DISTRICT CONSUMER DISPUTES REDRESSAL FORUM;BHADRAK
………………………
C.D.Case No.29 of 2014
Minati Senapati, aged about 42 years,
W/o: Late Jitendriya Senapati,
At: Bania, PO: Saragadia, Via:Charampa,
PS/Dist:Bhadrak
………………………..Complainant
(Vrs.)
1. The Secretary,
Erein Service Co-operative Society Ltd., Erein
PS/Dist: Bhadrak
2. The Branch Manager,
Balasore-Bhadrak Central Co-operative
Bank Ltd.,Bhadrak
At/PO/Dist: Bhadrak
3. Divisional Manager,
New India Assurance Company Ltd.,
Balasore Division Office,
1st Floor, Vivekananda Marg,
Dist: Balasore
…………………………Opp.Parties
Order No.21 dt.18.05.2015:
The case of the Complainant in nut-shell is that she is the legal heir and successor in interest of late Jitendriya Senapati. Her deceased husband was a farmer being admitted as Member bearing Membership No.1954 and obtained Identity Card No.050600822 from the O.Ps and also the O.Ps issued Kissan Credit Card. During his life time Jitendriya Senapati had availed loan facilities from O.P.No.1 and repaid the loan amount within the stipulated period for which O.P.No.1 being pleased issued “Kalinga Kissan Gold Card” and availed the facilities of Kissan Gold Card. Salient features of Kissan Gold Card are that the Member of Gold Card will participate in annual lottery, they will purchase fertilizers and pesticides in any place, loan for Rs.5,000/- to meet the daily expenses, there will be free personal accident death insurance coverage for Rs.1,00,000/- and the loan amount will be waived out in case of death of Members. According to Complainant her husband had availed loan of Rs.40,000/- from O.P.No.1. Unfortunately, on 15.04.2013 the husband of Complainant while sitting on a chair fell down and became unconscious and thereafter the husband of the Complainant was admitted in Bhadrak District Headquarters Hospital, Bhadrak and for better treatment he was shifted to Aditya Care Hospital, Bhubaneswar and also further shifted to Kalinga Hospital, Bhubaneswar. But the husband of the Complainant died on 17.04.2013 in spite of spending lakhs of rupees in course of treatment in different hospitals. The said accident was reported to the Bhadrak Rural Police Station and information was given to O.Ps about the death of the Member. O.P.No.1 demanded to the Complainant to clear up the loan amount which was incurred by her husband and threatened to take legal action under OCS Act and Rules. Thereafter, the Complainant requested to waive out the loan amount and to settle the insurance claim in her favour. But the O.P.No.1 ignoring the terms & conditions and benefits under Kalinga Kissan Gold Card insisted the Complainant to deposit the loan amount. The Complainant being compelled incurred hand loans and repaid the outstanding loan amount of O.P.No.1. So alleging deficiency in service on the part of O.Ps the Complainant filed this case on 12.03.2014 praying for a direction to O.Ps to disburse Rs.1,00,000/- towards accidental benefit with interest @ 12% per annum from 03.05.2013 as per terms & conditions of Kalinga Kissan Gold Card, to refund the deposited loan amount of Rs.40,000/- with interest @ 8% per annum from 19.12.2013, to pay compensation of Rs.1,00,000/- along with litigation cost of Rs.50,000/- to her.
O.Ps 1 & 2 in their written version stated that the husband of the Complainant was a “Kalinga Kissan Gold Card” holder of the O.P.No.1-Society. There is an accidental benefit scheme under New India Assurance Company for Rs.50,000/-. In order to avail this benefit, a specific circular was issued by the Bank with reference to the terms & conditions stipulated in the Policy issued by the Insurance Company. The accidental claim was to be settled by Insurance Company but the New India Assurance Company has not been made a party. After the death of the husband of the Complainant, the Complainant did not inform the matter to O.Ps within the stipulated period and failed to comply the criteria of the scheme issued by the New India Assurance Company. To avail the benefit, the Complainant has not submitted relevant documents before the O.Ps. Further, it is a mandatory provision of insurance Company that the death occurred due to accident shall be eligible for claim. To know the cause of death, the postmortem report is necessary which was not submitted by the Complainant. As such, for non-joinder of necessary party and non-compliance of relevant documents by the Complainant, this case is liable to be dismissed.
Complainant on 16.06.2014 filed a petition praying to implead New India Assurance Company as a party to this case. After having heard both sides, the amendment petition was allowed by this Forum on 16.07.2014 and New India Assurance Company was added as O.P.No.3 in this case.
O.P.No.3 on receipt of notice filed written version pleading inter-alia that the case is not maintainable, that there is no cause of action to bring this case against O.P.No.3, that the case is bad for non-joinder of party such as Head Office of Balasore Bhadrak Central Co-operative Bank Ltd. and that the case is premature as the Complainant has neither given intimation nor lodged any claim with O.P.No.3 with regard to the death of her deceased husband till date. According to O.P.No.3, the Head Office of Balasore Bhadrak Central Co-operative Bank Ltd.(PO 10289177) OT Road, Balasore had obtained a Group Personal Accident Insurance Policy bearing No.55080047122300000003 for the period from 05:36:49 PM on 01.08.2012 till 11:59:59 PM on 31.07.2013 against 1,50,000/- number of unnamed persons those possesses Kissan Credit Card or any group member of SHG disbursed with short term loan between 01.04.2012 to 31.03.2013 from its Bank or Service Co-operative Society for capital sum insured of Rs.50,000/- per person covering risk of death and total irrecoverable loss of sight of both eyes or both hand or both feet or of the actual loss of one eye and as such loss of one of the two entire hands or two entire feet, or of one entire hand and one entire foot or of such loss of sight of one eye and such loss of one entire hand or such loss of one entire foot and irrecoverable loss of sight of one eye, or of the actual loss of one entire hand or one entire foot of an insured person due to bodily injury resulting solely and directly from accident caused by outward, violent and visible means subject to terms, exclusions, definition and conditions expressed therein. It is one of the conditions of the said Janata Personal Accident Insurance Policy that upon happening of any event which may give rise to a claim under the issued policy the insured shall forthwith give notice thereof to Company unless reasonable cause is shown, the insured should within one week after the event which may give rise to claim under this policy, give written notice to the Company with particulars of the claim. But the Complainant has neither given notice to the O.P.No.3 about the death of her deceased husband Jitendriya Senapati nor lodged any claim thereof. Hence, the complaint of Complainant being devoid of merit is liable to be dismissed with cost.
During course of hearing Ld.Counsel for Complainant submitted that the Complainant’s husband Jitendriya Senapati was a small farmer and obtained Kalinga Kissan Gold Card. The husband of Complainant on 15.04.2013 while sitting on a chair fell down and became unconscious and he was thereafter admitted in Bhadrak District Headquarters Hospital, Bhadrak, Aditya Care Hospital, Bhubaneswar and also Kalinga Hospital, Bhubaneswar where he died on 17.04.2013 in spite of spending lakhs of rupees. Thus, the death was accidental but the O.Ps repudiated the claim of the Complainant on flimsy ground even though death intimation and copy of relevant documents were given to O.P.No.1 on 18.04.2013 i.e. after one day of death of life assured. The Advocate for Complainant emphasized on the letter No.6491 dt.10.08.2012 of the Secretary, Balasore Bhadrak Central Co-operative Bank Ltd. wherein it has been mentioned that “if any genuine claimant fails to get the claim from the insurance Company due to gross negligence of the PACS/Branch, the Secretary of concerned PACS and Branch Manager of the Branch shall be liable for payment of the claim at 50:50 ratio or according to the intensity of fault. Hence, the O.Ps be directed to disburse the accidental benefit and to waive out/refund the loan and interest already paid amounting to Rs.42,000/-. The contention of the O.Ps 1 & 2 is that intimation of death is to be given within 5 days of death but here in this case the Complainant intimated after 16 days of death of life assured. Further, the Complainant has not submitted the required documents such as Police inquest report, PM report etc. so as to know the cause of death. O.P.No.3 submitted that due to high blood pressure the life assured had Intra Cerebral Hemorrhage (ICH) in left Thalamo Capsular Region with extension into ventricles. Due to the ICH and bleeding in the brain, the patient became unconscious and fell down from Chair. This is not a case of brain injury as mentioned by the Complainants. Further, under Janata Personal Accident Insurance Policy, if insured person sustains any bodily injury resulting solely and directly from accident caused by external violent and visible means, then the Insurance Company shall pay to the insured the sum. As such, the Complainant is not entitled to the insured sum because it has not been established on record that the insured had sustained any bodily injury resulting solely and directly from accident caused by external violent and visible means.
The Complainant has prayed for a direction to O.Ps 1 & 2 to refund the deposited loan amount of Rs.40,000/- along with interest towards the benefit under Kalinga Kissan Gold Card. The O.Ps 1 & 2 have not whispered a single word regarding waiver of aforesaid loan amount. So the burden lies on the Complainant to prove that she is entitled to refund of deposited loan amount and its interest. The Complainant has not filed the copy of the scheme under which she claims the refund of deposited loan amount and interest. So we cannot direct the O.Ps 1 & 2 to refund the deposited loan amount as prayed for by the Complainant.
On perusal of list of documents filed by advocate for Complainant and received by O.Ps, it is found that the Complainant Minati Senapati in her letter dt.18.04.2013 intimated the O.P.No.1 about the death of deceased Jitendriya Senapati on 17.04.2013 in Kalinga Hospital, Bhubaneswar. The O.P.No.1 has received the said letter with an endorsement that “Received copy of all documents” with his seal and signature on 18.04.2013. Now the O.P.No.1 cannot say that no intimation of death was given immediately to him. It was the duty of O.P.No.1 to intimate his higher authority or the O.P.No.3 for early settlement of death claim after receipt of copy of all documents from the Complainant. Further, it is the specific case of Complainant that her husband while sitting on chair on 15.04.2013 fell down and became unconscious for which he was shifted to District Headquarters Hospital, Bhadrak and for better treatment he was shifted to Aditya Care Hospital, Bhubaneswar and thereafter Kalinga Hospital Ltd., Bhubaneswar. The deceased life assured while undergoing treatment expired in Kalinga Hospital Ltd., Bhubaneswar on 17.04.2013. The said accident was reported to Bhadrak Rural Police, Bhadrak. It is the case of O.Ps that to know the cause of death, the postmortem report is necessary which was not submitted by the Complainant. It has been specifically mentioned in the letter No.6491 dt.10.8.2012 of the Secretary, Balasore Bhadrak Central Co-operative Bank Ltd., the copy of which has been filed by O.Ps 1 & 2 that;
“The death occurred due to accident from 01.08.2012 to 31.07.2013 shall be eligible for claim. Please note that, death due to suicide, intentional self sustained injury and death, influence of intoxicating drink or drugs and death due to diseases including sun stroke, heart ailment etc. are beyond the scope of coverage of the policy.”
Undisputedly, the death of Jitendriya Senapati occurred during the insurance coverage period from 01.08.2012 to 31.07.2013. Death intimation was given to O.P.No.1 on 18.04.2013 enclosing copy of all documents. The Head Office of O.P.No.2 i.e. Balalsore Bhadrak Central Co-operative Bank Ltd.(PO10289177) is the insured under Group Janata Persoal Accident Insurance Policy in question. Condition No.2 of the Group Janata Personal Accident Insurance Policy stipulates that upon the happening of any event which may give rise to a claim under this policy the insured shall forthwith give notice thereof to the Company. Under the above circumstances, the Complainant has nothing to do in processing and settlement of claim after giving immediate death intimation on 18.04.2013 and submission of relevant documents to O.P.No.1, under whom the life assured was a Member. Admittedly, no P.M. examination has been conducted over the dead body of life assured. As such, the O.P.No.3 has entertained doubt about the cause of death as to accidental. It is no doubt true that the life assured was admitted in the District Headquarters Hospital, Bhadrak vide Regn.No.1559 dt.15.04.2013 after sustaining head injury and was referred to SCB Medical College & Hospital, Cuttack but for better treatment the life assured was admitted in Aditya Care Hospital, Bhubaneswar on 15.04.2013 and for better treatment he was also again shifted to Kalinga Hospital Ltd., Bhubaneswar on 15.04.2013. Treating Physician of Aditya Care Hospital, Bhubaneswar has categorically mentioned in the Discharge summary dt.15.04.2013 under the heading “HISTORY” that;
“55 years old male a known diabetic with H/o-CAD-S/P PTCA to LAD & OM1 on 28.12.2013 at KHL. Patient was on Dual Antiplatelet drug, fell down today morning while sitting on chair followed by vomiting & became unconscious. Patient primarily treated at DHQ, Bhadrak & referred here”.
Further, it has been mentioned in the said Discharge Summary under the heading”COURSE IN HOSPITAL” that ;
“On admission patient was comatose, GCS-3. Patient immediately intubated & put on ventilator. CT scan of brain showed Lt.Thalamic ICH with IVE large bleed with mass effect. Patient was treated with Inj.Mannitol, Tab.Asomex, Inj.Lasix, Poor prognosis explained to relatives. Patient was planned to shift to Kaling Hospital for Surgical intervention. Hence discharged today”.
It has also been mentioned in the outpatient prescription dt.15.04.2013 of Kalinga Hospital Limited,Bhubaneswar that “today morning 8 AM while sitting, fell down from chair, became unconscious”. Medical Certificate of cause of Death dt.17.04.13 issued by Kalinga Hospital Ltd.,Bhubaneswar also reveals that immediate cause of death was due to Left Thalamocapsular bleed with IVH(Inter Vascular Hemorrhage).Discharge Summary of Kalinga Hospital Ltd.,Bhubaneswar dt.29.10.2014 also makes it clear that the patient fell down while sitting on chair followed by vomiting and became unconscious due to head injury. The IIC, Bhadrak(R) PS who is a Public Servant, as is evidenced from the certificate dt.06.05.2013, that he has also enquired into the matter locally and ascertained that on 15.04.2013 morning at 8 AM while sitting on chair in a meeting at Saraswati Sishu Mandira, Bania the deceased fell down and became unconscious which fact has been entered in Bhadrak (R) PS SDE No.77 dt.03.05.2013. So, all these things taken together go to show that the deceased Jitendriya Senapati was injured due to falling down from chair and sustained head injury and the cause of death of the deceased has nexus with head injury sustained by him and not due to heart ailment. The Ld.Counsel for Complainant has relied on a decision of the Hon’ble National Commission reported in CPR-2013(4), Page-563 in the case of Life Insurance Corporation of India, Through Assistant Secretary, Northern Zonal Office- Petitioner Vs. N.Shanker Reddy-Respondent, where in it has been held by the Hon’ble National Commission that to prove death by accident either Police report or hospital records confirming death as to accidental are to be produced. Further, it has been held by the Hon’ble National Commission in the case of New India Assurance Co.Ltd. Vs. Jatinder Kumar Sharma reported in 2013(2) CPR 433(NC) that non-lodging of FIR cannot be sole ground for repudiation of claim. The aforesaid decisions have been relied on by the Ld.Counsel for the Complainant. Insurance Regulatory and Development Authority (Protection of Policyholders’ Interests) Regulations, 2002(IRDA) stipulate the Turnaround Times (TAT) for various services that an insurance company has to render to a consumer. In case of General Insurance Company offer of settlement/rejection of Claim after receiving first/addendum survey report is 30 days. When the Complainant has immediately intimated the O.P.No.1 on 18.04.2013 about death of the life assured who died on 17.04.2013 and submitted copy of all documents proving her case as accidental death, non-settlement of claim shifting responsibility on the shoulders of others by O.P.No.3 amounts to deficiency in service. Accordingly, it is ordered:
O R D E R
In the result, complaint is allowed on contest against the O.P.No.3 and dismissed against O.Ps 1 & 2. The O.P.No.3 is directed to disburse Rs.50,000/- towards accidental benefit with interest @ 9% per annum from 18.04.2013 as per terms & conditions of Kalinga Kissan Gold Card within a period of 30 days of receipt of this order to the Complainant. We further direct the O.P.No.3 to pay litigation cost of Rs.5,000/- to the Complainant within the aforesaid stipulated period.
