Haryana

Ambala

CC/301/2015

Jaspal Kaur - Complainant(s)

Versus

United India Inss Co.Ltd. - Opp.Party(s)

Jaspal Singh

17 Nov 2017

ORDER

BEFORE THE DISTT.CONSUMER DISPUTES REDRESSAL FORUM; AMBALA.

C.C.No.301 of 2015.

Date of Instt.:15.10.2015.

Date of Order: 17.11.2017.

 

1.Jaspal Kaur aged about 60 years wife of late Shri Kamaljeet Singh resident of village Sarangpur, Tehsil Derabassi District Mohali (Pb.)

2.Gurdarshan Singh aged about 25 years son of Shri Kamaljeet Singh resident of village Sanrangpur Tehsil Derabassi District Mohali (Pb.)

..Complainants.

     Versus

1.United India Insurance Company Limited Chenai, through its Branch Manager, United India Insurance Company Limited

2.Indian Bank, Jagadhri Gate, Ambala City through its Branch Manager.

          ..OPs.         

Complaint under Section 12 of the Consumer

 Protection Act, 1986

 

BEFORE:   SH. D.N. ARORA, PRESIDENT.

                   SH. PUSHPENDER KUMAR, MEMBER.

                   MS. ANAMIKA GUPTA, MEMBER.

                  

Present:       Sh.Jaspal Singh, Adv. for complainant.

                   Sh.Mohinder Bindal, Adv. for counsel for OP No.1.                                  OP No.2 exparte.

 

ORDER

                    Brief facts of the present complaint are that husband of the complainant No.1 and father of complainant No.2 took policy No.0105004215P999990002 PMSBY through account No.6003874676 dated 23.05.2015 with OP No.2. The policy holder Kamlajeet Singh died due to the injuries sustained by him in road side accident on 07.06.2015 when he was travelling on his motor cycle with his wife – Complainant No.1. The police of Police station Handesra recorded DDR No.13 dated 09.06.2015 in this regard.  The complainants informed the OP No.2 regarding the death of policy holder on 03.07.2015 and the prescribed form was forwarded to the Op No.1 through OP No.2 who did not accept the claim and intimated on 19.08.2015 that the claim under PMSBY was not accepted due to non-furnishing of post mortem report. The complainant No.1 is an illiterate lady. The medical certificate issued by Medical Practitioner, Mission Hospital, Ambala City, fully detailed certificate regarding the death of policy holder and copy of DDR are sufficient proof of injuries as well as death, therefore, the OP No.1 has wrongly declined the claim.  The act and conduct of the OPs clearly amounts to deficiency in service on their part. In evidence, the complainant has tendered affidavits Annexure C1, Annexure C2 and documents Annexure C3 to Annexure C18.

2.                On notice only Op no.1 appeared and contested the complaint of the complainant by filing reply wherein several preliminary objections such as locus standi, cause of action, maintainability of the complaint and suppression of material facts from this Forum etc. have been taken. It is submitted that insurance policy in question is different from another policies  because this policy does not confer legal rights on the nominee or any other person to claim the benefit under the policy being issued to create awareness about insurance among the masses  all the claims under this policy has to be entertained strictly as per terms and conditions. As per one of the condition, post mortem report of the deceased was marked mandatory for the disposal of any claim but the complainants have not produced any post mortem report and also did not provide any paper with regard to treatment of deceased in any hospital.  There was no deficiency in service on the part of OP No.1. Other contentions made in the complaint have been controverted and prayer for dismissal of the complaint has been made. In evidence, the OP No.1 has tendered affidavit Annexure RX and documents Annexure R1 to Annexure R3.

3.                OP No.2 appeared and filed its reply and submitted that as and when the intimation qua accident and death of insured was received it was immediately sent to the OP No.1 but the claim was declined due to non-submission of post mortem report. The Op No.2 is only a service provider and recognition of claim is in the domain of insurance company and the claim form clearly contains the clause that in case of death original FIR/Panchnama, Post mortem report alongwith Death certificate are required for recognition of claim and the present claim has been repudiated on non-submission of post-mortem report and in legal parlance ignorance of law is not at all excusable and religious practice does not have any legal effect. During the pendency of this complaint OP No.2 did not appear and was proceeded against exparte vide order dated 10.12.2015.

4.                Heard. The counsel for the complainant reiterated the averments made in the complaint and prayed for its acceptance whereas the counsel for OP No.1 reiterated the averments made in the reply and prayed for its dismissal by arguing that there is two days delay in lodging the DDR as well as the doctor who had issued the certificate had not informed the police qua the accidental injuries suffered by the life insured. Learned counsel for the Op No.1 has heavily stressed on the ground that the post mortem in the policy in question was must but the same has not been provided to the OP No.1 by the complainants, therefore, the claim was rightly repudiated.

5.                Undisputedly, the policy holder Kamaljeet Singh was insured with OP No.1 under PMSBY through OP No.2 as he was having bank account with Op No.2. The letter of repudiation dated 12.08.2015 Annexure R1 issued by Op No.1 reveals that the claim of the complainants was repudiated on the ground that the post mortem report, which was necessary in accidental death claim, was not produced as per the Claim Procedural Manual and the terms and conditions of the policy Annexure R3. The relevant condition No.4 is as under:

“The claim form shall be supported in case of death of the insured, by the original FIR/Panchnama, Post Mortem Report and Death Certificate and in case of permanent disablement, by original FIR/Panchnama and a disability certificate issued by a Civil Surgeon. A discharge certificate in the enclosed format shall  also be submitted by the claimant /nominee.”

6.                The question arises whether the claim of the complainants could have been repudiated merely on the ground of non-production of the post mortem report. In such like dispute Hon’ble State Consumer Disputes Redressal Commission Punjab (Chandigarh) while deciding the FA No.528 of 2012 on 16.05.2014 in case titled as  NIA Vs. Iqbal Kaur  has place reliance of case titled as Manager, Health Administrator Team, Bajaj Allianz General Insurance Co. Limited v. Ravinder Kaur & Ors. 2012 (1) CPC 100  wherein it has been held that where the insured died due to inhaling of insecticide the claim cannot be repudiated on the ground that the FIR was not filed and that the post mortem examination was not conducted. Similarly, it was held by this Commission in "Parkash Kaur & others v. ICICI Lombard General Insurance Company & another" 2009(1) CLT 74, which was a case of death due to snake bite, that the claim cannot be repudiated simply on the ground that the post mortem report or police report is not proved despite the fact that the snake bite or accident is proved by other evidence.

7.                However, to succeed in their complaint, the complainants were required to prove that the death of the insured was accidental. For proving the same the complainants proved on record their affidavits Annexure C-1 and Annexure C2. In their affidavits they have deposed about the facts, as alleged by the complainants in the complaint. The matter was reported regarding the accident to the police and in that connection DDR No.13 dated 09.06.2015 was recorded in Police station Handesra District Mohali and before death the deceased was brought to Bali Clinic. The doctor of said clinic issued certificate (Annexure C3) and certified that the injured Kamaljeet was brought to his clinic at 8.30 p.m. on 07.06.2015 with head injuries suffered in road side accident and the patient was declared dead on arrival.  In Annexure C6 i.e. C.T.Scan report the doctor has mentioned that there was head injury on the patient and gave impression that Sub-dural hemorrhage over the left tentorial surface.  There was close proximity of time between the receipt of the injuries and the death of the insured. He died on the day brought to the hospital and that very Hospital had also given the Certificate regarding the death. From the affidavit of the complainant and the other documents proved on the record, we conclude that the insured died; as a result of the receipt of the injuries in the accident and his death was accidental. As per the medical science the injury on the head is always considered serious and in the present case the insured after the accident had suffered head injuries which resulted into his death. The period between the receipt of the injuries and the death was such that it can easily be said that the death was the consequent of the accident itself. On this point reliance can be taken from case law titled as Life Insurance Corporation of India Vs. Smt.Paramjit Kaur Gill 1997 (2) CLT page 675 (Punjab State Commission) wherein Hon’ble Punjab State Commission has held that Consumer Protection Act, 1986, Sections 2 (1) (g) and 14, Interpretation of Statute- The Insurance Law is a welfare legislation and in construing the provisions of the said law the construction of the provisions has to be so adopted as would fulfill the policy of legislation- That construction which would uphold the claim of the policy holder should be preferred as against the one which would deny his claim.  Further Hon’ble National Commission in case titled as Mahesh Maganbhai Trivedi Vs. Divisional Manager, Life Insurance Corporation of India 2015 (4) CLT 406  has held that Insurance claim- The provision for payment of accidental benefits being a beneficial provision needs to be construed rather liberally and if two views are possible the court or the Forum must necessarily lean in favour of the interpretation which is favourable to the insured.    

8.                Keeping in view the above discussion we are considered view that the OP No.1 has wrongly repudiated the claim of the complainants on the ground of non-submitting of post mortem report despite the fact that there are sufficient material available on the case file to prove that the life insured had died due to injuries sustained in accident. Accordingly, we allowed the present complaint with costs which is assessed at Rs.5000/- to be borne by the Op No.1 which is further directed to pay a sum of Rs.2 lakh being insured amount under Pradhan Mantri Suraksha Bima Yojana alongwith interest @ 9 % per annum from the date of filing of the complaint till realization. The order be complied within 30 days on receiving of copy of this order. Copy of this order be supplied to both the parties free of cost. File be consigned after due compliance.

 

ANNOUNCED IN OPEN FORUM                            

Dt.17.11.2017.                                           

                                                                   (D.N.Arora)

                                                                   President,

(Pushpender Kumar)                           Distt.Consumer Disputes

      (Member)                                      Redressal Forum, Ambala.

 

 

 

                             (Anamika Gupta)

                                   (Member)