RAKESH SINHA vs NEW INDIA ASSURANCE COMPANY LTD.

AGGRIEVED by the order of Chhattisgarh State Consumer Disputes Redressal Commission, Raipur (for short as ''State Commission'' dismissing its complaint No. 12/2003 appellant has filed this appeal here under Section 19 of Consumer Protection Act. Facts in brief - -the complainant''s father late Sh. Badri Prasad Sinha had obtained "Janata Personal Accident Policy" from the New India Assurance Company Ltd, bearing No. 4745090308723, for a period of 5 years and the complainant was nominee under the said policy. The policy holder was insured for a sum of Rs. 10,00,000 for the period from 16.5.1998 to 15.5.2003, covering the risk of the Life Assured in the event of his sustaining injury or death resulting from an accident (e.g. road, rail, drowning, fall in bathroom, snake bite, dog bite, etc.) during the aforesaid period of the policy.

ON 11.10.1998 at around 12 -00 noon the life assured fell in the bathroom and was immediately admitted to the Holy Cross Hospital, Ambikapur, where he expired on 14.10.1998. The cause of death, as reported by the attending doctor, was Hepatic Failure and Hypovolemic Shock due to blunt injury in abdomen. On 16.10.1998 complainant had informed the opposite party and accordingly submitted claim forms on 20.12.1998. The opposite party had assured the complainant that his claim would be settled soon and the claim amount would be paid to him. However, the opposite party did not fulfil their promise and kept silent for a long time. Even thereafter opposite party kept on demanding various documents from the complainant with which the complainant complied and on 1.6.1999 submitted a fresh set of all documents to opposite party as demanded and again requested for early settlement of the claim.

THEREAFTER , on 17.6.1999 the opposite party repudiated the complainant''s claim on the ground that the cause of the death was due to a disease "Cirrhosis with Portal Hypertension Hepatorenal Syndrome with Hepatic Encephalopathy" and it was held that the claim was not payable in terms of the insurance policy, which was a Personal Accidental Policy.

SINCE opposite party had repudiated the genuine claim without due application of mind, the complainant got a legal notice issued on 19.3.2000 to the opposite party, but the said notice was neither replied to nor the amount, as demanded by the complainant under the policy paid. Being aggrieved complainant filed a complaint before the State Commission on grounds of deficiency in service and has prayed for direction to the OPs for settlement of the assured claim amount of Rs. 10,00,000 together with Rs. 50,000 towards compensation for mental harassment and suffering and Rs. 25,000 for litigation expenses and further prayed that the amount may be directed to be paid with interest @ 18% per annum.

THE opposite party has filed its reply and has denied all the averments made by the complainant. The opposite party has stated that the claim was rightly repudiated with full application of mind. The cause of death was not accidental and was therefore not covered under the scope of the policy. The opposite party, therefore, prayed that the complaint of complainant was maintainable and may be dismissed.

THE State Commission dismissed the complaint with the following observations: During the course of inquiry by the OP, Medical Supdt., Holy Cross Hospital, Ambikapur had intimated the Insurance Company that there was no injury on the person of the patient Simply because there is an endorsement by Dr. Tarun Mishra on A -18 that the patient had Blunt injury in abdomen after fall in bathroom on 11th at 12 noon, it cannot be concluded that the death was accidental especially in view of the fact that no such details were noted while recording the history at that time of admission and further in view of the fact that there is no such mention of injury in the letter issued by the hospital or in the death certificate. The endorsement made by Dr. Tarun Mishra is neither supported/corroborated by treatment record of the patient nor by the documents issued by the Hospital, it does not appear to be worthy of credence. Though the complainant had filed affidavit of various persons to show that the patient had fallen in bathroom but the fact that no injury or fall in bathroom was reported/recorded at the time of admission '' while recording history of the patient, the said lose creditworthiness.

We have heard the learned Counsel for appellant and respondent and perused a copy of the Impugned Order, insurance policy and medical records, including the hospital case sheets. We observe that the Life Assured had obtained the policy from the opposite party for death by accidental injury. It is also not disputed that the insurance policy was in force when the insured died. Therefore, the question arises for consideration is whether the Insurance Company rightly repudiated the claim.

NO doubt the insured fell in the bathroom on 11.10.1998 at 12.00 noon and was admitted in Holy Cross Hospital, at about 9:30 p.m. on 11.10.1998 with the complaints of distension of abdomen and severe stomach pain. He was treated for 4 days and died on 14.10.1998. As per the hospital records, he was diagnosed as Cirrhosis of Liver with Gastric Fundal varices, gastropathy with duodenitis i.e. suffering from liver problem for the last one year. He was earlier treated for liver ailment in MMI Hospital, Raipur. He died on account of "CIRRHOSIS with Portal Hypertension Hepatorenal Syndrome with Hepatic Encephalopathy". The insured had blood vomiting (hematemesis) which was not on account of blunt injury to abdomen but due to Liver Cirrhosis and esophageal varies.

APPELLANT had relied on the statement of Dr. Tarun Mishra, who had attended on the patient and certified that the cause of death was due to the blunt injury in the abdomen. However, from the evidence on record before the State Commission, we note that during cross -examination Dr. Tarun Mishra had admitted that he did not observe any injury on the patient and also that the patient had been taking medicine relating to medical problems for the last one year and he was given medicines for these very complaints. The Medical Superintendent of the hospital where patient was admitted has also stated that there was no injury on the patient nor has this fact been stated in the death certificate which clearly certifies that the cause of patient''s death was Cirrhosis with Portal Hypertension Hepatorenal syndrome with Hepatic Encephalopathy. The State Commission has discussed this aspect at length in its well -reasoned order and concluded that there is no credible evidence on record that the patient''s death was caused due to any injury that he may have suffered when he fell down. After going through the evidence on record, we agree with these findings of the State Commission based on credible documentary and factual evidence that patient did not die as the result of any blunt injury in the abdomen sustained during the fall but died because of Cirrhosis with Portal Hypertension, Hepatorenal Syndrome with Hepatic Encephalopathy. In view of the above fact and since patient was insured only against accidental injury, we agree that the Insurance Company had rightly repudiated the claim on the grounds that the cause of death of the insured not being an injury was not covered under the provisions of the insurance policy. We, therefore, upheld the order of State Commission and dismiss the first appeal. No costs.