District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.403/2021.
Date of Institution: 11.08.2021.
Date of Order: 21.11.2022
1. Mrs. Bela Ratra wife of Shri Subhash Chander Ratra, resident of House No. D-8, Nehru Ground, NIT, Faridabad (Haryana).
2. Ms. Ruhi Ratra @ Roohi Ratra aged about 38 years (Date of birth 6.9.1982) wife of late Shri Ankush Ratra, presently residing at House No.2-B/42, NIT, Faridabad, holding PAN:AJLPR4284P, having Adhaar card No. 466523873993.
3. Master Saksham Ratra S/o Shri Ankush Ratra R/o House No.2-B/42, NIT, Faridabad Minor through his mother/guardian/next friend Ruch Ratra @ Roohi Ratra.
4. Ms. Sanya Ratra D/o Ltd. Shri Ankush Ratra R/o House No.2-B/42, NIT, Faridabad Minor through her mother/guardian/next friend Ruhi Ratra @ Roohi Ratra.
…….Complainants……..
Versus
1. ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhivinayak Temple, Prabhadevi, Mumbai – 400 025. (Service be affected throgu first floor, SCO 17, Sector-16, Faridabad, Haryana – 121002).
…Opposite party……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. Ankur Gosain, counsel for the complainant.
Sh. Rakesh Dabaas, counsel for opposite party.
ORDER:
The facts in brief of the complaint are that complainant No.1 was the mother, complainant No.2 was the wife and complainant Nos. 3 & 4 were the minor children of late Shri Ankush Ratra who had died on 06.02.2020 in a Rail accident. Ankush Ratra had obtained an accidental cover insurance policy namely Personal Protect from opposite party bearing policy No.4111/MPL/188286182/00/000. Shri Ankush Ratra was born on 10.08.1982. After completing his studies he had joined the family business. Right since his young age of 23 years well prior to this marriage with complainant NO.2, Shri Ankush Ratra had inculcate the habit of his safeguarding life by way of insurance policies i.e medical insurance policies from different service providers and life insurance policies i.e. Medical Insurance Policies from different service providers and Life Insurance Policies from Life Insurance company.
A. Medical Insurance Policies:
i. As on 18.05.2005, i.e at the age of 23 years, said Shri Ankush Ratra had taken medical policy from United India Insurance co. Ltd., wherein he has self insured. The same was renewed in May 2006. Again it was renewed on 17.05.2007. Further, the same was renewed on 17.05.2008.
ii. As on 18.05.2020 above said medical policy with United India Insurance Limited was renewed whereby said Shri Ankush Ratra. Complainant Nos.2 to 4 and Subhash Chander Ratra were insured. Reliance was placed on cover note dated 19.05.2010 issued by the said insurance company. The same would provide the information that the date of first ever policy issued by United India Insurance co. Ltd was issued on 18.05.2005.
iii. As in the year 2011 insurer was changed form United India Insurance Co. Ltd., to Apollo Munich Health Insurance.Vide medical insurance cover note dated 18.05.2011 all the four member of Shri Ankush Ratra i.e. self, wife, son and daughter were insured for a sum of Rs.1,00,000/-.It was submitted that till his death Shri Ankush Ratra had never claimed any benefit out of said annual medical policies.
Policy No. Date of issue Name of policy Amount(Rs.) Maturity
121744820 28.03.2002 Medical 1,00,000/- 28.03.2022
122099706 28.07.2003 Jeevan Surbhi 1,00,000/- 28.07.2008.
28.03.2006 05,03,2006 Endowment insurance 50,000/- 28.03.2021
124768257 03.12.2009 Jeevan Saral 15,00,000/- 03.12.2025
126572727 10.08.2013 Jeevan anand 9,95,000/- 10.05.2034
126573318 28.09.2013 Jeevan Arogya 28.09.2062
127407466 28.06.2014 Amulya Jeevan -2 1,50,00,000/- 28.06.2048
128012628 09.02.2018 Amulya Jeevan-2 2,00,00,000/- 09.02.2052
128017959 01.12.2018 Amulya Jeevan-2 1,00,00,000/- 18.12.2051.
The above mentioned Accident Cover policy was obtained in the usual
manner by Shri Ankush Ratra and the same was valid for the period of
14.12.2019 to 13.12.2022 and a premium of Rs.10,668/- was duly paid by Shri Ankush Ratra.
Base Policy coverage & Benefit:
i. Death resulting from Accident: |
ii. Permanent Total Disablement resulting | Rs.30,00,000/-
from accident |
Beside the above said Shri Ankush Ratra had obtained following other insurance policies:
i. HDFC Ergo Health Insurance – Appolo Munich bearing policy No.111100/21002/2000187095-03.
Said policy used to be renewed every year.
ii. MAX Newyork Life, bearing policy No. 132087107
iii. Other policies form ICICI Lombard.
As usual said Shri Ankush Ratra had started the day on 06.02.2020 by attending to his duties as a partner/employee of M/s. Metropole, a partnership firm. Due to exignencies of the business of manufacture and sale of tubes that the partners of the said Firms had to go at times from Faridabad to Delhi through Train and at times he used to visit truck repairer shops and other vendors dealing in truck spare parts as the firm also owns some trucks and such shops were located near the railway track. As such on 06.02.2020 Shri Ankush Ratra was crossing the railway line New Town Railway Station, Faridabad. While passing through the level crossing path he died on Track III at about 1.35 p.m. being run over by a good train (STPB) from Agra to Tuglakabad, Delhi. The Loco Pilot Shri Sandeep Kumar gave intimation of the above fatal accident to Shri Manish Vijay, Deputy SS, Faridabad who in turn gave the information to Shri H.P.Kashyap, Station Master, Faridabad. Shri H.P.Kashyap, through his hand written Ruka while informing the SHO, GRP, Faridabad about the said accident, based on the information received by him through the mode as above but as perceived by him, that a man jumped ahead of train at Km. 1505/26 IIIrd Line at Faridabad and that dead body was lying on IIIrd line track. Having received the above information at the said GRP police station, Faridabad a Sub Inspector accompanied SPO Shri Gajinder Singh reached the site of the accident. Upon conducting the search following articles were found from the pocket of the deceased:
- Adhar card Ankush Ratra
- Cash Rs.2950/-
- Watch Golden/Silver Old
- One car key (H)
- One Ring Silver and one Ring Gold
- Two Telephone diaries.
Having found address of the deceased form the search as above, said SPO Sri Gajinder Singh came to the residence of the complainant No.1 at House No. D-8, Nehru Ground, NIT, Faridabad, Haryana at 3.30p.m. on 06.02.2020 to inform them about the abovesaid rail accident and death of Shri Ankush Ratra at New Town, Faridabad Railway Station. Hearing the news hell broke upon their head. Shri Subhash Ratra, father of deceased alongwith brother of the deceased as well as other relatives reached the site of accident and at the police station, GRP, Old Faridabad. Vide application dated 06.02.2020 Shri SubhashChander Ratra requested SHO, GRP, Old Faridabad for conducting investigation against accidental death of Shri Ankush Ratra.
The police at the said GRP police station conducted the Inquest proceedings. Statement of different persons were recorded. The testimony of the Loco Pilot left no manner of doubt that Shri Ankush Ratra was run over by the train while crossing the railway track and that Shri Ankush Ratra died in an accident. On the support of above Ruka, statements police prepared the Inquest report. As per the final police report filed in Inquest Report cause of death of Shri Ankush Ratra was due to railway accident. None was to be blamed for the death of Shri Ankush Ratra. The fact of death of Shri Ankush Ratara was duly registered with Municpal Corporation, NIT, Faridabad vide NO. D-2020:6-90213-000726 dated 02.03.2020. The claim on the death of Ankush Ratra was lodged with opposite party ICICI LOMBARD as per the format supplied by the opposite party itself, claiming thereby, a sum of Rs.30,00,000/- on account of accidental death of Shri Ankush Ratra. As such, necessary required documents were submitted to the opposite party. As submitted above deceased had obtained different insurance policies from Life Insurance Corporation . Accordingly, claims were lodged with LIC; Vide three separate Communications dated 05.06.2020 following detailed three claims were settled.
i. Net claim of Rs.11,74,450/- was sanctioned under policy NO. 126572727.
ii. Net claim of Rs.20,27,338/- was sanctioned under policy No. 124768257.
iii. Net Claim of Rs.1,50,00,000/- was sanctioned under policy No. 127407466.
iv. Thereafter, through another communication dated 28.09.2020 LIC had intimated the sanction of another claim of Rs.2,00,00,000/- was sanctioned under policy No. 128012628.
v. Against policy No. 126572727 claim amount of Rs.5,00,000/- was paid on 20.11.2020.
vi. Against policy No. 121744820 claim amount of Rs.1,00,000/- was paid on 20.11.2020.
vii. Against policy No. 122099706 claim amount of Rs,1,00,000/- was paid on 20.11.2020.
After having remained sitting on the claim file for a period of six months that the opposite party acting in a malafide manner had repudiate the claim as communicated through its repudiation letter dated 14.09.2020. Claim had been repudiated citing untenable plea that Shri Ankush Ratra had committed suicide. The opposite party had repudiated the claim on assumptions and presumptions as neither the attending circumstances nor the evidence, including police finding supported such a plea. At this stage vide application dated 30.12.2020 information was sought under RTI Act, form State Public Information Officer cum Deputy Superintendent of Police, Railways, Haryana, Ambala Cantt. In response to the said RTI application said RTI Authority, vide its communication dated 03.02.2021 had supplied the complete Inquest Report qua the said Rail accident on 06.02.2020. On the support of information, documents, records available with the complainants, more so, on the support of the documents obtained through RTI as above, it was humbly submitted that the repudiation of the claim was riddled with extraneous reasons”It is evident from the Police Final Report, that late Mr. Ankush Ratra expired in a rail accident while illegal trespassing on railwy track. Further it is noted that insured committed suicide. Hence, he same falls outside the purview of policy terms and conditions.”Whereas, the police after conducting a proper investigation had given a final report and the police in its final report had clearly stated the death of Shri Ankush Ratra to be a rail accident. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) pay the claim amount of Rs.30,00,000/- alongwith interest @ 18% since of the death of insured Shri Ankush Ratra i.e. 06.02.2020.
b) pay Rs.10,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs.1,00,000/ -as litigation expenses.
2. Opposite party put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that the instant consumer complaint filed by the complainants were devoid of any merit in law and the same had been done so as to make illegal and unscrupulous gains at the expense of the opposite party. It was submitted by the answering opposite party that the consumer complaint conveniently suppressed material facts that the deceased policyholder had committed suicide, due to which the insurance claim had been repudiated herein. Even prima facie, it was abundantly clear that the claim had been invalidated as per the terms, conditions and policies enumerated and agreed upon by both party and there could be no dispute regarding the same. The deceased policyholder had submitted a proposal form for purchasing an Personal Protect insurance policy in his name for sum insured of Rs.30,00,000/- on 14.12.2019 from the answering opposite party. Based on the said proposal form and other documents submitted by the deceased policyholder, a personal protect insurance premium policy bearing No. 4111/MPL/188286182/00/000 for a sum insured of Rs.30,00,000/- was issued in the name of the deceased policy holder for the period 14.12.2019 to 13.12.2022 against insurance premium of Rs.10668/- subject to excess clauses & compulsory deductibles so mentioned in the said insurance policy. Accordingly, the insurance company rely upon the terms and conditions contained in the insurance policy, issued accordingly favouring the complainant. It was submitted that the insurance company had never undertaken to indemnity and/or to provide insurance service to the insured, in case, violation of the terms & conditions of the insurance policy by the insured and/or out of scope of the insurance policy or non-performance of his part of obligation. It was submitted that the deceased policyholder had signed the proposal form after duly going through the terms and conditions and had full knowledge of the same. It was very clearly mentioned in the general exclusion clause of the proposal forms that “self-inflicted injury, suicide or attempted suicide” shall not be covered by the policy terms and conditions. The “General Exclusion” Clause of the proposal forms was being replicated herein for the benefit of this Hon’ble Commission. It was humbly submitted that the deceased policy holder had duly received and examined the policy related documents at the time of availing the insurance policy and the answering opposite party had never received any query or objection in relation to the said policies terms and conditions from the said deceased policyholder. As per the policy terms and conditions, the commission of suicide would render the policy void and the same had happened therein. It was hence abundantly clear from the face of the evidentiary record that suicide was excluded from the ambit of the policy benefits. In the policy terms and conditions, it was clearly mentioned that suicide or attempted suicide were not covered in the policy and were excluded. The relevant exclusion of the policy was reproduced below for the ready reference of this Hon’ble Commission:-
Relevant part of the exclusion was pasted hereunder for the ready reference of this Hon’ble Commission:
Policy copy Part I of the Policy: Policy schedule, under special conditions 1. Exclusions
“Suicide, attempt to suicide or intentionally self-inflicted injury, sexually transmitted conditions, mental disorder, anxiety, stress or depression” The answering opposite party had received a claim in the policy claiming an amount of Rs.30,00,000/- from the complainants on account of death of the policyholder Mr. Ankush Ratra on 06.02.2020. The answering opposite party thereafter had referred the said insurance claim for investigation through in house investigator. During the investigation, it was noted that the Loco Pilot of the train with which deceased policyholder had died had in his “
Rukka” sent to the Station Master had clearly stated that ”one man jumped in front of his train and his dead body was lying in the III Track” and from the same it was clear that when train was approaching the track, there were many persons who were waiting there for the train, however, when the train approached near the deceased policyholder, he jumped in front of the train and it was also known fact that nobody would risk his life by crossing the track in front of the approaching train and that too when many other people at same place were waiting for the train until and unless that person would like to commit suicide by jumping in front of the train. That was pertinent to mention herein that the photographs of the incident location clearly shows the foot-over bridge to cross the railway tracking i.e from one platform to another hence it was evidently clear that the mensrea of the deceased was to commit suicide by jumping before the train. Further as per the Railways Act, 1989 crossing the railway lines was illegal and a punishable offence. As per Section 147 in the Railway Act 1989 “Teaspass and refusal to desist from trespass-(1) if any person enters upon or into any part of a railway without lawful authority, or having lawfully entered upon or into such part misuses such property or refuses to leave, he shall be punishable(i.e. criminal intent). It was submitted that after the perusal of police records, the investigator verification report and the documents procured during the investigation, all the documentary and circumstantial evidence clearly establishes the commission of “suicide” by the deceased policy holder. Thus, it was proved beyond reasonable doubt that the deceased policy holder committed suicide and there was not a iota of evidence in support of the factum of death of the deceased policy holder having been caused by “Accident”. It was submitted by the answering opposite party that the deceased policyholder had intentionally committed suicide due to some personal reason. It was also relevant to mention here that no railway ticket or platform ticket was found with the deceased policyholder. It was submitted that the deceased policyholder had no other reason for going to the track after parking his car on the road as his home as well office/work was not on the tracks and as such the only purpose of visiting the railway track was the sole intention of committing suicide. Thus, from the facts and circumstances herein it could not be said that the death of policyholder was accidental under any circumstances rather the circumstances clearly establish that the motive of the deceased policyholder was to commit suicide. As admitted by the complainants, the said policy was obtained by the deceased policy holder against accident coverage but it was pertinent to note that the same was subject to terms, conditions and exclusions as stated therein and did not cover death by suicide. Also the deceased policyholder had purchased multiple policies from other insurance companies as well which proves that the sole motive of the deceased policyholder was to help his family to receive the insurance claims in the event of his death by ways of suicide. It was prima-facie apparent from the bare perusal of the complaint that the complainants had failed to establish the alleged statement of Accident in any manner whatsoever and there had been no negligence or deficiency in services whatsoever, on the part of opposite party in dealing with the concerned policy as the claim was rightly repudiated vide letter of intimation dated 14.09.2020 which decision can not be termed unconscionable at all. Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite parties– ICICI Lombard Gen. Insurance co. & Others with the prayer to: a) pay the claim amount of Rs.30,00,000/- alongwith interest @ 18% since of the death of insured Shri Ankush Ratra i.e. 06.02.2020. b) pay Rs.10,00,000/- as compensation for causing mental agony and harassment .c) pay Rs.1,00,000/ -as litigation expenses.
To establish his case the complainant has led in his evidence, Ex CW1/A – affidavit of Ruhi Ratra @ Roohi Ratra wife of late Shri Ankush Ratra, presently residing at House No.2-B/42, NIT, Faridabad, Ex.C1 – letter dated 14.12.2019 regarding Risk Assumption Letter, Ex.C-2 – Policy Certificate, Ex.C-3 – Mediclaim Insurance, Ex.C4& 5 - Individual Health Insurance Policy Schedule, Ex.C 6 & 7– Schedule –Easy Health Individual Standard, Ex.C 8 & 9 – LIC’s Amulya Jeevan-2, Ex.C-10 – Jeevan Anand with Profits (With Accident Benefit), Ex.C-11 – Jeevan Anand (with Profits), Ex.C-12 to 17– LIC, Ex.C-18 to 20 – Optima Restore Policy Schedule – Optima Restore Floater, Ex.C-21 – letter regarding Renewal of Optima Restore Policy, Ex.C-22 – Optima Restore Policy Schedule – Optima Restore Floater, Ex.C-23 – Renewal of Optima Restore Policy, Ex.C-24 to 28– Renewal of your Optima Restore Insurance Policy, Ex.C-29 – letter regarding renewal of your Individual Personal Accident Policy, Ex.C-30 to 32 – letter regarding Renewal of your Optima Restore Insurance policy, Ex.C-33 – letter regarding renewal of your Individual Personal Accident Policy, Ex.C-34 – letter to SHO GRP Faridabad, Annx.A7 – Fard Jama Takasi, Ex.C-35 – letter dated 6.2.2020 regarding request for investigation against accidental death of Shri Ankush Ratra, Ex.C-36 colly – post mortem examination report, Ex.C-37 – newspaper cutting,, Ex.C-38- Type to Search, Ex.C-39 & 40 – newspaper cutting, Ex.C-41 – statement of Gajender Singh, SRO, Ex.C-42 – Death Certificate, Ex.C-43 to 45- letters dated 05.06.2020, Ex.C-46 – letter, Ex.C-47 to 49– status report of policy , Ex.C-50 – letter dated 14.09.2020, Ex.C-51 – email, Ex.C-52(colly) – RTI letter dated 3.2.2021.
On the other hand counsel for the opposite party strongly agitated
and opposed. As per the evidence of the opposite party Ex.RW1/A – affidavit of Shri Rohan Mishra, Manager (Legal), M/s. ICICI Lombard General Insurance co. Ltd., 4th floor, Red Fort Capital Parsvnath Tower, Bhai Veer Singh Marg, Gole Market, New Delhi, Ex.R-1 – letter dated 14.12.2019 regarding Risk Assumption Letter, Ex.R-2 – letter dated 03.09.2020 regarding requirement of the required documents, Ex.R-3 – Claim Form for Personal Accident Insurance, Ex.R-4 – Post Mortem Examination Report, Ex.R-5 – ICLM Closure Report, Ex.R-6 – Questionnaire for claimant, Ex.R-7 - letter to SHO GRP Faridabad, Ex.R-8 – Inquest Report No. 36 dated 06.02.2020 GRPS Faridabad, Ex.R-9 - Repudiation letter dated 14.09.2020.
6. In this complaint , the complaint was filed by the complainant with the prayer of death of Ankush Ratra who was died on 06.02.2020 in a railway accident. It was repudiated opposite parties by taking flimsy plea that the insured committed the suicide. But after going through the evidence led by the complainant from Ex.C1 to C-17 which shows deceased was having multiple life insurance policies from different companies. The certificate issued by the opposite parties i.e ICICI Lombard. No doubt the person was insured with a premium of Rs.10,668/- as per Ex.C-2 by the opposite parties. As per the evidence led by the complainant from Ex.C-34 to C-52 (colly), as per the proceedings of 175 Cr.P.C and the final report filed by the complainant of 175 Cr.P.C. proceedings and report of DSP ( HQ) GRP also submitted the report in the RTI which is exhibited by the counsel for the complainant and the statement of Locomotive Pilot of the railway and the statement of Sandeep Kumar who was the eye witness stating “Bheed main Ek Aadmi Bhag Kar railway Line paar karne haga jo meri gaadi ke chapat main aa gya”. Then in the Inquest report the opinion given is “In my opinion the cause of death in this case due to Railway accident”. Further, in the final report by police the cause of death is Railway Accident. Similarly, in tasdeek byThana Prabhandak it has been held as a case of Railway Accident. Not only thus but the insured was also having LIC policies with Double benefit in case of accidental death, the LIC after thorough investigation passed the Death Claim of Shri Ankush Ratra and paid Double sum insured holding the death of Ankush Ratra in an accident.
7. In this complaint, the complainant deceased has obtained the Life Insurance Policy also from the LIC Carriers. They have paid the double of the claim amount to the complainant. As per the evidence led by the complainant and also paid the benefit of the double amount in case of accident. As per evidence Ex.C-41 (colly)page 91 regarding the statement of Shri Sandeep Kumar in which it has been stated that “Bheed main Ek Aadmi Bhag Kar railway Line paar karne bhaga jo meri gaadi ke chapat main aa gya”. The complainant also led in his evidence Annexure Ex.C-52 (colly) i.e. DSP Head Quarter of GRP has given his report and information in RTI to the complainant. As per the information of the DSP Head Quarter dated 03.02.2021 , it was a case of railway accident . After going through the postmortum report and page No. 114 RajPal SI given the post mortum report in which the cause of death is railway accident and the final report of SHO GRP, Faridabad on page No. 136 is proving the same and also filed the final report of the death on page 136. Cause of death is railway accident and as per Annexure A17, the documents of LIC and Ex.C-47 on page 107
it shows the double benefit amount was given to the complainant by the LIC.
8. The Counsel for the complainant has placed on reliance the authority titled JSK Industries Vs. Oriental Insurance Company passed by the Hon’ble Apex Court while deciding Civil Appeal No. 7630 of 2022.
Ratio of the authority is applicable to the facts of the present case
9. After going through the report of DSP, SHO, SI and documents of the LIC, the Commission is of the opinion that no doubt this was a case of railway accident and the complainant has the insurance policy. Hence, the complaint is allowed. Opposite party No.1 is directed to process the claim of the complainant and issue the claim of the complainant in due course of law within 30 days of receipt of the copy of order and pay the due amount to the complainant along with interest @ 9% p.a. from the date of filing of claim of the complainant till its realization. The opposite party No.1 is also directed to pay Rs.11,000/- as compensation on account of mental tension, agony and harassment alongwith Rs.11,000/- as litigation expenses to the complainant. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 21.11.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
