposite party No.1. The period of policy is from 01.11.2008 to 31.10.2009. The petitioner submitted a claim form before the opposite party. On getting the claim form the opposite party informed the complainant to submit postmortem report and FIR to process the claim. The alleged accident occurred on 31.08.2009 and the petitioner expired on 09.10.2009. The Doctor has reported that the case of death was Cardio respiratory arrest and the same was no way connected to the injuries sustained in fall from the height. As per the terms and conditions of the policy, the claim will be considered if the injury shall with 12 calender months of its occurrence be the sole and direct cause of the death of the insured. The party has to produce the proofs satisfactory to the company all matters upon which a claim is based. The basic required documents requested by opposite party ie the postmortem report and the FIR were not produced to prove the genuineness of the claim. Since the death happened after long time after the incident. The benefit of accident death must be decided upon the norms and procedure and as per the condition of the policy. The complainant has not responded to the request made by this opposite party. The complainant filed this complaint with some ulterior motive. This opposite party has not repudiated the claim, so there is no deficiency in service on the part of the opposite party and the complaint may be dismissed with cost of the opposite party.
4. In the version of opposite party No.3 it is submitted that the claim of the complainant is in connection with the Ksheera Karshaka Arogya Suraksha Padhathi. The Ksheera Karshaka Arogya Suraksha Padhathi is an accident insurance programme launched by opposite party No.2. This opposite party has forwarded the entire documents to opposite party No.1 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. The claim of the complainant is to be settled by the 2nd opposite party. There is no deficiency of service on the part of the opposite parties. Hence the complaint may be dismissed with cost of this opposite party.
5. On considering the complaint and versions the following points to be considered:-
1. Whether there is any deficiency in service on the part of opposite parties?
2. Relief and cost.
6. Point No.1 :- To prove the complainant's case she has filed her proof affidavit, and also produced Exts.A1 to A7 documents. In the proof affidavit she stated as stated in the complaint. In the complaint she stated that she has submitted her claim form along with documents to opposite party No.2 through opposite party No.3. In the version of opposite party No.1 it is submitted that the claim form along with other documents submitted to opposite party No.2 on 11.12.2009, it is not denied by opposite party No.2. But till date opposite party No.2 has not paid the insurance amount to the complainant. In the version they stated that the case of death was Cardio respiratory arrest. Hence they are directed the complainant to produce the FIR and Postmortem Certificates. In this case Dr. Sujith who treated the deceased Sivadasan at Kannur Super Speciality Medical College is examined as CW1. In the Certificate (Ext.A7) he clearly stated that the cause of death was Cardio respiratory arrest secondary to fall from height and its complications. The case sheet is produced by Dr. Sujith is marked as Ext.X1 Series. Ext.X1 series and the evidence of Dr. Sujith, Consultant Neurologist and Movement Disorder Specialist and Associate Professor and Head of Neurology in Kannur Medical College clearly stated that the death was due to Cardio respiratory arrest secondary to fall from height. So not sanctioning of the insurance claim is deficiency of service on the part of opposite party No.2. Point No.1 is decided accordingly. Opposite party No.1 and 3 has done their work without any delay. Hence there is no deficiency of service on the part of opposite party No.1 and 3.
7. Point No.2 :- Ext.B1 shows that the complainant's husband was insured for an amount of Rs.2,00,000/-. So she is entitled to get an amount of Rs.2,00,000/- 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 partly allowed. The opposite party No.2 is directed to pay an amount of Rs.2,00,000/- ( Rupees Two Lakh Only) with 10% interest from 29.08.2011 till the payment is made. Opposite party No.2 is also directed to pay an amount of Rs.3,000/- ( Rupees Three Thousand Only) as cost and compensation. This Order is to be complied by the opposite party No.2 within 30 days from the date of receipt of this.
Pronounced in Open Forum on this the day of 30th March 2012.
Date of Filing:29.08.2011.
