Haryana

Kurukshetra

CC/273/2019

Raj Kaur - Complainant(s)

Versus

United India - Opp.Party(s)

Ashish Deswal

01 Feb 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION  KURUKSHETRA.

 

Consumer Complaint No.273 of 2019

Date of Instt.:11.07.2019

Date of Decision: 01.02.2021

 

1.Raj Kaur, aged 50 years, w/o late Sh.Krishan Lal.

2.Neha Rani, aged about 27 years, d/o late Sh.Krishan Lal

3.Karan aged about 24 years, son of late Sh.Krishan Lal.

4.Akshay aged about 21 years, son of late Sh.Krishan Lal

        All residents of house no.2877/7, Ravidas Nagar, Kurukshetra Haryana and presently  residing at House No.15/11, BBMB Colony, Kurukshetra, Haryana.

5.Rachani Devi aged about 81 years, w/o late Sh.Parwara Ram and mother of late Sh.Krishan Lal, resident of House No.2877/7, Ravidas Nagar, Kurukshetra, Haryana.                         

                                                              …….Complainants. 

                                             Versus

 

1.United India Insurance Company Limited 24, Whites Road,Chennai- 600014, through Managing Director.

2.United India Insurance Company Limited,SCO -97, 1^st Floor, Sector 17, Kurukshetra through its Manager.

3. Syndicate Bank, Mohan Nagar, Kurukshetra through its Manager.

4.Syndicate Bank, Door No.16/355, & 6/365A Manipal, Udupi Disitrict Karnataka 576104 through its Managing Director.

                ….…Opposite parties.

 

Complaint under Section 12 of Consumer Protection Act.

 

Before       Smt. Neelam Kashyap, President.    

                   Ms. Neelam, Member.       

                   Shri Issam Singh Sagwal, Member.                     

 

Present:     Sh.Ashish Deswal counsel for the complainant.

                Sh.Rajesh Kumar Singhal Advocate for the OPs.

 ORDER

              This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by the complainant Raj Kaur and others  against United India Insurance Co. Limited and others - the opposite parties.

2.             In brief, the case of the complainants is that late Sh.Krishan Lal son of Sh.Parwara Ram husband of the complainant no.1 took a house loan of Rs.10.00 lacs from Syndicate Bank, Mohan Nagar, District Kurukshetra. The OP No.3 being the financer of said Krishan Lal got issued an insurance policy namely UNIHOME CARE  bearing No.1126002617P115431485 from OP No.1 and 2 regarding the bank loan as well as personal accident of the borrower for a total sum of Rs.36 lacs i.e. Rs.18.00 lacs each under two heads. The representative of OP no.2 and 3 assured the deceased Sh.Krishan Lal  that in case of death of deceased Krishan Lal and complainants   that in case of death borrower, nothing is to be paid by them and the remaining outstanding amount of the loan alongwith  interest thereon would be paid by the insurance company and the balance of the insured amount would be given to the legal heirs of insured.  Tenure of the said insurance policy is from 9.11.2017 to 8.11.2032. It is further averred that late Krishan Lal, husband of complainant no.1 had been paying the installments and interest thereon from time to time and after his death complainant no.1 is paying the same.  It is also averred that unfortunately in the night of September 18, 2018 husband of the complainant while returning from market met with an accident as his scooter slipped and he  fell down and received injuries and jerk/trauma in neck.  Due to feeling of pain, on 19.9.2018, complainant  no.1 took him to Soni Orthopedic Hospital, Kurukshetra for treatment of the injuries. As there was no relief, so doctor of J.P.Hospital, Kurukshetra was also consulted on 22.09.2018. On 26.09.2018 he was referred to PGI Chandigarh by Dr.Soni Hospital.  Thereafter Krishan Lal was taken  to Dr.Atul Arora of Arora Hospital Kurukshetra, who after examination  referred him to Neurosurgeon Dr.Himanshu Jain in Anand Hospital Kurukshetra.Said Krishan Lal got treatment from Anand Hospital, Kurukshetra  but there was no relief and ultimately he was   taken to PGIMER Chandigarh  and during treatment Krishan Lal died on 31.10.2018. It is submitted that as per death certificate issued by the PGIMER Chandigarh, the immediate cause of death of deceased Krishan Lal is mentioned as Cardio Pulmonary Arrest, the antecedent cause of his death i.e. the cause which lead to Cardio Pulmonary arrest is mentioned  as Cervical Spine Abscess and other significant condition contributing to death but not related to disease or conditions causing it are also mentioned as Herpes Zoster Quadriplegia.   It is mentioned that the cervical spine abscess was due to the neck trauma  which is clear from the record of Dr.Atul Arora, who has specifically mentioned in  his  medical prescription /record dated 26.09.2018 that  “history of trauma in neck on 18.9.2018 being treated  by ortho surgeon since then. Dr.Artul Arora also specifically mentioned trauma ( 8 days back).” Hence, it is clear that late Sh.Krishan Lal received neck trauma injury on 18.9.2018 by way of jerk in the accident, when his scooter was slipped. The complainant n.1 is wife of late Sh.Krishan Lal, complainants no.2 to 4  are children and complainant no.5 is mother of  Krishan Lal and as such all of them are legal heirs of deceased Krishan Lal. It is further averred that the complainants in the month of December 2018 contacted  OP No.3 regarding the loan and insurance claim, who suggested to move application for insurance claim alongwith the requisite documents and made the claim with requisite documents against the said insurance policy to OP no.3 as well as OP No.2.  After repeated reminders on 14.4.2019 the claim of the complainant was wrongly rejected on the ground that no FIR was lodged regarding the accident nor any information about the accident was given to the doctors treating the deceased and further on the ground that the manner of death is marked as natural in the death certificate issued by PGI Chandigarh.  As no other vehicle or person was involved in the accident, therefore, no FIR regarding the accident was lodged. It is submitted that regarding the cause of death, the IPD record of PGIMER Chandigarh of deceased Krishan Lal at page 23 is very much material and relevant wherein it is recorded as under:

 

                “Patient admitted in 22 ortho ward with diagnosis of  cervical spine lesion with quadriparesis with bowel bladder involvement, spinal lesion aspirated and culture sensitivity testing done and report came as pyogenic abscess. In CT Scan patient had multicoated lesion in preverterbal, paravertebral and parapharynageal space with C5- C7 Vertebral body destruction.

                In hospital course patient developed herpes bullae and he also developed difficult in breathing and Co2 retention for which he kept on non invasive ventilation.”

                 It is averred that said diagnosis of Pyogenic abscess and Vertebral body destruction could be the result of injury and in the present case the same were the result of the trauma as the deceased received the trauma in the accident on 18.9.2018, as already mentioned above and as such Krishan Lal died due to accident and the OPs have withheld the claim of the complainants illegally. Thus, it is prayed that non payment of claim by the OPs amounts to deficiency in services on the part of OPs and the OPs be directed to pay the insured amount  alongwith interest. It is further prayed that OPs no.1 to 4 be kindly directed to pay Rs.1,50,000/- as compensation for the harassment caused to the complainant alongwith litigation expenses.

 

3.             On notice OPs appeared. OP No.1 and 2 admitted the issuance of the insurance policy for Rs.18,00,000/- for fire policy and insurance for Rs.18,00,000/- was issued for personal accident claim.  Syndicate bank was assignee. The claim under the policy was payable only in case of accidental death of the  insured.  It is denied that  answering OP had  assured Krishan Lal and  in case of death of   insured, nothing  was to be paid by the complainants and the remaining amount alongwith interest would be paid by the insurance company. The personal accident claim was payable only in the case of accidental death of the life assured.  It is denied that deceased life assured had suffered any accidental injury on 18.9.2018  because no treatment was taken on 18.09.2018 which shows that there was no accidental injury. Moreover, in the treatment dated 19.09.2018, the concerned doctor had never mentioned that Krishan Lal had suffered any accidental injury. The record of Dr.Atual Arora and Dr.Himanshu Jain have been got manipulated later on to show the natural death as accidental death. However, the  treatment of the patient in PGI, Chandigarh  is admitted. It is worth to mention  herein that the doctors of PGI Chandigarh had specifically mentioned in the death report that Krishan Lal had died a natural death and it was a Non –MLC case. It is submitted that if the death would have been taken place due to any accident, the DDR or FIR should have been got registered and post mortem would have been got conducted on the body of the deceased.  All other averments made in the complaint have been denied and  preliminary objections  have been raised that the complicated questions of law and facts are involved and as such the present complaint is not maintainable before this Forum, that this Forum has got no jurisdiction to decide the complaint, that the complaint is bad for mis-joinder and non joinder of the parties and the complainants have no locus standi to file the present complaint.

4.             OP No.3 and 4  filed their separate written statement disputing the claim of the complainant. Preliminary objections regarding jurisdiction, cause of action, involvement of question and facts, maintainability and that of locus standi have been raised.

                On merits, it is submitted that complainant had contacted the OP no.3 and informed about the  death of Krishan Lal and OP No.3 had submitted the claim with the insurance company and the claim was rejected by the insurance company on the ground that the death was natural and the claim is not payable. The answering OP No.3 and 4 had no concern with the payment of the claim as the claim is to be processed and settled by the OP no.1 and 2 as the OP No.1 and 2 have come to the conclusion that the claim is not payable as per the terms and conditions of the insurance policy because  the insured Krishan Lal had died a natural death and not  an accidental death. All other averments have been denied by answering OP no.3 and 4 and it was submitted that there is no deficiency in services on the part of answering OPs and prayed for dismissal of the complaint.

 

5.             The complainants in support of their case have filed  affidavit Ex.CW1/A and tendered documents Ex.C1 to Ex.C-13 and closed their evidence.

 

6.             On the other hand OPs have tendered affidavits Ex.RW1/A, Ex.RW2/A and tendered documents Ex.R-1 to Ex.R-6 and closed the evidence of the OPs.

 

7.             We have heard the learned counsel for the parties and gone through the material available on the case file.

8.             Learned counsel for the complainant while reiterating the averments made in the complaint has argued that as per insurance policy Ex.C-1, Sh.Krishan Lal, deceased, was insured with the OP No.1 and 2 under two heads. The insurance policy had two Sections i.e. Section-I, for fire insurance policy for insured sum of Rs.18 lacs and  Section-II for Personal Accident  Insurance policy for insured sum of Rs.18 lacs. As per bank record, the insurance premium had been deducted from the loan account of the deceased by OPs. He has argued  that  scooter of the deceased was slipped and he sustained injuries. He was admitted to  attended by Dr.Soni of Soni Orthopedic Hospital, Kurukshetra and thereafter by other doctors. During his treatment at PGI, Chandigarh, deceased died and as such the complainants are entitled to accidental claim insurance from the OP No.1 and 2 but the OP no.1 and 2 vide letter dated 14.04.2019 repudiated the claim of the complainants. He has further argued that MLR and PMR are necessary in this case because no criminal act took place and post mortem is required to find out the cause of death. Ex.C-4 medical certificate of cause of death issued by PGI Chandigarh is on record declaring the cause of death, hence post mortem is not necessary in the present case. It is also argued that in Ex.C-5 i.e. prescription slip of Dr.Soni, it is clearly mentioned that the patient suffered Contusion Cervical Spine. The word “Contusion” means a region of injured tissue or skin in which blood capillaries have been ruptured and as per Oxford dictionary, it means an injury to part of the body that does not break the skin. Learned counsel for the complainant has placed reliance on the law laid down in cases Amarjit Kaur Vs. HDFC Ergo General Insurance Co.Limited 2017(4) CPJ 51, Nand Kishore Sharma Vs. New India Assurance Co.Limited and another 2010 (3) CPJ 323, The Oriental Insurance Co.Limited Vs.Sabar Singh Kunwar 2014, CPJ 49,, New India Insurance Co.Limited Vs.State of Haryana 2008(2) CPJ 371, Dr.Meena  Raghunathan Vs. OIC 2003 (1) CPJ 669, ICICI Lombard General  Insurance  Co. Vs.Raju Kachhawa 2009(1) CLT 328 and LIC of India Vs. Vijayanti Bai 2005(2) CPJ 445.

9.             On the other hand, learned counsel for OP No.1 and 2 argued that the investigator   had  collected  the relevant documents and had conducted a thorough investigation. After investigation of the case  and on the basis of documents, it was established that Krishan Lal had died a natural death and the claim was not payable under the policy of insurance and as such, the same was repudiated  by the competent authority after considering all the relevant facts and after applying its mind vide letter dated 14.04.2019. He has argued that as per  complainants, deceased met with an accident on 18.09.2019 whereas no treatment was  taken by deceased on that day, which prima facie proves that he had not suffered any injury in the accident.  Moreover, in the treatment record  and certificate issued by PGI, Chandigarh, it has been clearly mentioned that Krishan Lal had died a natural death. In this case there is no FIR or Post Mortem Report to show that Krishan Lal had met with an accident. Thus, it is argued that the claim of the complainants have been rightly repudiated and the complainants are not entitled to any relief.

                The learned counsel for OP No.3 and 4 has argued that  on receipt of the claim from the complainants, they have forwarded the claim to the OP no.1 and 2 and they had nothing to do in this case. The OP No.1 and 2 were the competent authority to settle the claim of the complainants.

10.            After hearing the learned counsel for the parties and going through the written arguments placed on the file by both the parties,  we are agree with the arguments advanced by the learned counsel for OPs. Issuance of the insurance policy by OP No.1 and 2  for the sum of Rs.18.00 lacs for fire insurance and Rs.18.00 for personal accident claim is not in dispute.  Death of Krishan Lal, deceased, in the PGI Chandigarh is also not in dispute. The only dispute in this case as to whether Krishan Lal, assured, died due to injuries sustained in the accident or he died a natural death. As per treatment record issued by PGI Chandigarh Krishan Lal, life assured, died a natural death. The investigation report Ex.R-3 shows that the deceased died natural death.  In this case, the only dispute is to find out the cause of death. As  per PGI treatment record, life assured Krishan Lal, died due to natural death. We are not agree with the contention of learned counsel for the complainant that that in Ex.C-5 i.e. prescription slip of Dr.Soni, it is clearly mentioned that the patient suffered Contusion Cervical Spine. None of the Medical Officer, who treated deceased Krishan Lal, has clearly mentioned that injuries, if any, sustained in the alleged accident were cause of death. Further, report of investigator Ex.R-3 clearly shows that the deceased Krishan Lal died natural death. FIR is the only document to prove that a person met with an accident and description of injuries is found mentioned in the said document, but no FIR has been ledged in this case. Therefore, it is held that deceased Krishan Lal died a natural death and not an accidental death. Hence, claim of the complainants have been rightly repudiated by the OP No.1 and 2 vide repudiation letter dated 14.04.2019. The authorities relieved upon by the learned counsel for the complainant are quite distinguishable from the facts and circumstances of the case in hand, therefore, the same are not applicable to the present case.

11.            In view of our aforesaid discussion, we do not find any merit in the present complaint, therefore, the same is hereby dismissed without any relief to the complainants. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the record-room, after due compliance.

 

Announced in open Commission.

Dt.:01.02.2021                                                              (Neelam Kashyap)

                                                                                                                                                       President.

 

 

                                                                         (Issam Singh Sagwal),         (Neelam)       

                                                                            Member                              Member.