Thilagavathy vs Life Insurance Corporation of India

THIS is a complaint under Section 17 read with Section 12 of the Consumer Protection Act.

THE complainant is the widow of late K.M.N. Murugavel, who was working as an Agent of Life Insurance Corporation of India. THE said Murugavel had taken 2 policies of insurance under the Twenty Years Money Back Policy with Profits (with Accident Benefits). THE first policy was numbered as 66631762/DCL for a sum of Rs. 1 lakh and the second one was numbered as 760455988/DCC for the sum of Rs. 25,000/-. THE complainant was the nominee under both these policies. In August ''91, the deceased was admitted as in-patient in the Senthil Clinic Coimbatore for observation and treatment in interrant fever pyrexia of unknown origin. On 31-8-91 while he was in the hospital, he slipped and fell down the stair case and sustained severe head injuries. In spite of the best medical attention he died on the said injuries of the head on 4.9.91. THE complainant preferred claims under these two policies. THE Opposite Party issued two cheques one for Rs. l,20,816-60p and another for Rs. 28,300/- representing the basic sum assured and profits accrued under these two policies, respectively. No reason was adduced for not entertaining the claim for accident benefit which was also covered by these two policies. THE complainant was however pursuaded to accept these cheques and advised to make further claims for the accident benefits. Accordingly, she made the claim which was rejected by the Opposite Party on 4.6.1992 on the ground that there was no documentary evidence to prove that the sole cause of death of the life assured was due to injuries sustained by him due to fall on the stair case. Hence this claim for recovery of a equal sum of Rs. l,20,816-60p under Policy No. 66631762 and Rs. 28,300/- under Policy No. 760455988 respectively as accident benefits, and for compensation in the sum of Rs. 30,000/ - with subsequent interest. The claim is resisted by the Opposite Party. It is admitted that the complainant''s husband had taken two policies for Rs. 1 lakh and Rs. 25,000/- respectively. The sum assured with bonuses were payable on the dates of maturity or on the death of the life assured if earlier. Besides, the additional sum equal to the sum assured was also payable if the nominee proves beyond doubt that the life assured had died due to an accident of the type specified in Clause 10 (b) of the Policy. The claim made by the complainant was examined and it was decided to settle the claim for basic sum assured plus bonus and accordingly payments were offered for Rs. l,20,816-60p and Rs. 28,300/- under these two policies. The payment was duly accepted by the complainant in full and final satisfaction and discharge of all claims and demands under the policies. It is not therefore open to the complainant to make the subsequent claim for accident benefits. On the question of accident benefits, it is the case of the Opposite Party that this benefit is "available only if the assured sustained any bodily injury resulting solely and directly from the accident caused by outward violent and visible means and such injury shall within 90 days of its occurrence, solely, directly and independently of all other causes result in the death of life assured. According to the Opposite Party, the assured was admitted in the Senthil Clinic on 29.8.91 for Pyrexis of unknown origin and was undergoing treatment. It is stated that he fell down while walking in the stair case on 31.8.91 and sustained head injury. The claim that the assured''s death was caused solely, directly and independently this fall is denied. According to the Opposite Party, the immediate cause of death was fever and head injury. The investigation revealed that the deceased was originally admitted for fever of unknown origin which was later detected to be "Broncho-Pneumonia". The deceased fell down on 31.8.91 at about 11 p.m. and a scan was taken; everything was alright and there was no internal haemorrhage or injury. Finally he died due to respiratory failure on account of "Broncho-Pneumonia" and not due to the nead injury. The complainant is not therefore entitled to the accident benefit portion of the policies.

Exhs. Al to All and B1 to B7 are marked by consent. Proof affidavits are filed. No oral evidence has been let in.

THE complainant''s husband has taken two policies of Life Insurance under Exh. A1 and Exh. A2. A1 is for Rs. 1 lakh and A2 is for Rs. 25,000/-. THEy are Twenty Years Money Back Policy with Profits and Accident Benefit. Under these policies on maturity or the death of the insured if the earlier, the assured sum with bonuses will be paid to the nominee. If the assured dies of any accident, an additional sum equal to the sum assured was also payable to the nominee. THE complainant''s husband was admitted in Senthil Clinic, Coimbatore on 29.8.91 for treatment of Parexia of unknown origin. While in the Hospital, he fell down from a stair case on 31.8.91 and suffered head injuries. According to the complainant he died on the said injuries of head on 4.9.91. THE complainant who is the nominee claimed the insurance amounts, the Opposite Party paid the basic sums with bonus that is Rs. l,20,816-60p under Exh. A1 policy and Rs. 28,300/- under Exh. A2 policy. THE Opposite Party did not pay the equal sums of accident benefit. THE complaint is laid for recovery of the accident benefit. The first contention of the Opposite Party is that the complainant has received the basic sums with profits under Exhs. B4, B5 vouchers in full and final satistaction and discharge of all claims under these two policies. She is not therefore entitled to make any further claim for the accident benefit No doubt Exhs. B4 and B5 read that the amounts are accepted in full and final satisfaction and discharge of all the claims under the policies. But we are unable to agree with the contention of the Opposite Party that the complainant who is a woman deliberately gave up her right to the accident benefit with full knowledge go the contents of the Exhs. B4 and B5. According to her, she was persuaded to accept the cheques and to make further representation for the accident benefits and subsequently she accepted these two cheques after issue Exhs. B4 and B5 vouchers. We accept her contention. It is also pertinent to note that when she preferred subsequent claim for the accident benefit under Exh. A8 dated 28.4.92 the Opposite Party has accepted the application and informed the Complainant under Exh. A9 that the papers have been forwarded to the Divisional Office for the consideration of accident benefit under the above policies. If claims made under Exhs. B4 and B5 vouchers, there had been full and final settlement, the Opposite Party could not have entertained her subsequent application under Exh. A8 for accident benefit. It is only under Exh. A11 dt. 4.6.92 the complainant''s claim for accident benefit which has been rejected on the ground that there was no evidence to prove that the cause of the death of the assured was injury sustained by the fall in the stair case. We therefore accepted the case of the complainant that , Exhs. B4 and B5 vouchers were issued only in respect of the basic sums and profits offered and that these two vouchers did not amount to any abdication of the right of the claim to the accident benefits covered by these two policies.

WE have now to see whether the death of the assured was due to the head injuries sustained by him as a result of the fall from the stair case on 31.8.91 or due to any other cause. It is not in dispute that the accident benefit will be available if the assured died due to injuries sustained in that accident and not to due to any other cause. Exh. A5/B2 is the medical attendance certificate issued by Senthil Clinic where the deceased was admitted on 29.8.91, where he suffered a fall on 31.8.91 and sustained injuries in the head and where he ultimately died on 4.9.91. In Exh. A5/B2 the cause of death is mentioned as follows: (a) Primary cause: Fell down on the stair case on 31.8.91 night in Senthil Clinic; (b) Secondary cause: Respiratory failure. From Exh. A5/B2 it is clear that the death was primarily due to the fall from the stair case in which he has suffered injuries on his head. No doubt he has been admitted in the hospital for treatment of Pyrexia of unknown origin. It was during the course of his stay in the hospital and that when he has been fallen down from the stair case on the night of 31.8.91 and sustained severe head injuries. It is contended by the Opposite Party that the scan of the head was taken and it revealed that everything was alright and there has no internal haemorrhage or injuries. But this statement made in the counter is not substantiated by any evidence. The Opposite Party has not also taken any steps to summon Senthil Clinic to produce any of these documents if available. WE are therefore convinced that the death of the assured was only due to the injuries sustained in the head as a result of the fall from the stair case on the night of 31.8.91 and the accident benefit clauses applied. The complainant is entitled to the same amount of the additional sum equal to basic sum and profits paid to the complainant i.e. Rs. l,20,816.60p under Exh. Al policy and Rs. 28,300/- under Exh. A2 policy. The complainant has claimed another sum of Rs. 3,000/- towards mental pain and agony. We are not inclined to accept this claim. She is however entitled to claim interest on the sum of Rs. 1,49,116.60p with interest thereon at 12% p.a. from 28.4.92 when she has made claim on the policy under Exh. A2 till realisation. In the result we order as follows: (1) The Opposite Party shall pay to the complainant the sum of Rs. 1,49,116.60p with interest thereon at 12% p.a. from 28.4.92 till realisation. (2) The Opposite Party shall also pay a sum of Rs. 1,000/- towards cost.

Complaint allowed with costs. ______________