GEETA DEVI vs UNITED INDIA INSURANCE CO LTD

IN this Revision Petition, under Section 21(b) of the Consumer Protection Act, 1986 (for short the "Act"), the Complainant questions the correctness and legality of the order passed by the State Consumer Disputes Redressal Commission, Rajasthan (for short the ''State Commission") in Appeal No. 1900 of 2008. By the impugned order, the State Commission allowed the Appeal and set aside the order of the District Consumer Protection Forum, Sirohi (for short "the District Forum") in CC No. 25 of 2007. By its order, the District Forum, allowed the complaint and directed the Insurance Company to pay the insured amount of ?2,00,000/ - together with compensation of ?5,000/ - and costs of ?1,500/ -.

THE brief facts of the case, according to the Petitioner who was the original Complainant before the District Forum, are that the Complainant''s husband had taken a Personal Accident Policy, covering the period 27.10.1997 to 26.10.2007, for an insured sum of ?2,00,000/ - from the Respondent -Insurance Company. While so, on 2.12.2005, the insured had a fall in the bathroom and subsequently died due to the injuries sustained. The Complainant had informed the Insurance Company on 19.12.2005 and submitted all the particulars. The Respondent vide their letter dated 26.9.2006 rejected the claim on the ground that the Complainant had not submitted the relevant documents and closed the claim as ''No Claim''. The Complainant had issued a legal notice on 21.6.2007 requesting the Respondent to send the prescribed proforma, but received no response. Hence the Complaint, seeking direction to the Insurance Company to pay the insured amount together with compensation of ?10,000/ - and costs of ?5,000/ -.

THE Respondent filed its written version before the District Forum and pleaded that the death of the insured was a natural one and not an accidental death. They averred that the Investigator had sent a letter to Dr. C. Ramji, working in Government Hospital, Pindwada, who observed that the insured was diabetic, hypertensive and a cardiac patient and that there was no visible ''injury'' on the patient. The Respondent pleaded that these are the symptoms of cardiac arrest and not the symptoms of haemorrhage and therefore, the death cannot be on account of fall in the bathroom. The injury report and the bed head ticket were not prepared as he was kept in the ICU only for observation. The Respondent further submitted that the Claimant had given information through letter dated 19.12.2005 and that the insured had died on 2.12.2005 i.e. 17 days after the death of the deceased and did not send the desired documents with the claim letter. On 17.5.2006 and once again on 12.6.2006, reminders were sent seeking certified copy of police report, panchnama, post -mortem report and the original policy within 15 days. The Applicant did not send these documents and therefore, the claim was closed as ''No Claim''. The District Forum based on the evidence adduced, allowed the complaint and directed the Respondent to pay the assured amount together with compensation of ?5,000/ - and costs of ?1,500/ -.

AGGRIEVED by the said order, the Insurance Company preferred an Appeal before the State Commission. The Commission allowed the Appeal, observing as follows: "Falling in this case could be regarded as an occurrence but could not be treated as an accident for want of head injuries. Had the deceased would have received some injuries even from the fall in the bathroom the position would have been different one as that head injury might have caused the death of the deceased and thus in such a case that could have been treated as an accidental one."

"The appellant had rightly repudiated the claim of the complainant respondent and the death of the deceased could not be treated as an accidental one and the complainant respondent is not entitled to any amount from the appellant insurance company and thus the appeal deserves to be allowed".

HENCE , the Complainant preferred this Revision Petition.

THE facts not in dispute are that the Petitioner''s husband had taken a Personal Accident Policy from the Respondent for an amount of ?2,00,000/ - covering the period from 27.10.1997 to 26.10.2007. It is the Petitioner''s case that her husband had a fall in the bathroom on 2.12.2005 and died on the very same day due to the injuries sustained after undergoing treatment in Mahavir Hospital Pindwada. The claim made by the Petitioner was repudiated by the insurance Company on the following grounds: "Ref: Your claim No. 140702/47/06/51/90000008 Sr. No. 1 On Policy No. 140702/47/97/00/00002067 Please note that your file stands closed, on account of Sr. No. 1 and 3 below:

Inspite of letters/reminders sent to you, you have not complied with the required papers/documents.

As you have withdrawn your claim by giving your consent through your letter dated . We are closing your claim -file as NO CLAIM.

We are closing your claim -file, on account of the following reason: - On repeated reminder and Regd. Notice you have not submitted as claim papers Hence claim file is closed as "NO CLAIM".

THE learned counsel for the Insurance Company submitted that the Petitioner did not submit copy of police report, Panchnama, post -mortem report and the original policy and therefore, the claim was rejected as ''No Claim''.

THE State Commission went beyond the repudiation letter and hold that the death cannot be construed to be an accidental one, as the deceased did not have any ''head injuries''. A brief perusal of the prescription dated 2.12.2005 given by Dr. Praduman Jain, M.B.B.S., M.D. (Medicine), General Physician and Heart Specialist of Mahavir Hospital, District Sirohi reads as under: ''''Date: 2/12/2005 Mr. Mohan Lal Ji Age 45 Yrs. M 5.00 A.M. C/o Fall in bathroom No asn. movement Sudden onset semi -conscious No chest pain Vomiting once with Blood KLC DM/HM 1 (A) (illegible) No NTC (illegible) No pain O/E P -] Not recordable BP -] CVS -S1 S2 Not heard 6 AM 1/2 contd. CMS -Pupil - dilated Planter - No Response BP/P not recordable R/s clear P/A soft patient unconscious (illegible) (illegible) 5.10 AM Patient conscious, Responding to V.C. Pupil dialated O/E P/BP Not Recordable 6.30 contd. Pupil Dilated P. Cyrosis ++ 5.20 AM Patient conscious, Responding to VC o/E P/] Not Recordable BP] ''''

A brief perusal of the patient''s history shows that at the time of admission in the hospital, the insured had a fall in the bathroom, vomited blood and was in a semi -conscious state. The treatment record shows that the insured was taken to the hospital at 5.00 A.M. immediately preceding the fall in the bathroom and he died at 6.30 A.M. on the very same day. It can be safely construed that any internal injury suffered by him on account of fall in the bathroom has a direct nexus to his death. In fact, the hospital record clearly states that the insured did not suffer from any ''Chest Pain''. The onus to prove that the death of the insured is a natural one and not an accidental death, shifts on the Insurance Company and they did not place any cogent or substantial evidence on record to establish their case that the death was on account of cardiac arrest and should, therefore, be inferred as a natural death.

WHEN it is a death caused by accidental fall, the question of reporting to the police and conducting a panchnama does not arise. Admittedly, the post -mortem was not done as the death of the insured was not construed to be a suspicious one. Therefore, repudiating the claim on the ground that the Claimant had not sent the documents, which were not relevant to the nature of death, is totally unjustifiable.

FOR the afore -mentioned reasons, we allow this Revision Petition and set aside the order of the State Commission and direct the Respondent Insurance Company to pay the assured amount of ?2,00,000/ - with interest at 9% per annum from the date of repudiation till the date of realisation together with costs of ?10,000/ -. If the amount is not paid within 4 weeks from the date of receipt of this order, the amount shall attract an interest of 12% per annum.