BEFORE THE DIST. CONSUMERS DISPUTES REDRESSAL FORUM; DHARWAD.
Complaint No.: 86/2016
ORDER DATED: 08TH Day of Nov.2016
PRESENT:
Smt.C.H.Samiunnisa Abrar,B.A., LLB :President
Sri.B.S.Keri, B.A.,LLB(Spl) : Member
Complainant: Padmavati W/o.Venkatesh
Konnur, Age:35, Occ;Household,
R/o: Near Basavanna Devar
Temple,
At & Post: Hebsur village-581209,
Taluk: Hubballi, District: Dharwad
(Rep.by.Sri.B.S.Hosakeri, Adv.,)
V/s
Respondent: Life Insurance Corporation of
India, Divisional office,
“Jeevan Prakash”, Collage Road,
Dharwad-580001,
Rep.by its Divisional Manager.
(Rep.by.Sri.M.G.Gadgoli, Adv)
JUDGMENT DELIVRED BY
SMT. C.H.SAMIUNNISA ABRAR, PRESIDENT:
The complainant has filed this complaint against the opposite parties (herein after referred in short as OP) under Sec.12 of Consumer Protection Act, 1986 alleging deficiency of service against OP.
1. The brief fact of the case is that the complainant’s husband Venkatesh Bhimappa Konnur was an agriculturist he had insured his life with the OP under the policies in questions detailed below.
Sl No | Policy Nos | Date…of Commencement | Sum Assured |
01 | 638645398 | 19/06/2013 | 3,00,000/- |
02 | 638641473 | 25/03/2013 | 2,00,000/- |
03 | 638641460 | | 2,00,000/- |
2. During the tenure of insurance that is on 29/03/2015 the policy holder Shri Venkatesh came to Dharwad for his personal work along with his brother Rajesh. After completion of his work at 2 PM he was proceeding towards New Bus stand Dharwad via SP office road by walk. While walking he had an accidental slip which leads to fall on the open protruded underground telephone OFC pipe. Consequently suffering serious head injury.
3. Further complainant submits that the brother of Venkatesh somehow reached their and he has found that his brother Venkatesh has fall on the OFC pipes which leads to serious head injury and he found him unconscious. After the accident Shri Venkatesh (Complainant’s husband) taken to KIMS hospital Hubli for Medicare ultimately the insurer was succumbed to the accidental injuries on 06/04/2016 at Hubli.
4. After the death of the policy holder (complainant’s Husband). The complainant as a nominee had approached the op seeking settlement of the insurance sum assured plus accident benefit plus vested bonus , despite submitting all the details the OP did not process the claim for long time , there after op has paid the sum assured under all policies but op has wrongly repudiated the claim relating accident benefits by its letter dtd.08/02/2016 on false ground stating that , “ We observe from the Hospital reports that , late Sri Venkatesh Konnur was suffering from psychiatric illness and was under medication. As per policy conditions 10 2 (b)(i) , Accident benefit cannot be paid under the above mentioned policies. Therefore, the accident benefit is not payable there under.” As such the alleged grounds the complainant filed this complaint.
5. Further complainant contended that the reputation of claim has utterly falls and baseless. The policy holder was in a good state of health at the time of making proposal, as there was no existence of any ailment, and he did not have any symptoms of psychiatric illness . Hence only in imagination, the OP cannot repudiated the accidental benefits. Complainant further submits that after satisfied about the good health of the policy holder the op has accepted the proposal and issued the policies and OP has failed to peruse all the document and appreciate their content in proper perspective the OP has arbitrarily repudiated the accident claim without applying its judicious mind, after reputation of accident benefits the complainant again personally requested the OP to reconsider its repudiation by allowing the double accidental benefits . But still complainant did not get any relief. Hence complainant approached to this forum and prayed that, the forum to direct the op to pay a double accidental benefits along with interest and other compensations further alleged that the OP had committed the deficiency in service.
6. The predecessors on seats received the complaint, registered and notice was issued to the op. Op appeared through his counsel filed his written version.
The brief fact of written version as under:
7. The contention of op is that the allegation made in the complaint are false, frivolous and vexatious and denied all the contents of the complaint. The op admitted that the complainant’s husband was insurer of their company and there is no dispute about the policies also. The main defense taken in w/v is that as per the investigation of op it was found out that assured was suffering from psychiatric illness and was on the treatment prior to his date of death.
8. Further the op submits that cause 10 2(b), death of the life assured to pay an additional sum equal to sum assured to under this policy, if the life assured shall sustain any bodily injury resulting slowly and directly from the accident caused by outward violent and visible means and such injury shall with in 180days occurrence, slowly, directly and independently of all other causes results in the death of the life assured. However some additional sum payable with respect of this policy, together with and such additional sum payable under other policies on the life assured shall not exceed Rs 5 lakh and taken the contention that the complainants husband’s death was due to intentional self-injury as such corporation is not liable to pay the additional sum and op denied that complainant has not lodged as FIR and the death of the assured person died in the accident. Hence it cannot be called as accidental death hence complainant is not entitled for any accidental benefit and insured was suppressed the material fact and stated that op had already paid the sum assured to the complainant. Further op stated that it could be a systematic and planned death of the life assured just to claim the heavy policy amount from the op.
9. OP admitted that complainant is the nominee of the insurer. The complainant while submitting the claim complainant breached, the trust of OP. As per the policy condition the complainant is not entitled any relief as sort in the complaint , op is not made any deficiency in service and prayed to dismiss the complaint with cost.
On the back ground of the above said pleadings, the complainant himself examined before this Forum and filed the documents as C-1 to C-11 and the documents are follows;
1. Ex.C-1 Complainants Adharcard
2. Ex.C-2 Copy of Policy 63864398
3. Ex.C-3 Copy of Policy 638641473
4. Ex.C-4 Death Certificate
5. Ex.C-5 Complaint to Police
6. Ex.C-6 P.M.Report
7. Ex.C-7 Letter of Taluka Exe. Magistrate
8. Ex.C-8 OP’s letter to KIMS
9. Ex.C-9 KIMS Hospital reply To the OP.
10. Ex.C-10 Repudiation of DAB
11. Ex.C-11 Complainants Bank A/c Statement
On the other hand OP filed his chief affidavit and filed 14 documents on his defence. Those documents are as follows;
- KIMS Hubli O.P.D .Slip in the name of
Venkatesh Konnur Dtd.29/3/2015
- Death Certificate of Venkanna Konnur
Issued by KIMS Hospital ,Hubli Dtd
- Treatment Chart of Venkanna-I.P.No.10353
Dt.5/4/2015
- Case Sheet of Venkanna/54178’ 29/3/2015 to 5/4/2015
- Treatment Chart of Venkanna I.P No.10353
Dt.30/3/2015
- Letter to Unit- C& Proof of Phychiatry
Dept.KIMS Hubli Dtd.02/04/2015
- Resustation Notes from 6/4/2015 7-15 AM
To 8-00AM
- Claim Forum No.A Claimants Statements
In respect of Venkatesh K.
- Letter written to Chief Manager LIC Hubli
Dtd.28/4/2015 by the claimant Smt.Padmavati
10)…Claimants requisition for claim Forums forms
For consideration of Death claim in respect of
Venkatesh Konnur Dtd.28/4/2015
11) Death Extract of Venkanna Konnur
Issued by KIMS Hubli Dtd.17/4/2015
12) Endowment Policy Bearing No.638641460
In the name of Venkatesh B Konnur R/o:Hebsur
Dtd.25/3/2013
13) Endowment Policy Bearing No.638641473
In the name of Venkatesh B Konnur R/o:Hebsur
Dtd.25/3/2013
14) Endowment Policy Bearing No.638645398
In the name of Venkatesh B Konnur R/o:Hebsur
Dtd.19/6/2013
On the basis of above said pleadings, oral & documentary evidence, the following points arises for adjudication are as follows;
- Whether the op proves that the reputation of the death claim is justifiable. ?
- Whether the complainant is entitled for relief?
- What order ?
Answer to the above points are as follows
- Negative
- Partly affirmative
- As per final order
Point 1 and 2 : Since both the points are interlinked and identical, we proceed both the points together to avoid the repetition.
10. The insured is an agriculturist, on 29/03/2013 he had gone to Dharwad to purchase seeds for agriculture, along with his brother Rajesh , around 2PM proceeding towards Dharwad near SP office road , he accidently slipped and fell down on the open protruded underground and sustained head injury and became unconscious. The passer bye’s help to his brother and shifted the insured to KIMS Hospital, Hubballi for the treatment and he was treated for a week ultimately he succumbed to accidental injury on 06/04/2014 at the hospital.
Per contra “op submits that the clause 10 (2)(b) death of a life assured to pay an additional sum equal to the sum assured under this policy, if the insured has sustained bodily injury resulting solely and directly from the accident caused by the outward and visible means such injury shall within 180 days of its occurrence .”
11. Taking into consideration the submission of both the parties, forum discussed the points as under. EXTERNAL VIOLENT AND VISIBLE MEANS ARE DEFINED BY THE HON’BLE NATIONAL COMMISSION IN III (2008) CPJ 82 (NC) PADMARAMANATHAN v/s NATIONAL INSURANCE COMPANY , WHERE IT HAS BEEN HELD THAT THE WORD VIOLENT, EXTERNAL VISIBLE HAS WIDE MEANING PRACTICALLY CO EXTENSIVE WITH ACCIDENTAL. FURTHER IT HAS BEEN HELPS THAT VIOLENT DOES NOT IMPLY ACTUAL VIOLENT BY NEARLY USED IN ANTITHESIS TO WITHOUT ANY VIOLENCE AT ALL, EXTERNAL MEANS TO USE TO POINT THE CONTRAST WITH SOMETHING INTERNAL ANY CAUSE WHICH IS NOT INTERNAL MUST BE EXTERNAL, BUT DOES NOT MEAN THAT THE INJURY MUST EXTERNAL THERE MAY BE AND OFTEN IS NOTHING EXTERNALLY VISIBLE TO INDICATE THE PRESENCE OF INTERNAL INJURY AT ALL. THE EFFECT OF THE TERM IS THEREFORE UNDERLINE THAT THIS ORDER ARISING WITH IN THE HUMAN BODY WITHOUT SUSTAINABLE REFERENCE TO ALL TO ANYTHING COMING FROM OUTSIDE OR NOT COVERED. The complainant had relied on this citation.
12. The op had produced medical certificate issued to the complainant, document no 1 clearly discloses that, the insurer had been admitted to KIMS Hospital Hubballi on 29/03/2015 as a MLC. The treated doctor declared dead on 06/04/2015 and issued a certificate, document no 3 and 4. The documents produced by the complainant postmortem report exhibits C-6 clearly disclose that the death was due to the head injury.
13. The learned counsel for op argued, during his argument taking defence that the insurer was suffering from psychiatric illness and he was under treatment for 4 months before the accident and the manager (Claims) LIC Dharwad wrote a letter to medical officer KIMS Hubballi Dtd 15/12/2015 seeking the copy of the case sheet pertaining to the treatment for psychiatric illness. The RMO KIMS hospital Hubballi in his reply on 22/12/2015 said that “V.B.KONNUR WAS ADMITTED FOR TREATMENT OF HEAD INJURY BY ACCIDENT AND PROVIDED MLC PAPER ALSO. AS PER OUR KIMS RECORD NO INFORMATION FOUND ABOUT PSYCHIATRIC ILLNESS. THERE IS NO CASE SHEET PERTAINING TO TREATMENT TAKEN FOR PSYCHIATRIC ILLNESS AND DATA NOT AVAILABLE REGARDING THIS.”
14. While scanning the document mark as at C- 8 and C-9 . The medical attendant certificates vide exhibits C-13 also prevails that the death of the insurer was due to the head injury. So the argument of the op cannot be accepted, apart from this the complainant had produced several other documents to prove that the death was exactly due to the head injury sustained by above said accident.
15. That it is absolutely not true that, the deceased Venkatesh B. Konnur was treated for psychiatric illness for 4 months prior to his death. The op fail to produce the documentary evidence or oral evidence to prove the insurer had taken treatment for psychiatric illness. The documents and the doctor certificates issued by the KIMS hospital Hubli clearly establishes that the death of the insured was due to the accidental fall. Merely and blindly the op has repudiated the double accidental claim. We relay up on the citation cited in the III (2016)CPJ335(NC)
III(2016)CPJ 335(NC)
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION,NEW DEHLI,
Mrs.M.Shreesha, Presenting Member
Saryauben B Shah V/S Life Insurance Corporation of India
Consumer Protection Act 1986-Sections(2)(1(g),21(b)-Insurance- Accidental Injuries,-Death of Insured-Double Accident Benefit-Claim repudiated-Deficiency of Service-District Forum Allowed complaint-State Commission allowed appeal –Hence Revision-Doctors Affidavit clearly establishes that death of insured was only on account of Accidental Fall and Septicaemia and acute Renal Failure all occurred on account of injuries and finding of Renal stone is only co-incidental- Merely because nephrologist stated that no orthopedic treatment was needed at that point of time, it cannot be construed that accidental injuries did not have any nexus with occurrence of Septicaemia- Repudiation not justified.
16. For the reason stated above we are in a view that the op LIC of Dharwad had committed deficiency in service. Hence the complainant is entitled for partial relief as such we answer point No 1 in negative and point No 2 in partly affirmative.
Point No3; For the reasons and discussions made above and finding on the above point we proceed to pass following order.
O R D E R
1. The OP is directed to pay Rs 7,00,000/- ( Rupees Seven lakhs only) towards Double Accident Benefit along with the interest @ of 6% p.a from the date of filing of this complaint.
2. The OP is directed to pat Rs 10,000/- (Rupees Ten thousand only) toward mental agony and harassment and Rs 1000/- towards litigation charges.
3. Further the op is directed to comply this order within 30 days from the date of this order failing which op is liable to pay interest @ of 12% p.a till realization.
(Dictated to steno, transcribed by her and edited by us and pronounced in the open Forum on this 8th day of Nov. 2016)
(Sri.B.S.Keri) (Smt.C.H.Samiunnisa Abrar)
Member President
Dist.Consumer Forum Dist.Consumer Forum
GDB
