The United India Insurance Co. Ltd., V/S Smt. Syeda Gousia Banu W/o. Late Riyazuddin - Consumer Court Case

Karnataka

Raichur

DCFR 95/06

Smt. Syeda Gousia Banu W/o. Late Riyazuddin - Complainant(s)

Versus

The United India Insurance Co. Ltd., - Opp.Party(s)

Sri. Dharma Chand Mootha

19 Dec 2006

ORDER

DIST. CONSUMER DISPUTES REDRESSAL FORUM
DIST. CONSUMER DISPUTES REDRESSAL FORUM,DC Office Compound, Sath Kacheri
consumer case(CC) No. DCFR 95/06

Smt. Syeda Gousia Banu W/o. Late Riyazuddin						...........Appellant(s)
Vs.
The United India Insurance Co. Ltd., The United India Insurance Co. Ltd.,						...........Respondent(s)

BEFORE:

Complainant(s)/Appellant(s):

OppositeParty/Respondent(s):

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ORDER

JUDGEMENT This is a complaint filed U/s. 12 of Consumer Protection Act by the complainant Syeda Gousia Banu against Divisional Manager, Insurance Company Raichur and Branch Manager United India Company Ltd., Bangalore. The brief facts of the complaint are as under:- The complainant is the legally wedded wife of deceased late Syed Riyazuddin Khadri who was working in Police Department DAR as Police Constable (Van Driver) A.P.C. No. 175, at Superintendent of Police Office, Raichur. Her husband was member of Respondents Insurance Company under Special Group Insurance Scheme for Rs. 1,00,000/- under policy Bearing No. 072401/42/00/00034. The complainant is the nominee of the said late Syed Riyazuddin Khadri. According to the policy if the insured person dies in accident or otherwise, then the Respondent has to pay Rs. 1,00,000/- to the nominee of the deceased-insured Late Syed Riyazuddin Khadri met with Road Traffic Accident on 19-10-2000 at about 8-30 PM., when he was going by walk near Chandramouleshwar Chowk, Raichur at that time one Auto Rikshaw bearing Registration NO. MH-12/J-5050 driven by driver Mohd. Iqbal in a rash and negligent manner and suddenly dashed to late Riyazuddin. Due to which late Syed Riyazuddin fell down and the said vehicle ran-over his body and he sustained grievous and multiple fractures on his hip, leg and all over the body. Immediately he was admitted in the District Hopsital, Raichur and operation was done and thereafter he was referred to Nandini Hospital, Raichur for further treatment and again the operation were done but due to grievous multiple and fatal injuries he was again referred to Victoria Hosital, Bangalore for better treatment where he died on 14-11-2000 while taking treatment in Victoria Hospital, Bangalore as an in-patient due to the injuries sustained in the said accident. Regarding the accident a criminal case was registered at Traffic Police Station Raichur in Crime No. 81/2000 against the Auto Driver Mohd. Iqbal and he was charge sheeted. After the death of late Riyazuddin the Respondent No-2 was informed by the Superintendent of Police, Raichur vide letter dt. 01-02-01 and requested for payment of claim amount of Rs. 1,00,000/-. The Respondents asked the complainant to produce PME Report and the same was produced with letter dt. 24-05-01 along with other documents. In-spite of submitting all necessary documents and in-spite of several reminder letters written by S.P. Office, Raichur and request letters by the complainant, the Respondents have failed to pay the claim amount and rejected her claim vide letter dt. 28-11-05 stating that late Riyazuddin died due to kidney ailment. This contention of the Respondent is vague and evading to avoid payment of claim and thereby there is clear deficiency of service by the Respondents. Hence for all these reasons the complainant has sought for direction to the Respondents to pay policy amount of Rs. 1,00,000/- together with interest at 18% p.a. till realization along with cost. 2. The Respondent No-1 has filed written statement which has been adopted by Respondent NO-2. In the written statement the Respondent NO-1 has admitted that late husband of the complainant was member of the Respondent Insurance Company under Special Group Insurance Scheme for Rs. 1,00,000/- under policy No. 72401/42/00/00034. As per the policy, the Respondent is liable to pay the policy amount only in case of death by the accident without any ailment and not otherwise. The Respondent is not liable to pay the policy amount if the death is due to any ailment. As per the FIR, statement of the insured-deceased Syed Riyazuddin Khadri, the injury sustained is near the knee of the left leg and there is no mention of any other injury on other part of the body. As per the PME Report the cause of death is reserved pending. Histopathology Report awaited. Part-V of P.M.E. Report shows that both kidney enlarged and multiple Cyst, left kidney weigh 900 grams and right kidney weigh 700 grams Bladder (empty) completely organs external and internal intact. As per the microsopic finding by the Department of Pathology Section show kidney tissue with multiple cysts of varying sizes lined by flattened epithelium shows multi layering at places. Atropolic plomiruti and tubles are seen. Some of the tibules contain secretrons. Intentrstral fibrosis with chronic inflammatory all infiltration seen few selerosed congested blood veesel are seen. Appearances are those of adult poly cystic kidney. So the death is on account of renal ailment which is chronic and the death is not due to accident. The Respondents have looked into all the documents furnished by the complainant and as per the Histopathology report and PM Report which is not vague and Respondent is not trying to avoid the payment of claim amount. The Insurance is only for accidental death arising out of the accident. But the injury sustained is not fatal as per the statement of the deceased-husband of the complainant. So the Respondent is not liable to pay any Insurance amount and so there is no deficiency in service. The insured had concealed material facts before making of the policy. It cannot be said that there was negligence or lapse on the part of this Respondent. Hence for all these reasons the Respondents have prayed for dismissal of the complaint with cost. 3. During the course of enquiry the complainant has filed sworn-affidavit of the complainant by way of examination-in-chief. In-rebuttal the Respondent NO-1 has filed his sworn-affidavit as examination-in-chief. Both the parties have not chosen to cross-examine. On behalf of the complainant (29) documents at Ex.P-1 to P-29 are got marked. On behalf of Respondents one document at Ex.R-1 was got marked. 4. Heard the arguments of both sides and perused the records. The following points arise for our consideration and determination: 1. Whether the complainant proves deficiency in service by the Respondents in not settling her claim under the Insurance Policy, as alleged.? 2. Whether the complainant is entitled for the reliefs sought for? 5. Our finding on the above points are as under:- 1. In the affirmative. 2. As per final order for the following. REASONS POINT NO.1:- 6. There is no dispute that late Syed Riyazuddin Khadri was a member of Respondents Insurance Company under Special Group Insurance Scheme for Rs. 1,00,000/- under policy Bearing No. 072401/42/00/00034 and according to this policy if the insured person dies in accident or otherwise then the Respondent has to pay Rs. 1,00,000/- to the nominee of the deceased insured. There is also no dispute that the complainant is a nominee of said late Syed Riyazuddin and this Riyazuddin who was working as driver in Police Department in DAR Police Department, Raichur met with vehicle accident on 19-10-2000 at about 8-30 PM while he was going by walk near Chandramouleshwar Chowk, Raichur by Auto Rickshaw and sustained injuries and died on 14-11-2000 while taking treatment in Victoria Hospital, Bangalore as an in-patient. The case of the complainant is that her husband-deceased policyholder died due to grievous and multiple fractures on his hip leg and all over the body as shown in the wound certificate and PME Report etc., On the contrary the Respondents has contended that as per the PME Report the cause of death reserved pending Histopathology Report. Part-V of the P.M.E. Report shows that both kidney enlarged and multiple Cyst. Left kidney weigh 900 grams and right kidney weigh 700 grams Bladder (empty) organs external and internal intact. As per the Microsopic finding by the Department of Pathology Section shows kidney tissue with multiple cysts of varying sizes lined by flattened epithelium shows multi layering at places. Atropolic plomiruti and tubles are seen. Some of the tibules contain secretrons. Intentrstral fibrosis with chronic inflammatory all infiltration seen few selerosed congested blood veesel are seen. Appearances are those of adult poly cystic kidney. So the death of the deceased was on account of renal ailment which is chronic. As such the death is not due to accident. Therefore the Respondents are not liable to claim of the complainant. 7. The complainant has produced (24) documents at Ex.P-1 to P-24 out of which wound certificate issued by Civil Hospital Raichur at Ex.P-3. Discharge certificate issued by Nandini Hospital at Ex.P-4. PME Report at Ex.P-5 are material. Similarly the Respondent Company has produced Histopathology Report issued by Department of Pathology Bangalore, (Medical College) Bangalore at Ex.R-1. PME Report at Ex.P-5 regarding Kidney (vide Part-VI) reads thus: Both kidney enlarged and multiple Cyst left kidney weigh 900 grams and right kidney weigh 700 grams Bladder (empty) completely organs external and internal intact.It also shows Left Hip joint dislocation with fracture in upper third of left femur is observed pending. Histopathology Report is awaited. Date: 14-11-2000. Sd/- Dr.K.H. Manjunath On the next page of this PME Report, it shows Final opinion of the doctor (who conducted PME) on the receipt of Histopathalogy Report No. RMC/FM/OPN/75/2001 dt. 04-04-2001 which reads as under: FINAL OPINION:- On perusal of Post Mortem Report, Histopathology Report and the brief history furnished by the investigating officer, I am of the opinion that the death was due to respiratory failure as a result of pulmonary and renal infection, consequent upon injuries sustained. Bangalore Sd/- 06-04-2001. Dr.K.H.Manjunath Ex.R-1 the Histopathology Report NO. 75/2000 dt. 04-04-01 reads thus: Kidney tissue with multiple cysts of varying sizes lined by flattened epithelium shows multi layering at places. Atropolic plomiruti and tubles are seen. Some of the tibules contain secretrons. Intentrstral fibrosis with chronic inflammatory all infiltration seen. Few selerosed congested blood veesel are seen. Appearances are those of adult poly cystic kidney. Sd/- Dr.Y.H.Kale Gowda. 8. From a close perusal of Final Opinion of the doctor who conducted Autopsy over dead body of deceased, it is evident that this Final Report is based on the Histopathology Report (Ex.R-1) and the doctor has opined that the cause of death was due to Respiratory failure as a result of pulmonary and renal infection consequent upon injuries sustained. If this is so the argument of the learned counsel for the Respondent that the death of the deceased insured was due to his suffering from kidney disease as per Histopathology Report and not due to injuries caused in the accident cannot be accepted in-view of final opinion report of the doctor who conducted the Post Mortem Examination and opinion is based on the Histopathology Report at Ex.R-1. Hence it follows that the death of insured Riyazuddin Khadri was due to the injuries sustained in the accident. Merely because the deceased-insured died subsequent to the accident it cannot be said that the death is not due to the accident, for the simple reason that the Final Opinion of the doctor which is on the basis of PME conducted by him and on the basis of Histopathology Report for the receipt of which he had reserved his Final Opinion, has opined that the cause of death of the deceased was due to Respiratory failure as a result of pulmonary renal infection consequent upon the injuries sustained. Hence we are not in agreement with the arguments advanced by the learned counsel for the Respondent and that the ruling relied upon reported in: II (2006) CPJ 191 (N.C.) Head Notes is not at all applicable to the facts in hand. In the said case the death of the insured occurred during operation due to negligence of operating surgeon and Not Accidental death to get accident benefit under the policy. So facts in the referred decision and the facts in the case at hand are on different footings. Therefore we hold that the complainant has proved that the death of the insured was due to the injuries sustained in the accident. Consequently the act of the Respondent in repudiating the claim of the complainant vide repudiation letter dt. 28-11-05 at Ex.P-24 amounts to deficiency in service by the Respondent Company. Therefore Point NO-1 is answered in the affirmative. POINT NO.2:- 9. The complainant has sought for direction to pay the policy amount of Rs. 1,00,000/- together with interest at 18% p.a. from the date of death of insured till realization along with cost of litigation. So far as the policy amount of Rs. 1,00,000/- is concerned, in-view of our finding on Point NO-1, the complainant is entitled and Respondent Company is liable to pay. In so far as the claim regarding interest at 18% p.a. from the date of death of the insured is concerned, having regard to the peculiar circumstances of the case as discussed in Point NO-1, it shows that the Insurance Company was not negligent or in-active in the settlement of claim. Under these circumstances and having regard to our finding on Point NO-1, we feel it just and proper to award a global compensation of Rs. 25,000/- including cost of litigation. In the result we pass the following order: ORDER The complaint of the complainant is allowed in part. The Respondent Company shall pay the policy amount of Rs. 1,00,000/- to the complainant-nominee along with global compensation of Rs. 25,000/- including cost of litigation. The Respondent Company shall comply this order within (6) weeks from the date of receipt of copy of this order. (Dictated to the Stenographer, typed, corrected and then pronounced in the open Forum on 19-12-06) Sd/- Sri. N.H. Savalagi President Dist.Consumer Forum-Raichur. Sd/- Sri.Pampannagouda Member. Dist.Consumer Forum-Raichur. On Leave/- Smt.Kavita Patil Member.

JUDGEMENT This is a complaint filed U/s. 12 of Consumer Protection Act by the complainant Syeda Gousia Banu against Divisional Manager, Insurance Company Raichur and Branch Manager United India Company Ltd., Bangalore. The brief facts of the complaint are as under:- The complainant is the legally wedded wife of deceased late Syed Riyazuddin Khadri who was working in Police Department DAR as Police Constable (Van Driver) A.P.C. No. 175, at Superintendent of Police Office, Raichur. Her husband was member of Respondents Insurance Company under Special Group Insurance Scheme for Rs. 1,00,000/- under policy Bearing No. 072401/42/00/00034. The complainant is the nominee of the said late Syed Riyazuddin Khadri. According to the policy if the insured person dies in accident or otherwise, then the Respondent has to pay Rs. 1,00,000/- to the nominee of the deceased-insured Late Syed Riyazuddin Khadri met with Road Traffic Accident on 19-10-2000 at about 8-30 PM., when he was going by walk near Chandramouleshwar Chowk, Raichur at that time one Auto Rikshaw bearing Registration NO. MH-12/J-5050 driven by driver Mohd. Iqbal in a rash and negligent manner and suddenly dashed to late Riyazuddin. Due to which late Syed Riyazuddin fell down and the said vehicle ran-over his body and he sustained grievous and multiple fractures on his hip, leg and all over the body. Immediately he was admitted in the District Hopsital, Raichur and operation was done and thereafter he was referred to Nandini Hospital, Raichur for further treatment and again the operation were done but due to grievous multiple and fatal injuries he was again referred to Victoria Hosital, Bangalore for better treatment where he died on 14-11-2000 while taking treatment in Victoria Hospital, Bangalore as an in-patient due to the injuries sustained in the said accident. Regarding the accident a criminal case was registered at Traffic Police Station Raichur in Crime No. 81/2000 against the Auto Driver Mohd. Iqbal and he was charge sheeted. After the death of late Riyazuddin the Respondent No-2 was informed by the Superintendent of Police, Raichur vide letter dt. 01-02-01 and requested for payment of claim amount of Rs. 1,00,000/-. The Respondents asked the complainant to produce PME Report and the same was produced with letter dt. 24-05-01 along with other documents. In-spite of submitting all necessary documents and in-spite of several reminder letters written by S.P. Office, Raichur and request letters by the complainant, the Respondents have failed to pay the claim amount and rejected her claim vide letter dt. 28-11-05 stating that late Riyazuddin died due to kidney ailment. This contention of the Respondent is vague and evading to avoid payment of claim and thereby there is clear deficiency of service by the Respondents. Hence for all these reasons the complainant has sought for direction to the Respondents to pay policy amount of Rs. 1,00,000/- together with interest at 18% p.a. till realization along with cost. 2. The Respondent No-1 has filed written statement which has been adopted by Respondent NO-2. In the written statement the Respondent NO-1 has admitted that late husband of the complainant was member of the Respondent Insurance Company under Special Group Insurance Scheme for Rs. 1,00,000/- under policy No. 72401/42/00/00034. As per the policy, the Respondent is liable to pay the policy amount only in case of death by the accident without any ailment and not otherwise. The Respondent is not liable to pay the policy amount if the death is due to any ailment. As per the FIR, statement of the insured-deceased Syed Riyazuddin Khadri, the injury sustained is near the knee of the left leg and there is no mention of any other injury on other part of the body. As per the PME Report the cause of death is reserved pending. Histopathology Report awaited. Part-V of P.M.E. Report shows that both kidney enlarged and multiple Cyst, left kidney weigh 900 grams and right kidney weigh 700 grams Bladder (empty) completely organs external and internal intact. As per the microsopic finding by the Department of Pathology Section show kidney tissue with multiple cysts of varying sizes lined by flattened epithelium shows multi layering at places. Atropolic plomiruti and tubles are seen. Some of the tibules contain secretrons. Intentrstral fibrosis with chronic inflammatory all infiltration seen few selerosed congested blood veesel are seen. Appearances are those of adult poly cystic kidney. So the death is on account of renal ailment which is chronic and the death is not due to accident. The Respondents have looked into all the documents furnished by the complainant and as per the Histopathology report and PM Report which is not vague and Respondent is not trying to avoid the payment of claim amount. The Insurance is only for accidental death arising out of the accident. But the injury sustained is not fatal as per the statement of the deceased-husband of the complainant. So the Respondent is not liable to pay any Insurance amount and so there is no deficiency in service. The insured had concealed material facts before making of the policy. It cannot be said that there was negligence or lapse on the part of this Respondent. Hence for all these reasons the Respondents have prayed for dismissal of the complaint with cost. 3. During the course of enquiry the complainant has filed sworn-affidavit of the complainant by way of examination-in-chief. In-rebuttal the Respondent NO-1 has filed his sworn-affidavit as examination-in-chief. Both the parties have not chosen to cross-examine. On behalf of the complainant (29) documents at Ex.P-1 to P-29 are got marked. On behalf of Respondents one document at Ex.R-1 was got marked. 4. Heard the arguments of both sides and perused the records. The following points arise for our consideration and determination: 1. Whether the complainant proves deficiency in service by the Respondents in not settling her claim under the Insurance Policy, as alleged.? 2. Whether the complainant is entitled for the reliefs sought for? 5. Our finding on the above points are as under:- 1. In the affirmative. 2. As per final order for the following. REASONS POINT NO.1:- 6. There is no dispute that late Syed Riyazuddin Khadri was a member of Respondents Insurance Company under Special Group Insurance Scheme for Rs. 1,00,000/- under policy Bearing No. 072401/42/00/00034 and according to this policy if the insured person dies in accident or otherwise then the Respondent has to pay Rs. 1,00,000/- to the nominee of the deceased insured. There is also no dispute that the complainant is a nominee of said late Syed Riyazuddin and this Riyazuddin who was working as driver in Police Department in DAR Police Department, Raichur met with vehicle accident on 19-10-2000 at about 8-30 PM while he was going by walk near Chandramouleshwar Chowk, Raichur by Auto Rickshaw and sustained injuries and died on 14-11-2000 while taking treatment in Victoria Hospital, Bangalore as an in-patient. The case of the complainant is that her husband-deceased policyholder died due to grievous and multiple fractures on his hip leg and all over the body as shown in the wound certificate and PME Report etc., On the contrary the Respondents has contended that as per the PME Report the cause of death reserved pending Histopathology Report. Part-V of the P.M.E. Report shows that both kidney enlarged and multiple Cyst. Left kidney weigh 900 grams and right kidney weigh 700 grams Bladder (empty) organs external and internal intact. As per the Microsopic finding by the Department of Pathology Section shows kidney tissue with multiple cysts of varying sizes lined by flattened epithelium shows multi layering at places. Atropolic plomiruti and tubles are seen. Some of the tibules contain secretrons. Intentrstral fibrosis with chronic inflammatory all infiltration seen few selerosed congested blood veesel are seen. Appearances are those of adult poly cystic kidney. So the death of the deceased was on account of renal ailment which is chronic. As such the death is not due to accident. Therefore the Respondents are not liable to claim of the complainant. 7. The complainant has produced (24) documents at Ex.P-1 to P-24 out of which wound certificate issued by Civil Hospital Raichur at Ex.P-3. Discharge certificate issued by Nandini Hospital at Ex.P-4. PME Report at Ex.P-5 are material. Similarly the Respondent Company has produced Histopathology Report issued by Department of Pathology Bangalore, (Medical College) Bangalore at Ex.R-1. PME Report at Ex.P-5 regarding Kidney (vide Part-VI) reads thus: Both kidney enlarged and multiple Cyst left kidney weigh 900 grams and right kidney weigh 700 grams Bladder (empty) completely organs external and internal intact.It also shows Left Hip joint dislocation with fracture in upper third of left femur is observed pending. Histopathology Report is awaited. Date: 14-11-2000. Sd/- Dr.K.H. Manjunath On the next page of this PME Report, it shows Final opinion of the doctor (who conducted PME) on the receipt of Histopathalogy Report No. RMC/FM/OPN/75/2001 dt. 04-04-2001 which reads as under: FINAL OPINION:- On perusal of Post Mortem Report, Histopathology Report and the brief history furnished by the investigating officer, I am of the opinion that the death was due to respiratory failure as a result of pulmonary and renal infection, consequent upon injuries sustained. Bangalore Sd/- 06-04-2001. Dr.K.H.Manjunath Ex.R-1 the Histopathology Report NO. 75/2000 dt. 04-04-01 reads thus: Kidney tissue with multiple cysts of varying sizes lined by flattened epithelium shows multi layering at places. Atropolic plomiruti and tubles are seen. Some of the tibules contain secretrons. Intentrstral fibrosis with chronic inflammatory all infiltration seen. Few selerosed congested blood veesel are seen. Appearances are those of adult poly cystic kidney. Sd/- Dr.Y.H.Kale Gowda. 8. From a close perusal of Final Opinion of the doctor who conducted Autopsy over dead body of deceased, it is evident that this Final Report is based on the Histopathology Report (Ex.R-1) and the doctor has opined that the cause of death was due to Respiratory failure as a result of pulmonary and renal infection consequent upon injuries sustained. If this is so the argument of the learned counsel for the Respondent that the death of the deceased insured was due to his suffering from kidney disease as per Histopathology Report and not due to injuries caused in the accident cannot be accepted in-view of final opinion report of the doctor who conducted the Post Mortem Examination and opinion is based on the Histopathology Report at Ex.R-1. Hence it follows that the death of insured Riyazuddin Khadri was due to the injuries sustained in the accident. Merely because the deceased-insured died subsequent to the accident it cannot be said that the death is not due to the accident, for the simple reason that the Final Opinion of the doctor which is on the basis of PME conducted by him and on the basis of Histopathology Report for the receipt of which he had reserved his Final Opinion, has opined that the cause of death of the deceased was due to Respiratory failure as a result of pulmonary renal infection consequent upon the injuries sustained. Hence we are not in agreement with the arguments advanced by the learned counsel for the Respondent and that the ruling relied upon reported in: II (2006) CPJ 191 (N.C.) Head Notes is not at all applicable to the facts in hand. In the said case the death of the insured occurred during operation due to negligence of operating surgeon and Not Accidental death to get accident benefit under the policy. So facts in the referred decision and the facts in the case at hand are on different footings. Therefore we hold that the complainant has proved that the death of the insured was due to the injuries sustained in the accident. Consequently the act of the Respondent in repudiating the claim of the complainant vide repudiation letter dt. 28-11-05 at Ex.P-24 amounts to deficiency in service by the Respondent Company. Therefore Point NO-1 is answered in the affirmative. POINT NO.2:- 9. The complainant has sought for direction to pay the policy amount of Rs. 1,00,000/- together with interest at 18% p.a. from the date of death of insured till realization along with cost of litigation. So far as the policy amount of Rs. 1,00,000/- is concerned, in-view of our finding on Point NO-1, the complainant is entitled and Respondent Company is liable to pay. In so far as the claim regarding interest at 18% p.a. from the date of death of the insured is concerned, having regard to the peculiar circumstances of the case as discussed in Point NO-1, it shows that the Insurance Company was not negligent or in-active in the settlement of claim. Under these circumstances and having regard to our finding on Point NO-1, we feel it just and proper to award a global compensation of Rs. 25,000/- including cost of litigation. In the result we pass the following order: ORDER The complaint of the complainant is allowed in part. The Respondent Company shall pay the policy amount of Rs. 1,00,000/- to the complainant-nominee along with global compensation of Rs. 25,000/- including cost of litigation. The Respondent Company shall comply this order within (6) weeks from the date of receipt of copy of this order. (Dictated to the Stenographer, typed, corrected and then pronounced in the open Forum on 19-12-06) Sd/- Sri. N.H. Savalagi President Dist.Consumer Forum-Raichur. Sd/- Sri.Pampannagouda Member. Dist.Consumer Forum-Raichur. On Leave/- Smt.Kavita Patil Member.