BEFORE THE DISTRICT CONSUMER FORUM AT NALGONDA
PRESENT: SRI MAMIDI CHRISTOPHER,
PRESIDENT.
SMT.S.SANDHYA RANI,
FEMALE MEMBER.
. . .
WEDNESDAY, THE EIGHTEENTH DAY OF DECEMBER, 2019
CONSUMER COMPLAINT No. 34 OF 2017
Between:
- Smt. Govinda Rajula Radha Kumari W/o Govinda Rajula Venkata Shobhan Chalapathi Rao, Age: 51 years, Occ:Housewife.
- Govinda Rajula Venkata Sai Sree Keerthi D/o Govinda Rajula Venkata Shobhan Chalapathi Rao, Age: 22 years, Occ:Student
Both are R/o Srinagar Colony, Nalgonda Town and
Nalgonda District.
…COMPLAINANTS.
AND
The United India Insurance Company Limited, Miryalguda
Branch, Miryalguda Town, Nalgonda District-508207, T.S.
Represented by its Branch Manager.
…OPPOSITE PARTY.
This complaint coming on before us for final hearing, in the presence of Sri G.Krishna Reddy, Advocate for the Complainant, and Sri M.Shankar, Advocate for the Opposite Party, and on perusing the material papers on record, and having stood over for consideration till this day, the Forum passed the following:
ORDER OF THE FORUM DELIVERED
BY SMT.S.SANDHYA RANI, FEMALE MEMBER
1. This complaint is filed by the Complainant, U/S 12 of the Consumer Protection Act, 1986 to direct the Opposite Party to pay insured amount of Rs.5,00,000/- with interest @ 24% p.a. from the date of death of the insured deceased till the date of realization along with costs.
2. The facts of the case as disclosed from the complaint are as follows:
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The husband of Complainant No.1 Sri GVS Chalapathi Rao was practicing as Senior Advocate at Hyderabad city and Nalgonda town and he had membership in Bar Association, Nalgonda. The husband of the Complainant No.1 obtained Individual Personal Accident Policy, vide Policy No.0514024215P116228145 from the Opposite Party on 28/03/2016 and the said Policy was in force from 28/03/2016 to 27/03/2017. As per the Policy, if the policy holder dies accidentally, his nominee would be entitled for an amount of Rs.5,00,000/-. The husband of the Complainant No.1 was a good healthy person and he had actively practicing as Senior Advocate in all courts. The husband of the Complainant No.1 Sri GVS Chalapathi Rao died accidentally on 30/06/2016 at Rohini Super Speciality Hospital, Hanamkonda due to sudden heart attack and the same was occurred while he was taken into operation theatre for Spinal Fusion Procedure/Operation at 8-00 a.m., on 30/06/2016. After the death of the deceased, the Complainants submitted the claim form along with all the required papers to the Opposite Party. The Complainants bring notice to the Opposite Party that, sudden heart attack also comes under accidental death as per the citation of the Hon’ble National Commission, New Delhi, CPJ 2007 (4) NC 355 by sending it with legal notice and e-mail. The Opposite Party failed to pay the claim amounts under the Group Personal Accident Policy and repudiate the claim of the Complainants on 20/07/2017 on the ground that ‘Sudden Heart Attack not comes under accidental death’. The brother of Complainant No.1 lodged a complaint before the Police, Nalgonda-II Town, against the doctors and Managing Directors of Rohini Super Speciality Hospital, Hanamkonda on 01/07/2016, stating that the deceased Sri GVS Chalapathi Rao died due to medical negligence. The Police, Nalgonda-II Town, registered
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a case in Cr.No.192/2016 and conducted inquest and they had sent the viscera of the deceased and got TSFSL Report from the concerned department and later they had issued the FSL Report and PME Report to the Complainants. The said FSL Report also reveals that the death of the deceased life assured was occurred due to sudden heart attack. The Complainants being the legal heirs of the deceased are entitled for an amount of Rs.5,00,000/- with interest from the date of death of the deceased as per the terms and conditions of the policy. The ground on which the repudiation made by the Opposite Party is a baseless ground and it is not valid. The acts of the Opposite Party amounts to deficiency of service on their part and as such the Complainants filed this complaint.
3. The Complainant No.1 filed her proof affidavit and marked Exs.A-1 to A-20.
4. The Opposite Party filed written version. In their written version, the Opposite Party denied all the averments and allegations made by the Complainants in the complaint. The Opposite Party admitted they had had issued Group Personal Accident Policy bearing No.0514024215P116228145 for the period from 28/03/2016 to 27/03/2017 to the deceased Sri G.V.S.Chalapathi Rao, subject to scope, policy terms and conditions in pursuance of proposal form submitted by him, which is the basis of contract. The scope of the policy is death due to accident and the definition of accident is “a sudden, unforeseen and involuntary event caused by external, visible and violent means”, but the policy does not cover death due to heart attack. The Opposite Party denied that Sri GVS Chalapathi Rao was well and good healthy person, in fact GVS Chalapathi Rao was
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suffering from spinal problem. The Opposite Party denied that the said GVS Chalapathi Rao died accidentally and admitted that he died due to heart attack while he was taken into operation theatre for the purpose of spinal fusion procedure/operation. With regard to the citation in National Commission in CPJ 2007 (4) NC 355 submitted by the Complainant, the Opposite Party submitted that facts in that case are quite different to the facts of the present complaint. The Opposite Party denied that the said GVS Chalapathi Rao was well and good healthy person as on the date of the policy, but the said averment is contrary to the contents of police complaint, dated 01/07/2016 given by K.V.Janardhan Rao (brother-in-law of GVS Chalapathi Rao) to Police Station, Nalgonda-II Town, which was registered under F.I.R.No.196/2016. In the claim form submitted by the Complainant No.1 and even in the present complaint there is no whisper about cause of death due to external, visible and violent means, and, therefore, the Opposite Party has rightly repudiated the claim submitted by the Complainant No.1, in view of scope of policy coverage, i.e. the alleged heart attack is not due to sudden, unforeseen and involuntary event caused by external, visible and violent means. There is no deficiency in service on the part of the Opposite Party and they are not liable to pay the amounts as claimed in the complaint. Ultimately, the Opposite Party prayed for the dismissal of the complaint.
5. Sri L.Amar Singh, Branch Manager, United India Insurance Co.Ltd., Miryalguda Branch filed his proof affidavit on behalf of the Opposite Party and marked Exs.B-1 to B-3. Written arguments were filed on behalf of the Opposite Party.
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6. The points for consideration are:
1) Whether there was deficiency in service on the part of the
Opposite Party?
2) Whether the Complainants are entitled for the claims
they made in their complaint?
3) If so, to what extent?
7. POINT No.1:
It is not in dispute that the husband of Complainant No.1 Sri GVS Chalapathi Rao has obtained Individual Personal Accident Policy from the Opposite Party on 28/03/2016, vide Policy No.0514024215P116228145 and the said policy was valid from 28/03/2016 to 27/03/2017. As per the Policy, if a policy holder dies accidentally, his nominee or nominees would be entitled for an amount of Rs.5,00,000/-. According to the Complainants, the deceased Sri GVS Chalapathi Rao was a good healthy person and he had actively practicing as Senior Advocate in all courts and he died accidentally on 30/06/2016 at Rohini Super Speciality Hospital, Hanamkonda due to sudden heart attack and the same was occurred while he was taken into operation theatre for Spinal Fusion Procedure/Operation at 8-00 a.m., on 30/06/2016. After the death of the deceased, the Complainants submitted the claim form along with all the required papers. The Complainants brought to the notice of the Opposite Party that sudden heart attack also comes under accidental death as per the citation of the Hon’ble National Commission, New Delhi, CPJ 2007 (4) NC 355 by sending legal notice and email to the Opposite Party. The Opposite Party repudiated the claim of the Complainants on 20/07/2017 on the ground that ‘Sudden Heart Attack does not come under accidental death’. The brother of Complainant No.1 lodged a
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complaint before the Police, Nalgonda-II Town, against the doctors and Managing Directors of Rohini Super Speciality Hospital, Hanamkonda on 01/07/2016, stating that the deceased Sri GVS Chalapathi Rao died due to medical negligence. The Police, Nalgonda-II Town, registered a case in Cr.No.192/2016 and conducted inquest and they had sent the viscera of the deceased and got TSFSL Report from the concerned department. The said FSL Report also reveals that the death of the deceased life assured was occurred due to sudden heart attack, and the repudiation of the claim on the sole ground is not a legally valid ground. The Complainants being the legal heirs of the deceased are entitled for an amount of Rs.5,00,000/- with interest from the date of death of the deceased under Individual Personal Accident Policy.
8. The Opposite Party admitted that the deceased had obtained Individual Personal Accident Policy, vide Policy No.0514024215P116228145, which was valid from 28/03/2016 to 27/03/2017. The Opposite Party denied that the deceased Sri GVS Chalapathi Rao died accidentally and submitted that he died due to heart attack while he was taken to operation theatre for the purpose of spinal fusion procedure/operation. According to the Opposite Party, the scope of the policy is death due to accident and the definition of accident is “a sudden, unforeseen and involuntary event caused by external, visible and violent means”, but the policy does not cover death due to heart attack. The Opposite Party submitted that the citation in National Commission in CPJ 2007 (4) NC 355 submitted by the Complainants is not applicable to the present complaint. In the said case, the main impact was cold wave, but in the present complaint, there is no external impact. The Opposite Party submitted
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that the averments made in the complaint is contrary to the contents of police complaint, dated 01/07/2016 given by K.V.Janardhan Rao (brother-in-law of GVS Chalapathi Rao) to Police Station, Nalgonda-II Town, which was registered under F.I.R.No.196/2016. The Opposite Party submitted that the death due to heart attack is not due to sudden, unforeseen and involuntary even caused by external, visible and violent means. The Opposite Party submitted that the claim form submitted by the Complainant No.1 and even in the present complaint there is no whisper about cause of death due to external, visible and violent means, and, therefore, the Opposite Party has rightly repudiated the claim submitted by the Complainant No.1, as per the terms and conditions of the policy.
9. Ex.A-4 is the Medical Certificate of Cause of Death, issued by Rohini Super Speciality Hospitals, Hanamkonda, wherein the cause of death was mentioned as ‘sudden cardio respiratory arrest due to hypertension’. Exs.A-8 FSL Report and A-9 PME Report also reveals that the deceased died due to cardiac arrest. Ex.A-20 is the Enquiry Report filed by team of doctors, who conducted enquiry in Cr.No.401/2016 of PS.Subedari, wherein it was stated that ‘there was no negligence on the part of the team of doctors, and the patient died due to sudden cardiac arrest’. Ex.A-19 is the Final Report, wherein the finding given by the doctor reveals that as per Bolam Test as mentioned in the Supreme Court Judgments, gave a finding by way of opinion that the death of the deceased is not on account of the negligence of doctors attended the surgery to the deceased, but the death is only due to cardiac arrest. Ex.B-1 is the Individual Personal Accident Policy, and as per the terms and conditions of the said Policy,
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if any person 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 or his legal personal representatives as the case may be, the sum or sums in respect of any of the insured persons specified in the schedule. Ex.B-2 is the Medical Certificate of Cause of Death, issued by Rohini Super Speciality Hospitals, Hanamkonda, wherein the cause of death was mentioned as ‘sudden cardio respiratory arrest due to hypertension’. As per the Exhibits filed by the Complainants and the Opposite Party, it is revealed that there is absolutely no whisper about cause of death of the deceased Sri GVS Chalapathi Rao due to external, visible and violent means, and all the exhibits confirms the death of the deceased only by ‘Cardiac Arrest’, i.e. natural death.
10. In support of the case of the Complainants, the counsel for the Complainants filed the following citations:
1) IV (2007) CPJ 355 (NC)
2) III (2018) CPJ 471 (NC)
3) II (2016) CPJ 364 (NC)
4) IV (2017) CPJ 51 (Punjab State Commission)
5) I (2019) CPJ 441 (NC).
The above citations/findings of the Hon’ble National Commission and Hon’ble Punjab State Commission are not applicable to the case of the Complainants.
11. In a decision reported in Alka Shukla Vs.LIC of India (Supreme Court of India) 67, [Civil Appeal No.3413/2019], the Hon’ble Supreme Court observed that:
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Consumer Protection Act, 1986 – Sections 2(1) (g), 23 – Insurance (Life) – Death claim – Heart attack – Accident benefit denied on ground that death was not due to accident – Deficiency in service – District Forum allowed complaint – State Commission Dismissed appeal – National Commission allowed revision – No material on record to indicate that assured sustained specific injuries as a result of a fall from motorcycle or that injuries were caused by outward, violent and visible means, which was the sole and proximate cause of his death – No direct nexus or causation between assured suffering a heart attack and injuries sustained in an accident by outward, violent and visible means – Medical evidence on record is itself proof that insured died due to a heart attack and not due to an accident of falling from the motorcycle – Heart attack had a distinct effect of the insured falling off from his motorcycle – Assured died as a result of a heart attack which was not attributable to the accident – Repudiation justified.
12. In the present case, the Complainants have failed to prove that the deceased died accidentally to claim the amounts under Individual Personal Accident Policy.
13. In support of their contention, the Opposite Party filed the following citations:
- AIR 1966 SC 1644.
- AIR 1999 SC 3252.
- AIR 2004 SC 4794.
- AIR 2010 SCW 6490.
- AIR 2016 SC 363.
- AIR 2019 SC 2088.
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15. POINTS No.2 and 3:
In the light of the findings under Point No.1 and in the light of the findings of the Hon’ble Supreme Court in the above stated citations, the Complainants are not entitled for the claims under Individual Personal Accident Policy.
In the result, the complaint is dismissed without costs.
Dictated to Steno-Typist, transcribed by him, corrected and pronounced by us in the open Forum on this 18th day of December, 2019.
FEMALE MEMBER PRESIDENT
APPENDIX OF EVIDENCE
WITNESSES EXAMINED
For Complainants: For Opposite Party:
Affidavit of the Complainant No.1. Affidavit of the Opp.Party.
EXHIBITS MARKED
For Complainants:
Ex.A-1 Dt.27/04/1989 Xerox copy of Certificate, issued by
Bar Council of Andhra Pradesh, Hyderabad.
Ex.A-2 Dt.28/03/2016 Xerox copy of Individual Personal Accident
Policy.
Ex.A-3 Dt.12/07/2016 Xerox copy of Death Certificate, issued by
Municipal Corporation, Warangal.
Ex.A-4 Dt.30/06/2016 Xerox copy of Medical Certificate of cause of
Death, issued by Rohini Hospitals,
Hanamkonda.
Ex.A-5 Dt.30/06/2016 Xerox copy of Death Report of the insured
GVS.Chalapathi Rao.
Ex.A-6 Dt.01/07/2016 Xerox copy of F.I.R. in Cr.No.192/2016
of P.S.Nalgonda-II Town.
Ex.A-7 Dt.01/07/2016 Xerox copy of Inquest Report.
Ex.A-8 Dt.28/02/2017 Xerox copy of FSL Report.
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Ex.A-9 Dt.01/07/2016 Xerox copy of P.M.E. Report.
Ex.A-10 Dt.01/06/2017 Xerox copy of Personal Accident Insurance
Claimants’ Statement.
Ex.A-11 Dt.01/06/2017 Postal Receipt and Postal Acknowledgment.
Ex.A-12 Dt.20/07/2017 O/c of legal notice issued by the counsel for
the Complainants to the Opposite Party.
Ex.A-13 Dt.20/07/2017 Postal Receipt and Postal Acknowledgment.
Ex.A-14 Dt.20/07/2017 Xerox copy of Repudiation Letter.
Ex.A-15 Dt.22/12/2016 Xerox copy of Family Members Certificate.
Ex.A-16 Xerox copy of Aadhar Card of the
Complainant No.1.
Ex.A-17 Xerox copy of Aadhar Card of the
Complainant No.2.
Ex.A-18 Dt.08/12/2016 Xerox copy of F.I.R. in Cr.No.401/2016
of PS.Subedari.
Ex.A-19 Dt.16/07/2017 Xerox copy of Final Report in FIR No.401/16
of PS.Subedari.
Ex.A-20 Dt.09/02/2017 Xerox copy of Letter issued by
Superintendent, MGM Hospital, Warangal
to the Inspector of Police, Subedari P.S.
along with Enquiry Report, issued by
MGM Hospital, Warangal.
For Opposite Party:
Ex.B-1 Dt.28/03/2016 Attested copy of Individual Personal Accident
Policy bearing No.0514024215P116228145.
Ex.B-2 Dt.30/06/2016 Xerox copy of Medical Certificate of Cause of
Death, issued by Rohini Hospitals,
Hanamkonda.
Ex.B-3 Dt.01/07/2016 Xerox copy of F.I.R. in Cr.No.192/2016
of P.S.Nalgonda-II Town.
PRESIDENT
DISTRICT CONSUMER FORUM
NALGONDA
