Complainant Smt.Sukhwinder Kaur through the present complaint filed under Section 12 of the Consumer Protection Act, 1986 (for short, ‘the Act’) has prayed that the opposite parties be directed to pay Rs.4,00,000/- on account of her sum assured and pay Rs.50,000/- on account of compensation for harassment and mental agony and Rs.10,000/- as litigation expenses to her, in the interest of justice.
2. The case of the complainant in brief is that her mother Smt.Swaran Kaur (Deceased) became the member of Dauphin Touch Network Pvt.Ltd. through their agent Kunan Singh son of Shive Singh, resident of village Bidhipur, P.O.Dhariwal, District Gurdaspur which have tie up with the National Insurance Co.Ltd. So, Swaran Kaur had got insurance from the opposite party under the Scheme of Dauphin Touch Network Pvt.Ltd. Vide policy No.361201/42/12/8200000264 vide Certificate No.NIC/GPA-0969 dated 26.11.2012 and she had been declared as assignee in the abovesaid policy by her mother Swaran Kaur as such she is consumer of the opposite party after her mother’s death. She has further pleaded that the opposite party insured her mother for Rs.4,00,000/- as per the policy detailed, 80% is to be covered in case of person accident and 20% is to be paid in case of hospitalization. The present case is of both i.e. person accident and hospitalization. Smt.Swaran Kaur met with an accident on 7.8.2013 at about 3 PM on Fatehgarh Churan Near Village Thathe, Distt.Amritsar and was admitted to Amandeep Hospital Amritsar on the same day where she was operated upon and spent Rs.41,772/- on hospitalization but on 10.8.2013 she died and later on 11.8.2013 her postmortem was conducted at Govt.Medical College, Amritsar. According to postmortem report and in the opinion of Medical Officer “the cause of death is failure of brain function as a result of injury to head which is sufficient in ordinary course of nature to cause death” and the abovesaid injuries were due to road side accident. In this regard police had done proceedings U/s 174 Cr. P.C. Vide DDR No.17 dated 11.8.2013 at P.S.Ghanie Ke Banger. She has also informed the opposite party no.2 vide letter dated 16.8.2013 and 3.10.2013 alongwith required documents. She also personally visited to the office of opposite party no.1 and submitted the documents required by them but the opposite party was not ready to settle her claim and is prolonging the matter with one pretext or the other. Thereafter, she filed complaint U/S 12 of the C.P.A. In this Hon'ble Forum on 26.2.2014, which was decided on 27.8.2014 with the direction to the opposite party to decide her claim within the period of 30 days from the receipt of the abovesaid order, but the opposite party did not pay any heed towards the orders of this Hon'ble Court and she had to file application U/S 25/27 of C.PA. On 22.10.2014 and then finally the opposite party vide letter dated 20.11.2014 repudiated her claim on the plea that her mother died due to rise of blood sugar which lead the attack of hyperglycemia. She has next pleaded that in the opinion of the Medical Officer “the cause of death is failure of brain function as a result of injury to head which is sufficient in ordinary course of nature to cause death” and the abovesaid injury is due to road side accident and the same information was sent to the police that “the deceased alleged to have died on road side accident. The opposite parties are harassing her without any fault on her part for which the opposite parties will be held responsible. The opposite party has repudiated her genuine claim. Hence this complaint.
3. Upon notice, the opposite parties appeared through their counsel and filed the written reply by taking the preliminary objections that complaint is not maintainable and is liable to be dismissed, no cause of action action has been accrued to the complainant against the opposite parties for filing the present complaint and the complaint is absolutely false, frivolous. On merits, it was admitted that the opposite party insured the mother of the complainant with a total amount of Rs.4,00,000/- as per the policy detailed, 80% is to be covered in case of person accident and 20% is to be paid in case of hospitalization. Actually, after getting information from the complainant on 12.08.2013 the opposite party appointed S.A. Investigating & Consulting Agency Investigators & Consultants 'Ashiana' Canal view Enclave, Abrol Nagar Pathankot to investigate the matter. S.A. Investigating & Consulting Agency Pathankot submitted its report on 24.11.2014 and as per his findings of report the death of deceased Mrs. Swaran Kaur is not accidental in nature and the proximate cause is hyperglycemia. The deceased Smt.Swaran Kaur wife of Deewan Singh mother of complainant had died due to attack of hyperglycemia resulting into giddiness which caused her fall off the motorcycle as a result of which there was head injury. The insured deceased Smt.Swaran Kaur had first suffered an attack of hyperglycemia and as she was pillion rider on motorcycle no. PB-58F-2510 at the time of said attack of hyperglycemia resulting thereby felt giddy to fall of the vehicle. There is no accident involved in this claim. That as per post postmortem report of the deceased the cause of death is “Brain Failure as result of injury to head”. Thus, this means that first there was brain failure due to which she sustained head injury as she fell from the motorcycle. That as per police record vide DDR dated 11.08.2013 the proximate cause of death is Rise of blood sugar which lead attack of hyperglycemia due to chronic Diabetes. So from the facts mentioned above the claim of the complainant is not maintainable as per Terms and Conditions of the policy. The opposite party vide its letter dated 20.11.2014 repudiated the claim of the complainant being not maintainable as per Terms and Conditions of the policy. All other averments made in the complaint have been denied and lastly the complaint has been prayed to be dismissed with costs.
- Complainant tendered into evidence her own affidavit Ex.C1 alongwith other documents Ex.C2 to Ex.C9 and closed the evidence.
- Sh.Parveen Chadha Manager of the opposite parties tendered into evidence his own affidavit Ex.OP-1, alongwith other documents Ex.P-2 and Ex.OP3 and closed the evidence.
6. We have examined all the documents/evidence produced on record and have also duly considered and perused the arguments duly put forth by the learned counsels for both the sides, while adjudicating the present complaint. We find that the impugned claim has been repudiated Ex.C3 (Ex.OP2) on the basis/strength of the ‘investigation report’ Ex.OP3 of the SA Investigating & Consulting Agency, who were deputed by the OP insurers to investigate the same. Somehow, the said report is not supported by the necessary ‘affidavit’ of either the investigator or by the ‘statement’ of any ‘single’ person examined/ interviewed/interrogated during the entire exercise. No expert medical evidence pertaining to the ‘interpretation’ of the PMR (Post Mortem Report) has been produced. The interpretation as to the ‘cause of death’ is unwarranted since the PMR clearly states the same as: ‘Brain failure as result of injury to head’ and by no stretch of imagination the investigator’s interpretation that ‘first’ there was ‘brain failure’ on account of ‘hyperglycemia’ (imbalance of blood sugar) and as a result the DLA (deceased life assured) fell off the Motorcycle that ‘caused’ injury to her head, can be accepted/ believed. At the best, it has been an interpretation of ‘convenience’ and nothing more need be said. Further, it has been alleged that at the time of accident the DLA had come to Fatehgarh Churian for medical treatment of ‘Diabetes’ and was referred for super-specialist treatment at Amritsar, but no cogent evidence for the same has been put forth. Under the circumstances, we find the impugned ‘repudiation’ to be unfair, arbitrary and solely based upon illogical deductions and are inclined to set-aside the same along with the investigator’s report.
7. In the light of the all above, we partly accept the present complaint and thus ORDER the OP insurers to settle and pay the impugned ‘insurance claim’ pertaining to related Policy in question with full accrued benefits etc if any, along with Rs.5,000/- as compensation for the undue harassment inflicted besides Rs.2,000/- as cost of litigation; within 30 days of receipt of the copy of these orders, otherwise the entire awarded amount shall attract interest @ 9 % PA form the date of filing of this complaint till actually paid.
8. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.
(Naveen Puri)
President.
ANNOUNCED: (Jagdeep Kaur)
June 23, 2015 Member.
*MK*
