Punjab

Ludhiana

CC/22/270

Harish Kumar - Complainant(s)

Versus

United India Insurance Company Limited - Opp.Party(s)

Mohit Verma

07 Aug 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                             Consumer Complaint No:270 dated 08.07.2022.                               Date of decision: 07.08.2024.

 

Harsh Kumar Laroiya son of Smt. Raj Rani, resident of House No.B-XXXIV-3202, Street No.5, New Tagore Nagar, Haibowal Kalan, Ludhiana. EMAIL-harsh_laroiya@yahoo.com.in. M.98140-07657.                                                                                                                                     ..…Complainant

                                                Versus

United India Insurance Company Limited, Ferozepur Road, Ludhiana through its Divisional Manager.                                                                                                                                                                        …..Opposite party 

Complaint Under section 35 of the Consumer Protection Act, 2019.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Mohit Verma, Advocate.

For OP                           :         Sh. Govind Puri, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Briefly stated, the facts of the case are that mother of the complainant Smt. Raj Rani obtained Individual Personal Accident Insurance Policy No.2009004220P111535257 valid from 11.01.2021 to 10.01.2022 in renewal to the previous policy. She had been regularly obtaining the said policy for last more than 20 years without any break. The complainant stated that he is the only son of his mother Smt. Raj Rani and lawful assignee of the policy proceeds. Further he is lawfully entitled to all the accruable proceeds after death of his mother due to the direct and proximate cause of an accident. On 30.03.2021, Smt. Raj Rani suddenly fell in the washroom and suffered left hip injury as a sole and direct result of accidental fall which was diagnosed by the attending surgeon of D.M.C. & Hospital, Ludhiana as “closed fracture intertrochanteric Femur left side” and she was operated upon 30.03.2021 for the fracture and was discharged on 09.04.2021 with advise for four weeks bed rest w.e.f. 30.03.2021 under medical supervision. The complainant further stated that Smt. Raj Rani was bedridden due to accident and was unable to perform her daily routine life activities. On 09.04.2021, the complainant got engaged services of Life Time Health Care Services, IssaNagari, Ludhiana for providing nurse for 24 hours to look after his mother from 09.04.2021 till 03.04.2021. Even the complainant had to avail services of Dr. Jagdip Madaan, M.S. Ortho, Jagjit Nagar, Central Town, Ludhiana for constant medical supervision and consultations. Smt. Raj Rani died on 30.04.2021 when she was bedridden as a sole and direct consequence of accidental domestic fall resulting into fracture on the left hip as was diagnosed by DMC Hospital, Ludhiana. The complainant gave intimation to the OP regarding death of his mother but the OP repudiated the claim vide letter dated 09.07.2021 on the grounds, reproduced as under:-

“i)     The insured did not suffer any financial loss, hence compensation under table IV of the policy is not payable.

ii)      The proximate cause of death of the insured is due to asthma and not due to accidental injury.”

According to the complainant, the OP in para no.4 of their letter dated 20.08.2021 admitted this fact that “the Proximate Cause of Bed Rest was sudden & accidental and she was admitted in DMC Hospital for treatment.” This fact was also endorsed by Dr. T.L. Gupta, the empanelled doctor of the OP. However, the OP made a meager amount of Rs.22,500/- on account of financial loss of 31 days through NEFT in the bank account of the complainant unethically and illegally. Even no discharge voucher for full and final payment was got signed by the OP from the complainant. The complainant further stated that he approached Insurance Ombudsman against letter dated 09.07.2021 against repudiation of the claim, but the Insurance Ombudsman erred in considering on all the aspects of compensation and vide order dated 30.03.2022 advised the complainant to approach the other Forum/court.

                   The complainant further stated that Smt. Raj Rani died due to the proximate cause of left hip injury/fracture suffered in accident on 30.03.2021 due to domestic fall for which the complainant claimed to have entitled for the relief and reimbursement of Rs.14,50,000/- in terms of the policy, which is reproduced as under:-

i)Rs.5,00,000/- under Table III for death due to accident.

ii)Rs.5,00,000/- under Table IV for financial loss for death.

iii)Rs.4,50,000/- on account of cumulative bonus earned on perpetual renewal of policy over the long span of 20 years.

 

Non-reimbursement of Rs.14,50,000/- by the OP on account of proximate cause of death of the insured amounts to deficiency in service and unfair trade practice due to which the complainant has suffered mental tension, pain, agony and monetary loss for which he is entitled to compensation of Rs.2,00,000/-. In the end, the complainant has prayed for issuing directions to the OP to pay amount of Rs.14,50,000/- (detailed above) along with compensation of Rs.2,00,00/- and litigation expenses of Rs.33,000/-.

2.                Upon notice, the OP appeared and filed written statement and by taking preliminary objections, assailed the complaint on the ground of its maintainability; the complainant being estopped by her own act and conduct; the complainant being not a Consumer; lack of jurisdiction etc. The OP stated that the complaint has been filed by the complainant with mischievous intentions to enrich himself at the cost of the OP by filing frivolous claim. The OP further stated that the claim of the complainant was considered by them in the light of investigation/verification report dated 26.06.2021 of B.S. Narang & Associates, Insurance Investigators & Tracers and made the remarks and opinion in it.

                   The OP further stated in the light of the investigation report of B.S. Narang & Associates dated 26.06.2021 and in the light of the medical history of the insured Mrs. Raj Rani that she was a chronic patient of Asthma since long, has rightly declined the claim vide letter dated 09.07.2021. The OP in letter dated 09.07.2021 has duly explained that "it has been observed that insured did not suffer any financial loss due to bed rest against the above claim. Hence, the compensation under Table-IV of the policy is not payable." Further as per investigation report as well as evidence it has been found that "Proximate cause of death of the insured is due to asthma and not due to accidental injuries." Keeping in view of the above facts the claim file stands closed as NO CLAIM.

                   The OP further stated that the complainant challenged the repudiation of the claim before the "Insurance Ombudsman" at Chandigarh vide complaint ref No.CHD-G- 051-2122-0217 titled 'Harsh Kumar Laroiya vs The United India Insurance Co. Ltd. wherein the Hon'ble Ombudsman has passed an award dated 15.02.2022 in favor of complainant directing OP insurance company "to pay the admissible injury claim under policy No.2009004220P111532688 of insured Smt. Raj Rani reported under table-IV temporary total disablement (weekly compensation) for the period from 30.03.2021 to 30.04.2021 and treatment taken from DMC, Ludhiana and given by Dr. Rajnish Garg as per policy terms and conditions within 30 days from the receipt of award copy." As such, the OP company towards the compliance of the award paid a sum of Rs.22,500/- to the complainant. Even after compliance of the order/award of Insurance Ombudsman, the OP again deputed B.S. Narang & Associates, insurance investigators to seek the opinion of doctor, to be self satisfied with their decision. The investigator after seeking expert opinion of Dr. Balwant Singh Hunjan, submitted his report dated 29.04.2022 wherein he has confirmed that as per the opinion of Dr. Balwant Singh Hunjan “the cause of death of insured is not the accidental injury but is only the natural death due to other illness which she was carrying i.e. Asthma”. According to the OP, there is no deficiency in service, breach of contract and any negligence on its part.

                   On merits, the OP reiterated the crux of averments made in the preliminary objections. The OP has denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

3.                In support of his claim, the complainant tendered his affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 is the copy of Individual Personal Accident Policy Schedule, Ex. C2 is the copy of repudiation letter dated 09.07.2021, Ex. C3 and Ex. C15 is the copy of order dated 30.03.2022 of Insurance Ombudsman, Ex. C4 is the copy of certificate of Dr. Jagdip Madaan, Ex. C5 is the copy of Personal Accident Insurance-Medical Report, Ex. C6 is the copy of letter dated 20.08.2021 of the OP, Ex. C7 is the copy of death certificate of Smt. Raj Rani, Ex. C8 is the copy of report dated 26.06.2021 of the investigator, Ex. C9 is the copy of letter dated 15.09.2021 of the complainant, Ex. C10 is the copy of Patient and Patient Family Agreement with Life Time Patient Care, Ex. C11 is the copy of award dated 15.02.2022 of Insurance Ombudsman, Ex. C12 is the copy of Claim Note Sheet, Ex. C13 is the copy of account statement of the complainant, Ex. C14 is the copy of discharge summary dated 09.04.2021 and closed the evidence.

4.                On the other hand, counsel for the OP tendered affidavit Ex. RA of Ms. Lipi Moitra, Asst. Manager of the OP along with documents Ex. R1 is the copy of investigation report dated 26.06.2021, Ex. R2 is the copy of repudiation letter dated 09.07.2021, Ex. R3 is the copy of award dated 15.02.2022 of Insurance Ombudsman, Ex. R4 is the copy of report dated 29.04.2022 of the investigator, Ex. R5 is the copy of opinion of Dr. Balwant Singh Hunjan and closed the evidence.

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written reply along with affidavit and documents produced on record by both the parties.

6.                Admittedly, Smt. Raj Rani, mother of the complainant obtained ‘Individual Personal Accident Policy’ Ex. C1 having validity from 11.01.2021 to 10.01.2022 for a premium of Rs.1663/- having the risk and coverage, reproduced as under:-

Name of the Insured	Age	Occupation	Relationship	Risk Category	CB%	CB (in amount)
Raj Rani	84	Traders & Business men	Self	Risk Category 1	50	450000

 

Name	Covers	CSI (₹)	Premium (₹)	Risk Loading/Discount	Premium
Raj Rani	Table III Death PTD PPD	500,000.00	475.00	Loading for age factor over 70 years	122.50
	Table IV Death PPD PTD TTD	500,000.00	750.00	Family Discount	122.50
	Medical Expenses	0.00	245.00

 

On 30.03.2021, Raj Rani fell in washroom and suffered left hip injury. She was taken to DMC Hospital, Ludhiana for surgery where she was discharged on 09.04.2021 and her condition at that time was afebrile, stable and progressive. She was advised rest for 4 weeks with follow up after 5 days. The extract of discharge summary dated 09.04.2021 Ex. C14 is reproduced as under:-

“Hospital Course: Patient was taken up for surgery after initial investigations. Chest clearance under Dr. Anil Kashyap in view of pre-existing Asthma. Cardiology clearance under Dr. Abhishek Goyal, Medicine Clearance under Dr. Sandeep Puri and PAC clearance. Check X-rays were satisfactory. Psychiatry consultation was taken under Dr. Rupesh in view of restlessness and the patient was managed accordingly. Regular ASDS and physiotherapy was done. Now the patient is being discharged in stable and afebrile condition with sutures in SITU & a healthy suture line. Attendants have been cancelled regarding the comorbidities and general condition of the patient.”

 

She remained bedridden and finally took her last breath on 30.04.2021. The complainant preferred a Personal Accident Claim vide report Ex. C5, on the receipt of which M/s. B.S. Narang and Associates was appointed to conduct investigation/verification of the claim relating to death of Raj Rani. He made the following remarks and opinion in his report Ex. R1:-

“OUR REMARKS & OPINION:- Based on our verifications/investigations supported by documentary/verbal/ circumstantial evidences were are of the opinion that:-

1. The insured met with an accident and remained bed ridden.

                   2. The treatment was taken by injured from DMC Hospital,                         Ludhiana.

                   3. The medical opinion of Dr. T.L. Gupta is on the file.

                   4. The report of Dr. T.L. Gupta is justified only when it is a case of            any working/earning insured which is not there in this particular             case.

5. The compensation under table-IV of the policy is payable only when the insured suffers loss of income due to not attending to work/profession because of bed rest. In this case the insured did not suffer any loss of income due to her bed rest on account of accident. Our investigations/ findings reveal that the handloom sale shop claimed to be run by the deceased insured is not practically there. In fact beauty parlor attached with sale of little number of ladies readymade garments located on the said shop is being run by Mrs. Shama Laroiya wife of the claimant/nominee.

6. From the statement of the claimant/nominee, discharge summary of hospital as well as based on other evidences we found the proximate cause of death of Mrs. Raj Rani is due to asthma disease and not due to accident injuries. In this situation the relevancy of ITR having or not having, does not matter. As such the claim of the insured does not become maintainable under the policy which is recommended for denial and file be closed as no claim.”

After scrutinizing the documents and report of the investigator, the claim of the complainant was repudiated by the OP vide letter dated 09.07.2021 Ex. C1 = Ex. R2, the operative part of which reads as under:-

“While processing of the claim file and as per investigation report No.BSNA/IR/2021/1110 dated 26.06.2021 it has been observed that insured did not suffer any financial loss due to bed rest against the above claim. Hence the compensation under Table IV of the policy is not payable.

As per investigation report as well as evidence it has been found that PROXIMATE CAUSE OF DEATH OF THE INSURED IS DUE TO ASTHMA AND NOT DUE TO ACCIDENTAL INJURIES.

Keeping in view of the above facts that the claim file stands closed as NO CLAIM.”

 

7.                Aggrieved by the repudiation of his claim, the complainant filed a complaint before the Insurance Ombudsman who was pleased to pass an award dated 15.02.2022 Ex. C11 = Ex. R3, the operative part of which is reproduced as under:-

“Taking into account the facts & circumstances of the case and the submissions made by both the parties during the course of online hearing, the insurance company is directed to pay the admissible injury claim number 2009004221C050002001/1 under policy no.200900422OP111532688 of insured Smt. Raj Rani reported under table IV temporary total disablement (weekly compensation) for the period from 30.03.2021 to 30.04.2021 and treatment taken from DMC, Ludhiana and given by Dr. Rajnish Garg as per policy terms and conditions within 30 days from the receipt of award’s copy.”

In compliance of the award, an amount of Rs.22,500/- was worked out vide claim note sheet Ex. C12 and which was paid to the complainant.

8.                Now the point of consideration arises whether on 30.03.2021 Raj Rani sustained bodily injury resulting solely and directly from accident caused by external, violent and visible means and whether the OP was justified in denying the personal accident claim of the complainant?

9.                It is desirable to reproduce relevant definitions and conditions of the policy as under:-

“1. Accident – An accident is a sudden, unforeseen and involuntary event caused by external and visible and violent means.

10. Injury – Injury means accidental physical badly harm excluding illness or disease solely and directly caused by external, violent and visible and evident means which is verified and certified by a Medical Practitioner.

20. Surgery or Surgical Procedure – Surgery or Surgical Procedure means manual and/or operative procedure(s) required for treatment of an illness or injury, correction of deformities and defects, diagnosis and cure of disease, relief of suffering or prolongation of life, performed in a hospital or day care centre by a Medical Practitioner.”

Further the relevant condition No.1, 1(a) and 1(f) is reproduced as under:-

“1. If at any time during the currency of this policy the insured shall 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 representative(s) as the case may be the sum or sums hereinafter set forth that is to say:-

a)If such injury shall within twelve calendar month of its occurrence be the sole and direct cause to the death of the insured persons the Capital Sum Insured stated in the Schedule herein…….

f)If such injury shall be the sole and direct cause of temporary total disablement, then so long as the insured person shall be totally disabled from engaging in any employment or occupation of any description whatsoever a sum at the rate of one percent (1%) of the capital sum insured stated in the schedule herein per week, but in any case not exceeding Rs.5000/- per week in all under all policies per week in any case not exceeding 25% of the monthly salary.”

 

                   Conjoint reading of the aforesaid definitions would make it crystal clear that deceased insured must suffer some bodily injury resulting solely and directly from the accident which should be sudden, unforeseen and involuntary event caused by sudden unforeseen and violent means. Further accidental bodily injury needs to be verified and certified by a Medical Practitioner.

10.              The counsel for the complainant has referred to certificate dated 01.04.2022 Ex. C4 issued by Dr. Jagdip Madaan, MBBS Ortho, Senior Orthopaedic Surgeon, Ludhiana under whose supervision, consultations further treatment of Raj Rani was carried out when she was bedridden. The operative part of Ex. C4 is reproduced as under:-

“This is to submit that expertise that Mrs. Raj Rani W/o. Mr. Ved Parkash who got left hip injury due to domestic fall, got treated in DMC Hospital with admission from 30.03.2021 to 09.04.2021 remained under my consultation for some period after discharge and consequently expired on dt. 30.04.2021 due to inability of tolerating trauma. As per my opinion proximate cause of death her hip injury which normally is unbearable at the age of 84 yrs.”

 

As per said certificate Ex. C4, the doctor has opined that the proximate cause of death was left hip injury due to domestic fall and she has expired due to her inability to tolerate trauma in advance age of 84 years. This medical opinion has gone unrebutted. The investigator also consulted empanelled doctor Dr. T.L. Gupta, but strangely enough, the investigator expressed  certain reservations qua the opinion of a Medical Expert for the reasons best known to him.  However, in letter dated 20.08.2021 Ex. C6 addressed to the complainant, the OP company was in agreement with the opinion of empanelled doctor Dr. T.L. Gupta. The relevant extract of the letter/reply are reproduced as under:-

“1-3. Under these points it is admitted fact that an injury claim No. 2009004221C050002001/1 under policy no.200900422OP111532688 of insured Smt. Raj Rani reported Under Table – IV- Temporary Total Disablement (Weekly Compensation) for the period from 30.03.2021 to 30.04.2021 and treatment taken from DMC, Ludhiana and given by Dr. Rajnish Garg.

4. It is admitted fact that Proximate cause of BED REST under the above Claim of PA Policy is SUDDEN & ACCIDENTAL and she was admitted in DMC Hospital for treatment. 

5. We do agree that Company Panel Doctor T.L. Gupta has also given his recommendation for 31 days Bed Rest from 30.03.2021 to 30.04.2021.”

The factum of opinion of empanelled doctor also finds mention in para No.21 of the award of the Insurance Ombudsman which pertains to ‘Observations and Conclusions’. It is also apposite to note that the Insurance Ombudsman directed the OP to pay admissible injury claim under Table IV Temporary Total Disablement for a period of 30.03.2021 to 30.04.2021 and those directions were complied by the OP. So, therefore, it emerges out that the deceased was unable to perform her daily chores due to injury suffered in accident till 30.04.2021. So this Commission is of the opinion that death of Raj Rani had proximate connection with injury suffered by her in the accidental fall. The opinion of the OP that she died due to Asthma is not supported by any medical record or expert opinion. In absence of any such evidence, the version of the OP regarding cause of death cannot be sustained. The complainant has been able to prove that bodily injuries sustained in the accident are perpetually proximate to cause the death of his mother.

11.              In this regard, reference can be made to Civil Appeal No.4769 of 2022 in National Insurance Company Ltd. Vs The Chief Electoral Officer & Others 2023 LiveLaw (SC) 90 whereby the Hon’ble Supreme Court has made the following observations:-

“32. We have benefit of elucidation in this behalf arising from the judgment of this Court in Smt. Alka Shukla Vs Life Insurance Corporation of India (2019) 6 SCC 64. The Court noted the divergence of opinion of courts between courts across international jurisdictions making a distinction between “accidental means” and “accidental result” while deciding insurance claims. Thus, an unexpected accident and unforeseen consequence or result from a normal or routine activity may constitute an accident but it would not qualify as “accidental means”. Two illustrative examples given are: (a) a fatal heart attack while dancing would be called “accidental” but would fail to attract insurance cover as not due to “accidental means”; (b) heart attack suffered as a result of over-exertion on being chased by a ferocious dog the death might attract the insurance cover as it was caused by “accidental means”. In the first example it was a normal activity while in the second it was an unintended activity and not a normal activity. The given type of injury may thus, fall within or outside the policy according to the event which led to the death and it is this particular cause which is required to be examined. The accident, thus, per se postulates a mishap or untoward happening, something which is unexpected or unforeseen.

33. The aforesaid judgment also emphasises the importance of a plain reading of the policy as a guiding principle. A proximate causal relationship between the accident and the body injury is a necessity.”

So by applying ratio of the above said citation and keeping in view the facts and circumstances of the case, this Commission is of the view that the OP was unjustified in repudiating the claim of the complainant and as such, it would be just and appropriate if the OP is directed to settle and reimburse the claim of the complainant regarding death of the insured Smt. Raj Rani along with composite costs of Rs.10,000/-.

12.              As a result of above discussion, the complaint is partly allowed with direction to the OP to settle and reimburse the claim of the complainant regarding death of the insured Smt. Raj Rani within 30 days from the date of receipt of copy of order along with interest @8% per annum on the settled amount from the date of filing of complaint till date of actual payment. The OP shall also pay a composite costs of Rs.10,000/- (Rupees Ten Thousand Only) to the complainant within 30 days from the date of receipt of copy of order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.      

13.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)                                (Sanjeev Batra)

Member                                                President         

 

Announced in Open Commission.

Dated:07.08.2024.

Gobind Ram.