Sri.G.V.Balasubramanya,<br /> Member<br /> <br /> Common order in CC 59 & 60/06<br /> <br /> 1. We are disposing of these complaints through a common order as the contesting parties are same and the cause of action has arisen from the same incident.<br /> 2. The husband of the first complaint and the father of the second complainant Late Rangappa had taken a Nagarika Suraksha policy bearing No.422400/2002/1176 from the opposite party which was a personal accident policy with an added benefit of reimbursement of hospitalization expenses. Similarly, Late Rangappa had a motor cycle which was insured with the opposite party under policy No.2006/2305. Late Rangappa met with an accident on 9.6.2005 and subsequently died at Basappa Memorial Hospital on 14.6.2005. A post mortem was conducted which revealed the cause of death as respiratory failure as a result of lung infection. The complainants lodged claims with the opposite party for the benefits under both the Nagarika Suraksha Policy as well as the motor vehicle policy. The claims were repudiated on the ground that the death of Rangappa was not attributable to the injuries sustained in the accident. <br /> 3. The complainants have alleged that though the opposite party obtained a second opinion from the doctor who conducted the post mortem, the claim has been unjustly repudiated. They have, also, alleged that Rangappa died because of the negligence of the doctors in the hospital. They have filed separate complaints for the claims under the two policies. Under the motor vehicle insurance policy they have claimed Rs.1,00,000/- and under the Nagarika Suraksha policy they have claimed Rs.80,000/- with accumulated bonus. They have, also, claimed incidental expenses like interest from the date of lodging the claims, cost and damages [In the both the CC 59/06 and 60/06, the complainants have referred to Nagarika Suraksha plocy in the prayer column. But, it was clarified by the learned counsel for the complainant that CC 59/06 pertains to Nagarika Suraksha policy and CC 60/06 refers to personal accident benefit under the motor vehicle insurance policy].<br /> 4. The defence of the opposite party in both the complaints is the same. Firstly, they have justified the repudiation on the ground that since the death of the insured was not attributable to accident personal accident benefit under both the policies cannot be released. Secondly, they have questioned the veracity of the second opinion given by the doctor who conducted the post mortem saying that it is a result of connivance between the doctor and the complainants. In fact, the opposite party says that deceased Rangappa had respiratory problem even before he took Nagarika Suraksha policy and he suppressed this fact at the time of taking the policy.<br /> 5. From the above contentions, the following points arise for our consideration:<br /> I. Whether the complainants prove that Rangappa died as a consequence of the injuries he suffered at the accident? <br /> <br /> II. Whether the complainants, further, prove that by repudiating their claim, the opposite party has committed deficiency in service?<br /> <br /> III. What order or relief?<br /> <br /> 6. After hearing both parties and perusing the documents we have answered the points as under:<br /> <br /> Point I: In the negative<br /> <br /> Point II: In the negative<br /> <br /> Point III: As per final order<br /> <br /> REASONS<br /> <br /> 7. The complainants have examined Dr.Kumar, the doctor who conducted post mortem on the body of Rangappa as CW1. They have, also, examined Dr.Pundareeka Herle, the doctor who treated Rangapaa at B.M.Hospital as CW 2. Shri.Sri Harsha, the Administrative Officer with the opposite party has been examined at RW 1.<br /> <br /> 8. During the course of proceedings, the complainants sought amendment of their complaints to acknowledge receipt of Rs.18,260/- from the opposite party as reimbursement of hospitalization expenses under the Nagarika Surksha policy. <br /> 9. Points I & II:- The case sheets of B.M.Hospital, Mysore where deceased Rangappa underwent treatment from the date of accident till the date of his death are before us. Similarly, the opposite party has produced the original office file. On 9.6.2005 Rangappa while riding his motorcycle, hit an electric pole near Panchavati circle and sustained injuries to his left leg. He was admitted to B.M.Hospital, Mysore where on the same day skin grafting was done by CW 2. Though he was a known hypertensive, everything was apparently normal till 11.6.2005. On that day he had complaints of frequent urination with bed wetting. He was referred to a Nephrologist who after an abdominal sonologic test observed bilateral minimal hydronephrosis with large post voidal residue suspected outlet obstruction and advised cystoscopy. However, he was cleared for the surgery only on 13.6.2005. There is nothing abnormal recorded in the case sheets leading up to cystoscopy. It was performed on 13.6.2005. But the same day he had an episode of breathlessness and sweating. On 14.6.2005 he was feeling apprehensive and passed stools in the bed. An ECG was ordered. By evening he was in an anxiety mode and an echocardiography was ordered to be carried out the next day. However, at 7.30 p.m he went to the toilet, fell down and lost consciousness there. There was no pulse or blood pressure. He was immediately shifted to CCU and from the case sheets it is seen that attempts were made till 10.35 p.m to revive him. He was pronounced dead at 10.35 p.m. <br /> 10. On 15.6.2005 a police complaint was filed by the brother of Rangappa and the same was registered under Section 174, Cr.P.C. It appears the relatives of Rangappa were agitated about the cause of his death. The body was sent for post mortem. CW 1 who conducted the post mortem opined that the death was due to respiratory failure as a result of lung infection. The repudiation of the personal accident benefit under both the Nagarika Suraksha policy as well as the motor vehicle insurance policy is due this post mortem report which does not link the cause of death to the injuries Rangappa suffered in the accident. <br /> 11. Curiously, the opposite party wrote a letter dated 22.9.2005 to CW 1 seeking clarification as to whether Rangappa’s death was due to injury he suffered in the accident or due to infection not related to accident. CW 1 wrote back on 25.1.2006 that “the extensive nature of injury he suffered to the leg required major surgical procedures and the combined effect of these could have resulted in lung infection and respiratory failure”. It is obvious that the opposite party wrote the letter seeking clarification from CW 1 only to make sure that death was in no way related to the accident. Repudiation of the claims has been made only after CW 1 gave the clarification. <br /> 12. There is no doubt that the clarification letter of CW 1 is rather vague. It is more of a hypothesis rather than an opinion. However, in his oral evidence he has admitted that his opinion given in the post mortem report is final. He has, also, said that he has neither changed his opinion in his clarification letter nor did he see Rangappa’s body before giving the clarification letter. The doctor’s reply has come full four months after the opposite party wrote the letter seeking clarification. By then Rangappa’s death was more than six months old. Further, the opposite party who sought the opinion has himself cross examined the doctor. Hence, it is not necessary to attach much importance to this letter of CW 1. In other words the fact remains that Rangappa died due to respiratory failure as a result of lung infection. This conclusion would also mean that the death is not attributable to the injuries he suffered in the accident.<br /> 13. The personal accident benefit clause of Nagarika Suraksha policy is very clear as to the circumstances in which the benefit accrues to the insured or legal heirs of the insured. It reads thus: “If, at any time during the currency of the policy the insured person shall sustain any bodily injury resulting solely and directly from Accident caused by external, violent and visible means then the Company shall pay to the Insured person or his legal personal representative(s) as the case may be, the sum hereinafter set forth that is to say……………” [Emphasis supplied]. Thus, for the complainants to succeed here, they must prove that Rangappa died as a direct result of the injuries he sustained in the accident. <br /> 14. Coming to the two insurance policies late Rangappa had taken, it is seen that the motor vehicle insurance policy carried personal accident benefit also. But Nagarika Surksha policy had two main components namely personal accident benefit wherein the insured would be covered for injuries or death by accident and hospitalization expenses reimbursement benefit. Apart from these benefits, the policy envisages payment cumulative bonus, compensation for loss of employment, expenses for carrying the dead body and education fund for dependant children. Under the terms of the policy, these benefits are linked to personal accident section and would accrue only if personal accident benefit becomes payable. Of the first two components [personal accident and hospitalization expenses], the opposite party has paid the hospitalization expenses amounting to Rs.18,260/-. The complainants have no grievance about this. Similarly, the motor vehicle insurance policy also has personal accident benefit. Since there is no evidence to link Rangappa’s death to the injuries he sustained in the accident repudiation of personal accident benefit has to be upheld. It follows that the complainants are not entitled to the other benefits under Nagarika Suraksha policy that would have accrued if personal accident benefit had been allowed. Therefore, we answer both the points in the negative and proceed to pass the following order.<br /> <br /> <br /> <br /> ORDER<br /> <br /> A. Both complaints are dismissed<br /> B. No costs.<br /> C. Retain the case sheets produced by the B.M.Hospital, Mysore for a period of two months from the date of this order.<br /> D. Keep original order copy in C.C.59/06 and Xerox copy in C.C.60/06.<br /> E. Give a copy of this order to each party according to Rules.<br />