By Smt.Padmii Sudheesh, President
The case is that the husband of complainant availed a policy from the respondent for a period from 10/7/05 to 9/7/05. As per the terms of the policy the respondents would pay the insured amount of Rs.35,000/- in the event of insured succumbing or incurring permanent disability on account of road accident. On 13/7/04 at 10.30 AM the husband of complainant was travelling in an autorickshaw and on account of rash and negligent driving of the driver of autorickshaw it had overturned and capsized. There were two persons travelling in the vehicle and on account of the accident the husband of the complainant sustained serious injuries and was taken to West Fort hospital, Thrissur. The condition of the husband of complainant deteriorated on account of wrong diagnosis and treatment of the doctors at West Fort hospital and discharged from there and admitted at Mother hospital, Thrissur. He was admitted at Mother hospital when he developed chest pain and found it difficult to breath. He was died on 24/7/04 at 2.45pm on account of the injuries sustained to him in the road traffic accident. The complainant applied to get the policy benefits but was refused. The respondent wanted to produce death certificate, FIR and original policy. The claim was denied on the ground that the death of husband was on account of cardio respiratory arrest and not due to accident. This act of respondent is deficiency in service. Hence the complaint.
2.The counter averments are that the respondent admitted that a Gramin and Janatha Personal Accident Policy was issued to the husband of complainant from 10/7/95 to 9/7/06. The risk covered is only for accidental death and the injuries mentioned in the policy. The complainant has informed the death of the insured on 13/9/04 and thereafter the claim form along with other papers were submitted to the company. On scrutiny it is seen that post mortem had not been conducted. In the accident the insured sustained injuries like fracture of left clavicle, right fibula and he was applied knee slab and clavicle brace, treated with analgesis and antibiotics. He was admitted at the hospital on 13/7/04 and after curing the disease he was discharged on 17/7/04. He was again admitted at Mother hospital on 24/7/04 with symptom of abrupt on set severe breathlessness and chest pain and he died on the same day at 2.45pm. The doctor says that the primary cause of the death is acute cor pulmonale, cardio respiratory arrest and the secondary cause is pulmonary embolism and that was ascertained from clinical features and confirmed by Echo. As per the terms and provision of the policy the settlement of death claim is subject to submission of death certificate, post mortem and original policy. In this case post mortem was not conducted. The complainant is not entitled to get any claim under the policy. Hence dismiss.
3. Points for consideration are that :
1) Whether there isany deficiency in service committed by respondent?
2) If so reliefs and costs ?
4. Evidence consists of oral testimony of PW1, Exhibits P1 to P5, Exhibits R1 to R10 and Exhibit X1.
5. Points : The complaint is filed by the wife of insured to get policy benefit wherein the insured is no more. The husband of complainant was Janatha Personal Accident Insurance Policy holder of respondent and during the policy period a road accident was occurred and he was seriously injured. He was taken to West fort hospital and later he was admitted at Mother hospital on 24/7/04 and died there. She states that the husband was died on account of the injuries sustained to him in the road traffic accident.
6. The respondent filed their version and contended that the death of insured was on account of cardio respiratory arrest and pulmonary embolism and so complainant is not entitled to get any claim under the policy. The respondent stated that the injury caused to the insured out of road traffic accident was on 13/7/04 and the death was on 24/7/04 at Mother hospital, Thrissur. But the cause of death was pulmonary embolism and not due to the injury sustained in the accident. According to them the deceased was admitted at the hospital on 13/7/04 wherein the accident was occurred and recovered the disease and he was discharged on 17/7/04. Again he was admitted at Mother hospital on 24/7/04 with the symptom of abrupt on set severe breathlessness and chest pain. So the respondent would say they have rejected the claim with genuine reason and cause of death is not covered under the policy.
7. The complainant produced Exhibits P1 to P5 documents in support of the claim. Those documents are not sufficient to establish the claim of complainant. The doctor who had treated the insured on 24/7/04 is examined as PW1 and Exhibit X1 is marked through him. The treatment of husband of complainant on 24/7/04 was admitted by the doctor and he has deposed that the patient was admitted with chest pain and sweating. According to him the patient who was laid up due to accident has every possibility of venus thrombosis and the consequent complication pulmonary embolism. The cause of death was pulmonary embolism. In this case on 13/7/04 the road accident was occurred and he was discharged on 17/7/04. The complainant stated in the complaint that the condition of the husband was deteriorated on account of wrong diagnosis and treatment at West Fort hospital, Thrissur. It is also stated, with medical opinion he was discharged from West fort hospital and admitted at Mother hospital, Thrissur. There are no records to prove the same and these are baseless allegations. There is no evidence at all to show that after the discharge from the West fort hospital on 17/7/04 complications had arisen to the deceased. The complainant very cunningly refrained from stating the date of discharge from West fort hospital and the date of admission at Mother hospital. The records would show that the deceased discharged on 17/7/04 and there were no complications. Complainant also unwilling to step into the box to prove her case. But PW1 deposed that there is every possibility of pulmonary embolism to such kind of patients. As per Exhibit X1 and PW1 the patient was admitted at Mother hospital at 24/7/04 with the complaints of chest pain and sweating. The history of decease as per Exhibit X1 is sudden onset. So it can be considered that on 17/7/04 the condition of the patient was better. It is true that there was deficiency in service on the part of respondents in rejecting the claim of complainant. But the complainant is not entitled to get compensation because she tried to twist the case and mislead the Forum.
8. In the result the complaint is allowed and the respondent is directed to pay Rs.35,000/- with costs Rs.1,000/- within two months from the date of receipt of copy of this order.
Dictated to the Confdl. Asst., transcribed by her, corrected by me and pronounced in the open Forum this the 26th day of November 2012.
