Chandigarh

DF-I

CC/522/2023

SAROJ BALA - Complainant(s)

Versus

THE NEW INDIA ASSURANCE COMPANY LIMITED - Opp.Party(s)

DEVINDER KUMAR

04 Jun 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/522/2023
Date of Institution	:	01/11/2023
Date of Decision	:	04/06/2024

 

Saroj Bala (age 51 years) widow of late Sh. Ramesh Chand, deceased r/o 152-A, Backside Police Station, Near Blind School, Sector 26, Chandigarh.

… Complainant

V E R S U S

1. The New India Assurance Company Limited, Regional Office through Regional Manager, SCO No.36-37, Sector 17-A, Chandigarh 160017.
2. HDFC Bank Limited through its Branch Manager, SCO No.371-372, Sector 35-B, Chandigarh 160035.

… Opposite Parties

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	Sh. Devinder Kumar, Advocate for complainant
	:	Sh. J.P. Nahar, Advocate for OP-1
	:	Sh. A.P.S. Sehgal, Advocate for OP-2.

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Smt.Saroj Bala, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations, as projected in the consumer complaint, that the husband of the complainant namely Sh. Ramesh Chand was working as Head Constable with the Chandigarh Police (hereinafter referred to as “employer”) vide Belt No.3106/CP. During the course of employment, employer of the husband of complainant had opened his salary account in HDFC Bank/OP-2 vide account No.50100027680007 and OP-2 had also issued an ATM card, through which he was insured with OP-1 for ₹30.00 lacs in case of accidental death. On 10.4.2021, when the husband of complainant (hereinafter referred to as “insured”) was on duty, he was knocked down by a car bearing registration No.CH01-BX-7865, as a result of which he suffered multiple injuries and the said accident had occurred due to rash and negligent driving of the driver and FIR No.17 dated 11.4.2021 (Annexure C-4) was registered against the driver.  Copies of identity card and ATM card of insured are Annexure C-2 and C-3. Thereafter the insured was taken to GMCH-32, Chandigarh for treatment on 10.4.2021 from where he was discharged on 15.4.2021. After that the insured was taken home, where he was not showing any remarkable recovery and accordingly on 17.4.2021 he was taken to Alchemist Hospital, but, the hospital authorities refused to treat him due to second wave of COVID-19 pandemic.  On account of his critical condition, insured was again brought to GMCH-32, Chandigarh, but, he was advised to take rest at home.  On 27.4.2021, he was again taken to New Lifeline Hospital, Zirakpur for treatment where he remained admitted upto 29.4.2021 and on having his critical condition, he was taken to PGI, Chandigarh on the same day.  However, the insured could not recover and died on 1.5.2021 due to the reason of accident. Copies of medical record and death certificate are Annexure C-5 (colly.) & C-6. Thereafter, intimation about the death of the insured was given to the OPs and requisite documents were also submitted. Vide letter dated 20.8.2021 (Annexure C-7), employer of the deceased insured had also requested OP-1 to release the claim amount in favour of the complainant. The complainant approached the OPs to know about the status of claim, but, the matter was lingered on one pretext or the other.  However, instead of paying the genuine claim of the complainant, OP-1 vide letter dated 11.3.2022 (Annexure C-9) repudiated the same on the ground that the insured had not died on account of accidental injuries, rather he had died due to COVID pneumonia.  In this manner, the aforesaid act of the OPs amount to deficiency in service and unfair trade practice. OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OPs resisted the consumer complaint and filed their separate written versions.
3. In its written version, OP-1 admitted that deceased Sh. Ramesh Chand was insured with the answering OP vide subject policy namely “Personal Accident Insurance ((Group(Unnamed))” (Ex.OP-1/1), obtained by OP-2/bank w.e.f. 19.5.2020 to 18.5.2021 with accidental death coverage of ₹30.00 lacs.  However, it is alleged that, in fact, the deceased insured had not died on account of accidental death, rather he had died from natural cause i.e. COVID-19 pneumonia, which fact has also mentioned in the MCCD and post mortem report by the hospital. Copies of opinion of the panel of doctors of PGI and post mortem report are Ex.OP-1/2 and Ex.OP-1/4 respectively.  It is further alleged that as the case of the complainant is not covered under the subject policy, her claim was rightly repudiated.  The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
4. In its written version, OP-2, inter alia, took preliminary objections of maintainability and cause of action.  However, it is admitted that as per the MoU (Annexure R-1) between the Chandigarh Police (employer) and the answering OP, its role was limited to facilitating the documentation with regard to accidental insurance claim to OP-1 and it is for OP-1 only to decide about the claim lodged by the complainant, especially when the decision has to be taken by OP-1 only and not by the answering OP. On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
5. In replication, to the written version of OP-1, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.  However, the complainant chose not to file replication to the written version of OP-2.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully, including written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of parties that OP-2/bank, on behalf of Chandigarh Police (i.e. employer), had obtained the subject policy (Ex. OP-1/1) from OP-1 and deceased, Sh. Ramesh Chand alongwith other personnel of Chandigarh Police, was insured under the subject policy with OP-1 in pursuance to MOU (Annexure R-1) executed between the employer and the Bank (OP-2) under which free personal accident death cover of ₹30.00 lacs on the salary account (without any condition of swiping of debit card) was provided and he had met with an accident on 10.4.2021 and immediately thereafter he was taken to various hospitals  and finally he died on 1.5.2021 at PGI Chandigarh, as is also evident from the death certificate (Annexure C-6) and Inquest report (Annexure C-4/A), and the claim lodged by the complainant was repudiated by OP-1/insurer on the ground that the deceased insured had not died on account of accidental injuries, rather he had died due to COVID pneumonia, the case is reduced to a narrow compass as it is to be determined if OP-1/ insurer is unjustified in repudiating the genuine claim of the complainant and she is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if OP-1/insurer is justified in repudiating the claim and the consumer complaint of the complainant, being false and frivolous, is liable to be dismissed, as is the defence of OP-1/insurer.
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the subject policy, medical record and the repudiation letter and the same are required to be scanned carefully for determining the real controversy between the parties.
   3. Perusal of the subject policy (Ex.OP-1/1) clearly indicates that the personnel/employees of the Chandigarh Police, including the insured, were covered under the same w.e.f. 19.5.2020 to 18.5.2021. Further, copy of MoU (Annexure R-1) clearly indicates that each employee was covered for ₹30.00 lacs in case of accidental death. The relevant portion of the said MoU is reproduced below for ready reference:-

        “3.   We are pleased to offer your personnel below Insurance covers as part of our salary account subject to all of your personnel will draw their monthly salaries through HDFC Bank only and the last month salary credit in HDFC Bank Salary account before the death of the employee.

        a)     Free Personal Accidental Death cover of ₹30 Lakhs on the salary account (without any condition of Swipe of Debit card).”

 

4. Copy of FIR (Annexure C-4) clearly indicates that the deceased husband of the complainant i.e. the insured had met with an accident while he was discharging his duty on 10.4.2021.
5. Ex.OP-1/5 is copy of the repudiation letter vide which the OP-1/insurer had repudiated the claim of the complainant and the relevant portion of the same is reproduced below for ready reference :-

“In the claim of Mr. Ramesh Chand it was observed from the postmortem report that the ‘cause of death is Covid pneumonia resulting in ARDS. The injuries suffered from the accident were caused by blunt force impact but not contributing to death.’

As per the PA clauses, any bodily injury resulting solely directly from an accident caused by external, violent and visible means is covered.  In this case, cause of death is due to Covid pneumonia and not due to accidental injuries.

In view of the above fact, the claim does not fall under the purview of the GPA policy.”

 

6. Copy of medical record (Annexure C-5 Colly.) further indicates that the insured was firstly taken to GMCH-32 on 10.4.2021 with multiple injuries where he remained admitted and was discharged on the next day.  Copy of discharge summary (Ex.OP-1/3) of GMCH-32 further indicates that the insured was again admitted on 12.4.2021 and was treated for injuries sustained in the accident and discharged on 15.4.2021.  Ex.OP-1/4 is the copy of post mortem report which indicates that insured had died on 1.5.2021 and the cause of his death has been mentioned as COVID pneumonia resulting in ARDS.
7. Ex.OP-1/2 is the most material document i.e. opinion on the cause of death of insured, which has been given by the panel of doctors of PGI, and relevant portion of the same is reproduced below for ready reference :-

       “OPINION

                The cause of death in this case is COVID-19 Pneumonia contracted during the course of treatment as certified in MCCD and PMR.  However, the possibility of the aforementioned risk factors on account of injuries sustained and treatment received following roadside accident, being responsible for acquiring and exacerbating COVID-19 Pneumonia cannot be ruled out.

 

8. The learned counsel for the complainant contended with vehemence that as it stands proved on record that the deceased insured suffered injuries in the accident and he died on account of the same, mere reference of the insured died due to COVID pneumonia resulting in ARDS in post mortem report does not mean that it is the sole cause for his death and the consumer complaint of the complainant be allowed as prayed for.
9. On the other hand, learned counsel for OP-1 contended with vehemence that as it stands proved on record that the insured had died on account of natural death and COVID and not due to accidental injuries, which has also been mentioned in the post mortem report (Ex.OP-1/4), the claim was rightly repudiated and the consumer complaint be dismissed.
10. However, there is no merit in the contention of learned counsel for OP-1/insurer as the Inquest Report (Annexure C-4/A) clearly indicates that the deceased insured had died on account of injuries suffered in the accident, which has further been endorsed by the medical panel of PGI in its report (Ex.OP-1/2) whereby it has specifically opined that the possibility of cause of death in this case as COVID-19 pneumonia due to risk factors on account of injuries sustained and treatment received following roadside accident, being responsible for acquiring and exacerbating COVID-19 pneumonia, cannot be ruled out. 
11. In this manner, in the light of the opinion given by the medical panel in its report (Ex.OP-1/2), it is unsafe to hold that the deceased insured had died on account COVID-19 only, rather it is safe to hold that consequences of multiple injuries suffered by the insured in the roadside accident, for which he remained under treatment in various hospitals till his death, cannot be ruled out.  Hence, it is unsafe to hold that OP-1/ insurer was justified in repudiating the claim of complainant and the said act certainly amounts to deficiency in service and unfair trade practice on its part.
12. Now coming to the quantum of amount to be awarded in the instant case, as discussed above, since the deceased husband of the complainant was insured for ₹30.00 lacs, it is safe to hold that OP-1 is liable to pay the said amount to the complainant alongwith interest and compensation etc.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OP-1 is directed as under :-

1. to pay the insured sum of ₹30.00 lacs to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim i.e. 11.2.2022 onwards.
2. to pay ₹40,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by OP-1 within forty five days from the date of receipt of its certified copy, failing which, the payable amounts, mentioned at Sr.No.(i) & (ii) above, shall carry interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Since no deficiency in service or unfair trade practice has been proved against OP-2, the consumer complaint against it stands dismissed with no order as to costs. 
7. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
8. Certified copies of this order be sent to the parties free of charge. The file be consigned.

04/06/2024 hg	Sd/- [Pawanjit Singh] President
	Sd/- [Surjeet Kaur] Member
	Sd/- [Suresh Kumar Sardana] Member