KHULESH BAI vs Oriental Insurance Company Ltd.

THIS appeal arises out of the order dated 28.4.2006 passed in Complaint No. 22/2004 by the District Consumer Disputes Redressal Forum, Sarguja, Ambikapur (hereinafter referred to as ''District Forum'' for short) whereby the complaint was dismissed.

BRIEF facts necessary for disposal of this appeal are that the complainant''s deceased husband Bannuram was an employee of the O.P. No. 2 and he had, in his life-time, through the O.P. No. 2 obtained Janta Personal Accident Insurance Policy from the O.P. Nos. 1 and 3 for the period from 16.10.1999 to 15.10.2009. The complainant''s husband met with an accident on 15.1.2003 and he subsequently died on account of the aforesaid accident on 14.8.2003 while he was under treatment. Despite intimation and despite filing claim form and completing formalities in this regard, the insured failed to pay the claim amount of Rs. 5,00,000, hence the complainant approached the District Forum seeking a direction regarding payment of the assured sum together with damages as detailed in the complaint. The opposite party No. 1-insurer denied all the averments made in the complaint including those of deficiency in service. It was averred by the insurer that the complainant failed to submit relevant documents despite repeated demands hence she is not entitled to any relief. It is further averred that the insurer had cancelled the aforesaid policy prior to the death of the complainant''s husband. Subsequent to vacation of stay by the High Court, the insurer had refunded the amount of premium to the O.P. No. 2 vide cheque dated 28.3.2005. In the circumstances of the case, the claim is liable to be dismissed.

The O.P. No. 2 had in written version admitted that the husband of the complainant was employred under the O.P. No. 2 and the O.P. No. 2 had deducted the amount of premium from his salary and had remitted the same to the O.P. No. 1 for obtaining insurance from the said O.P. for the period from 16.10.1999 to 15.10.2009 and it was during this period that husband of the complainant died and the O.P. No. 2 had duly intimated the O.P. No. 1 in the preseribed format but the said O.P. did not call the complainant for receiving payment of the assured sum. O.P. No. 3 did not file any separate written version.

LEARNED District Forum had dismissed the complaint. Hence, the complainant has preferred this appeal. Final arguments of the parties heard and record perused.

LEARNED Counsel for the appellant submitted that the learned District Forum has passed the impugned order without proper appreciation of material on record and failed to conclude that the death of the insured was on account of accident though it was apparent from the documents that earlier the insured was treated at the Regional Hospital of the O.P. No. 2 at Bishrampur and subsequently he was referred to Apollo Hospital, Bilaspur. LEARNED Counsel for the complainant/appellant submitted that the complainant is an illiterate village woman and is not aware of the niceties of the legal requirements. She was not aware that the post-mortem was required to be conducted to prove that her husband died due to injuries sustained by him in accident in the month of January. Further that the complainant was perturbed due to long illness and subsequent death of her husband. LEARNED Counsel for appellant further submitted that since the death was within 12 months of the accident and the complainant has placed ample material on record to show that the death was as a result of accident the complaint ought to have been allowed but the learned District Forum has erred in not doing so. He submitted that the impugned order be quashed and the appeal may be allowed. Learned Counsel for the respective respondents reiterated the stand taken by them before the District Forum. It appears that after the insured Bannuram met with an accident on 16.1.2003, he was admitted to and treated at S.E.C.L. Hospital, Bishrampur and the next day i.e., on 17.1.2003 he was referred to Apollo Hospital, and remained admitted at Apollo Hospital, Bilaspur from 17.1.2003 to 30.3.2003 and was referred to the neurosurgeon Dr. Sunil Sharma. As per Annexure A-6 (A) i.e., Discharge Summary of the Apollo Hospital, Bilaspur principal diagnosis was ''Traumatic Fracture Dislocation of C6-C7 with cord compression with quadriparesis with carotid sinus hypersensitivity with septicemia''. It further appears from the said documents that Anterior Cervical Discectomy at C6-C7 level was done on 25.1.2003. Post release of locking facet joints and Anterior Cervical Plating was done on 30.1.2003. It further appears from the aforesaid document that ''just after surgery in OT the patient had developed bradycardia, hypotension and immediately cervical collar and drain were removed thinking that there was compression of carotid sinus. Bradycardia and hypotension were not improved and suspected carotid hypersensitivity. Dopamine infusion were started and cardiologist opinion was taken. Cardiologist Dr. R. Rathi suspected the same and advised the same treatment. After removing collar, bradycardia and hypotension were gradually stabilized. During his SICU, he had developed aspirated pneumonitis and the Dyspnoea. For this, Dr. Sanjay Bhargava (Respiratory Medicine) was consulted and treated. He had repeated bradycardia and hypotension and treated with dopamine infusion and O2 inhalation. Later, he was diagnosed to have septicaemia and responded to sensitive antibiotics. After surgery, his neurological deficit gradually improved (upper limb faster than lower limb). On the other hand urine retention was persisting for which repeated CIC and bladder irrigation were done using Betadine. He had continuous fever in the ward and urine C/S showed E.coli growth, sensitive only to Inj. Meropenem. After starting Inj. Meropenem, fever subsided gradually. For his bed sore over sacral and bilateral trochanteric regions, Dr. Pandey''s (Plastic Surgeon) opinion was taken Debridement was done and daily dressing was advised by Plastic Surgeon. It is further mentioned that ''Now he is afebrile and stable vital signs with healthy granulation tissue. His upper limb motor power is 3-4/5 and lower limb 1-2/5 which are likely to improve gradually in the course of time. He is being discharged today with advice of daily dresssing and CIC. In special instructions to patient certain medicines have been prescribed and the patient is advised to take high protein diet and to undergo physiotherapy as advised before. CIC to continue till residual urine comes to around 50ml. Daily bed sore dressing etc. were also advised. Main purpose of reproducing the details from Discharge Summary is that it clearly appears from the same that the patient had several complications and that even at the time of discharge urination was not normal and the bed sores still required daily dressing. All this was due to the injury sustained in accident.

ON an application by the complainant record of Central Hospital, Bishrampur (Sarguja) was requisitioned and the said documents are placed from pages 69 to 81 of the record of the District Forum. These documents pertain to the record of progress and treatment. It appears from the said record that the patient Bannuram remained admitted to the Central Hospital from 31.3.2003 (i.e., the very next day of discharge from Apollo Hospital) to 12.5.2003 and had left the hospital against medicine advice. This shows that even at the time of discharge from the said hospital, the patient was not normal. The consent regarding discharge against medical advise has been signed by the life assured''s brother Sukhnandanram on 12.5.2003 at 2 :00 p.m. Thereafter, the patient remained at home and subsequently died on 14.8.2003. It is stated in affidavit of the complainant that even long treatment of her husband did not yield satisfactory results and medical expenditure also crossed the limits of financial capacity of the complainant hence they got Bannuram discharged at their own responsibilty and thereafter he was treated by local doctor but subsequently his condition continued to deteriorate and her husband died on 14.8.2003. It is a matter of common knowledge that medical expenses are too heavy now-a-days. There is material on record to show that the life assured had many complications and was treated in some hospital or the other for a long period of nearly 5 months and when ultimately he was discharged, it was against medical advice. This lends support to the statement of the complainant that treatment did not yield satisfactory results and their financial capacity had exhausted and that is why they got the insured discharged against medical advice.

IT is further noted that document A-3 is the Death Report Form containing intimation regarding death of Bannuram s/o Deosay and it also contains other relevant particulars. IT appears from the aforesaid document that intimation regarding death of Bannuram s/o Deosay was given by Sukhnandanram on 17.8.2003 and there is material to show that Sukhnandanram is the brother of the deceased. The cause of death as mentioned in the said form is due to fall from the vehicle. We are of the opinion that immediately after three days of death, the family members of the deceased insured cannot be expected to be in a mental state to plan a strategy and to report the death of the deceased to be due to accident as part of the said strategy. Hence, though the death of the life assured was after nearly 8 months of the accident we have to consider the material on record in the light of the fact that the complainant is an illiterate village woman. In the circumstances, we are of the opinion that death of Bannuram was in consequence of the injuries received by him in accident dated 16.1.2003. So far as the contention of the insurer regarding cancellation of policy is concerned, there is nothing on record to suggest that intimation regarding cancellation was given to the insured i.e., Bannuram. In the circumstances, the alleged cancellation cannot be held good as has been decided by this Commission in a number of earlier decisions. Similarly, writ petition also would not adversely affect the rights of the complainant as the complainant is not a party of the said proceedings.

In view of the above discussion, the impugned order cannot be sustained and it is set aside. This appeal is allowed and the insurer is directed to make payment of the assured sum of Rs. 5,00,000 to the complainant within a period of 2 months. The aforesaid amount shall also carry interest @ 9% per annum from the date of complaint till final realisation. In case, the payment is not made within the stipulated period interest @ 12% shall be payable from the date of default. Appeal allowed.