Chandigarh

DF-II

CC/140/2014

Saroj - Complainant(s)

Versus

Universal Sompo General Insurance Company Limited - Opp.Party(s)

Anamika Mehra

30 Jan 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II

U.T. CHANDIGARH

 

Consumer Complaint No.	:	140/2014
Date of Institution	:	20.03.2014
Date of Decision	:	30/01/2015

 

                  

                                                         

 

Saroj w/o Late Sh.Vidyadhar r/o H.No.3117, Sector 29-D, Tribune Colony, Chandigarh.

                                      ...  Complainant.

Versus

1.       Universal Sompo General Insurance Co. Ltd., Unit 401, 4th Floor, Sangam Complex, 127, Andheri, Kurla Road, Mumbai through its Regional Manager.

 

2.       Universal Sompo General Insurance Co. Ltd., SCO No.72, Swastik Vihar, Sector 5, Panchkula through its Divisional Manager.

 

3.       The Allahabad Bank, Sector 17, Chandigarh through its Branch Manager.

 

4.       The Allahabad Bank, Marketing Department, # 2, Netaji Subhas  Road, Kolkata-700001 through its General Manager.

 

…. Opposite Parties.

 

BEFORE:  SHRI RAJAN DEWAN, PRESIDENT

SMT. MADHU MUTNEJA, MEMBER

SHRI JASWINDER SINGH SIDHU, MEMBER

 

Argued by:  Ms.Anamika Mehra, Counsel for the complainant

                        Sh.Rajeev Abhi, Counsel for OPs No.1 and 2

Sh.Gaurav Bhardwaj and Sh.Sumit Batra, Counsel for OPs No.3 and 4.

 

PER RAJAN DEWAN, PRESIDENT

1.           In brief, the case of the complainant is that her husband namely Sh.Vidyadhar was an account holder of Allahabad Bank and was issued Free Personal Accident Insurance Facility against Policy No.3317/50704407/01/000.  It was stated that on 25.03.2012, her husband Sh.Vidyadhar, Life Assured (for short L.A.) died accidently.  It was stated that Opposite Parties No.1 and 2 falsely alleged that the deceased was under the influence of alcohol whereas the PMR dated 29.03.2012 indicated that no traces of alcohol were found in the body.  According to the complainant, she submitted the claim, which was illegally rejected by the Insurance Company vide its letter dated 18.03.2013, Annexure C-3 in view of Exclusion Clause 5 of the Insurance Policy, on the ground, that the deceased was under the influence of alcohol during the mishap.   Thereafter, the complainant served a legal notice, Annexure C-6 upon the Insurance Company but to no effect.  Alleging that the aforesaid acts amounted to deficiency in service and unfair trade practice on the part of the opposite parties, the complainant filed the instant complaint.
2.           In its written statement, Opposite Parties No.1 and 2 stated that the policy, in question, was a Group Insurance Policy obtained by Allahabad Bank for the benefits of its customer. The said policy schedule alongwith the relevant terms and conditions was sent to the Allahabad Bank.   It was denied that the husband of the complainant died accidently. It was stated that  DDR No.69 dated 25.03.2012 was lodged on the statement of Smt.Seema wife of Sh.Avdesh Kumar in which it was stated that the deceased was a habitual drunkard and on the date of his fall from the window,  he was under the influence of the excessive alcohol. It was further stated that during investigation, it came to light that the insured was under the influence of alcohol at the time of accident and, therefore, the claim was rightly repudiated vide letter dated 18.03.2013 in view of the Exclusion Clause 5 of the Insurance Policy.   According to the answering Opposite Parties, there was no deficiency in service on their part and the complaint qua them deserves to be dismissed.
3.           In their separate written statement, Opposite Parties No.3 and 4 admitted that the insured was issued Free Personal Accident Insurance Facility under the Janata Personal Accident Policy, in question, issued by the Opposite Party No.2 and 3. However, it was stated that they are only facilitator/agent of the Insurance Company for the procurement of the business and the claim, if any, was to be settled by Opposite Parties No.1 and 2.  Pleading that there was no deficiency in service on their part, a prayer for dismissal of the complaint was made.
4.           The complainant filed separate replications to the written statement filed by opposite parties controverting their stand and reiterating her own version.
5.           We have heard the learned Counsel for the parties and have gone through the documents on record.
6.           The core question to be decided by this Forum is as to whether the claim of the complainant was rightly and legally repudiated by the Insurance Company vide its letter dated 18.03.2013(Annexure C-3) citing Exclusion Clause 5 of the Insurance Policy.   Exclusion Clause 5 of the Insurance Policy as mentioned in the repudiation letter, aforesaid, reads as under:-

“Payment of compensation in respect of death or injury as a consequence of/resulting from-whilst under influence of intoxicating liquor or drugs is not payable”.

7.           To justify their stand, the Insurance Company has relied upon the report of the investigator and the copy of the DDR to arrive at a conclusion that the deceased was under the influence of liquor when he fell from the window at his residence. 
8.           It is important to mention here that while arriving at an opinion that a person dead or alive is under influence of intoxication, liquor or any drug, a medical report to that effect is necessary to establish the same. However, in the instant case, the investigator has not placed any medical report of the L.A. alongwith his report to establish his opinion that the L.A. was under the influence of the liquor or any drug and if so to what quantity of alcohol.  It is also important to add here that mere verbal or bald assertions of the Insurance Company/Investigator without there being any medical report to the effect that the deceased was under the influence of liquor, cannot be believed.   In our view, mere mentioning in the DDR by Smt.Seema wife of Sh.Avdesh Kumar that the L.A. was under the influence of alcohol is not sufficient in the absence of cogent and reliable evidence to support the contention of the Insurance Company.   Further such a stand goes contrary to the PMR prepared by the GMCH, Chandigarh in response to the DDR No.11 dated 25.03.2012 wherein it had nowhere been mentioned that the deceased was under influence of intoxicating liquor or drugs. 
9.           Our view is further fortified from the judgment of the Hon’ble National Commissions in the case titled National Insurance Co. Ltd. Vs. Soma Devi reported in II (2012) CPJ 50 (NC) in which it was held as under:

“8.       …………….We have carefully perused the documents on file and we find force in the contention of the Counsel for Respondent that no credible or substantive evidence has been filed by the Petitioner to indicate that the deceased was in an inebriated condition/intoxicated which resulted in his accidental fall and death. Both the post-mortem report and the investigator’s report merely state that the deceased had consumed alcohol without giving any details about the actual amount of alcohol consumed or the type of intoxicants consumed. Even if the post-mortem report stating that the deceased had consumed alcohol is accepted, this is not adequate proof that he was intoxicated, in the absence of any evidence regarding the quantity of alcohol consumed. Apart from this as observed by the Fora below, we agree that the post-mortem report does not inspire much confidence in view of the contradictory statements made it. On the other hand, it is an admitted fact that the deceased was on patrol duty in uniform when he was found dead under the bridge. Taking into account these facts in their totality, we are of view that the Petitioner has not be able to produce any credible evidence to repudiate the claim by citing the Exclusion Clause in the insurance document that the insuree was intoxicated which resulted in his death….”

10.                    In this view of the matter, we are of the considered view that the Opposite Parties No.1 and 2 were deficient in rendering service by repudiating the legitimate claim of the complainant.
11.                    In view of the above discussion, the present complaint deserves to be allowed and the same is accordingly allowed. Opposite Party Nos.1  and 2 are directed as under ;-

1. To pay sum assured under the Janata Personal Accident Policy, in question, to the complainant. 
2. To pay Rs.11,000/- as compensation for mental agony and harassment caused to the complainant;
3. To pay Rs.5,500/- as costs of litigation. 

                   This order be complied with by Opposite Party Nos.1 and 2, within 45 days from the date of receipt of its certified copy, failing which the amounts at Sr.No.(i) &(ii) above shall carry interest @12% per annum from the date of this order, till actual payment, besides payment of litigation costs.

12.           However, the complaint qua Opposite Party No.3 and 4 stands dismissed.                   
13.           Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

30/01/2015

Sd/-

(RAJAN DEWAN)

PRESIDENT

 

Sd/-

 (MADHU MUTNEJA)

MEMBER

Sd/-

(JASWINDER SINGH SIDHU)

MEMBER