D.O.F : 18/03/2024
D.O.O : 30/10/2024
IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KASARAGOD
CC.85/2024
Dated this, the 30th day of October 2024
PRESENT:
SRI.KRISHNAN.K : PRESIDENT
SMT.BEENA.K.G : MEMBER
- Smt. Vasanthi, aged 48 years
W/o Yadava Kumara C.H.
Cheral House,
Bayar village and post – 671348.
- Vaishnavi, aged 19 years
D/o Yadava Kumara
Cheral House,
Bayar Village and post – 671348.
(Adv: K. M. Ballakuraya) : Complainants
And
SBI General Insurance Company Ltd
9th floor, West port,
Pan card Club road,
Banet, Pune,
Maharashtra – 411045. : Opposite Party
ORDER
SMT.BEENA.K.G : MEMBER
The brief facts of this case is that the complainant No. 1 is the widow and complainant No. 2 is the daughter of deceased Yadava Kumara C. H. The complainant No. 1 and Yadav Kumara are having 2 more minor female children namely, Janhavi C. H. and Arpitha C. H. The complainants are filing this complaint on behalf of the said minors also. Yadava Kumara C. H. was a government employee working as senior grade auditor in Kerala State Audit department. Yadava Kumara C. H. was the only bread winner in the family of the complainants. The deceased Yadava Kumara C. H. had obtained insurance policy from the respondent under personal accident insurance policy on 11/03/2023 and it was in force till 10/03/2024. On 12/06/2023 at about 8.30 AM the Yadava Kumara C. H. was at his old house, accidently due to loss of balance fell down at that time and he had stepped on a rusted nail and thereby sustained injury. Even though Nail was removed later, Yadava Kumara C. H. was suffering heavy pain due to the said injury so he was taken to PHC Bayar. There he was given TT injection, first aid and was advised to take rest. So he was taken back to the house. On the next day due to the injury sustained by Yadava Kumar, fever started and he was taken to KIMS Hospital at Kasaragod and was admitted there. The ultra sound was advised and he was treated by Dr. Avinash. On 14/06/2023 the pain aggravated and it resulted in breathing problem also. His condition was worsened and he reached a state of septic shock. He had multi organ failure and acute respiratory distress syndrome, AKI, Myocarditis with LV dysfunction. The doctors at KIMS advised to take Yadava Kumara to a higher center for a better treatment and accordingly the deceased was discharged and taken to INDIANA Hospital at Mangalore. He was admitted and was treated as an impatient in ICU for 5 days thereafter he was shifted to general room and there the treatment continued. On 30/06/2023, Yadava Kumara C H had sudden collapse and found to have triple vessel disease on coronary angiogram. OCT guided angioplasty was done. His condition was worsened and he expired on 30/06/2023 at 23 hours. The death of Yadava Kumara C. H. occurred only due to the accidental fall over rusted nail. As per the terms of insurance policy, the complainants are entitled for the insured amount of Rs. 20,00,000/-. The complainants submitted a claim form before the respondent, but they refused the claim through a letter dated 30/10/2023 on false ground. However through a letter dated 30/10/2023, the respondent informed that, if better particulars are given, respondent is ready to modify the repudiation. The complainants again submitted all relevant documents to the respondent, on 23/01/2024, the opposite party again repudiated the claim on different ground. The rejection ground No. 1 pointed out by the respondent is that the hospital has changed their statement. It is absolutely incorrect. The respondent has raised such a contention to evade from the liability. The second ground for rejection is misrepresentation. But respondent did not clarify what is misrepresentation. The complainants have clearly stated the facts and events lead to the death of Yadava Kumara. The details of accidental injury caused and subsequent treatments are clearly stated in the discharge summary of INDIANA Hospital, which was produced before the respondent. According to the complainants, by rejecting the claim without any justifiable ground the respondent had committed deficiency in service. The rejection of the claim by the respondent is illegal, improper and contrary to the terms of the policy. The respondent had adopted unfair trade practice. The cause of action for the complaint arose on and since 23/01/2024 the date of rejection of claim received by the complainants at Bayar Village, Kasaragod District within the jurisdiction of this commission. The complainant is seeking direction against respondent to pay Rs. 20,00,000/- to the complainants with an interest at 12% per annum from 30/06/2023 (the date of death of Yadava Kumara) till payment with a compensation of Rs. 50,000/- for mental agony along with cost of litigation.
The notice of opposite party served, name called absent, set exparte.
The complainant filed proof affidavit in lieu of chief examination. The documents produced are marked as Ext. A1 to A8 marked. Heard the complainant. The following questions raised for consideration.
- Whether the complainant is a consumer?
- Whether there is any deficiency in service/unfair trade practice on the part of opposite party in rejecting the claim of deceased Yadava kumara?
- Whether the complainant is entitled for relief?
- If so, what is the relief?
For convenience questions 1 to 3 can be discussed together. The deceased Yadava Kumara C. H. had obtained an insurance policy from the respondent under personal accident insurance policy on 11/03/2023 and it was in force till 10/03/2024. By purchasing a policy and by paying premium amount, Yadava Kumara C. H. is a consumer under C P Act 2019. The policy is a contract between parties and both parties are bound by the terms of contract. The Yadava Kumara was the only bread winner in the complainant’s family. On 12/06/2023 at about 08.30 AM, when Yadava Kumara was at his old house, accidently due to loss of balance he fell down and at that time he had stepped on a rusted nail and sustained injury. The nail was removed but suffered heavy pain due to injury. He was taken to PHC Bayar, he was given TT injection, first aid given and advised to take rest. The treatment certificate issued by medical officer, family health center, Bayar is produced and marked as Ext. A1. Therefore he was taken back to the house. On the very next day due to the injury sustained by Yadava Kumara, fever started and he was taken to KIMS Hospital at Kasaragod and was admitted there. He treated by Dr. Avinash. On 14/06/2023 the pain aggravated and resulted in breathing problem also. His condition was worsened and he reached in a septic shock and had multi organ failure and acute respiratory distress syndrome, AKI myocarditis with LV dysfunction. The doctors at KIMS advised to take the deceased to a higher center for better treatment, thus he was discharged and taken to INDIANA Hospital at Mangalore. There he was treated as an impatient in ICU for 5 days and thereafter shifted to general room and treatment continued. Discharge summary issued from INDIANA Hospital Mangalore is produced and marked as Ext. A2. On 30/06/2023, the deceased had a sudden collapse and found to have triple vessel disease on coronary angiogram. OCT guided angioplasty was done but the condition was worsened and he was expired on 30/06/2023 at 23 hours. The complainants submitted a claim before the respondent but they rejected the claim by stating false grounds. The claim rejection letter dated 30/10/2023 was produced and marked as Ext. A3. In Ext. A3 letter it was stated that if better particulars are given respondent is ready to modify the repudiation amounts to unfair trade practice followed by them. The complainant again submitted all the relevant documents to the respondent with claim application. But the respondent again rejected the claim through the letter dated 23/01/2024. The said letter is marked as Ext. A4. EXT. A5 is the policy details. Ext. A6 is the certificate issued by Dr. Adithya V Bhardwaj. Ext. A7 is the copy of letter received from SBI dated 11/03/2023. Ext. A8 is the copy of the Group Personal Accident Insurance Policy No. 32728523. The root cause lead to the death of Yadava Kumara C. H. is the accidental fall and nail injury on the right foot. Even though TT was administered from PHC Bayar, serious health issues developed thereafter. The complainants are entitled to get relief in this case. The deceased Mr. Yadava Kumara C. H. had a valid accidental insurance policy at the time of accident. Hence he is entitled for the policy amount. The illegal rejection of the claim by opposite party is clear evidence for their unfair trade practice and deficiency in service. Due to the irresponsible attitude of opposite party, the complainants had undergone huge loss, mental agony and hardships. The opposite party is bound to compensate the complainant’s monitory loss and mental agony. Ext. A8 assures an amount of Rs. 20 lakhs in case of accident death of policy holder. It appears from the materials on record that on 30/06/2023 Yadava Kumara C. H., the deceased expired and the complainant made claim. Her grievance at different stages have been rejected and communicated to her. It appears that she has run from pillar to post to get the claim amount. Thus she has got mental agony being harassed twice by the opposite party. So considering the mental agony and the physical labour, we are constrained to hold that the complainant is entitled to compensation of Rs. 50,000/- besides litigation cost.
The claim of the complainant is for Rs. 20,00,000/- with 12% interest per annum from the date of death till payment with a compensation of Rs. 50,000/- and cost. This commission allows Rs. 50,000/- as compensation in this case for the long suffering of the complainant’s family due to the continuous repudiation and deficiency in service on the part of opposite party of the claim.
In the result, complaint is allowed directing opposite parties to pay the claim amount of Rs. 20,00,000/- (Rupees Twenty lakhs only) with interest at the rate of 9% from 30/10/2023 (the date of repudiation) till realization with a compensation of Rs. 50,000/- (Rupees Fifty thousand only) along with cost of Rs. 5,000/- (Rupees Five thousand only) to the complainant within 30 days from the date of receipt of copy of this order.
Sd/- Sd/-
MEMBER PRESIDENT
Exhibits
A1 – Treatment certificate
A2 – Discharge summary
A3 – Claim rejection letter
A4 – Claim rejection letter
A5 – Policy details
A6 – Certificate issued by Dr. Adithya V. Bhardwaj
A7 – Copy of the letter received from SBI
A8 – Copy of the Group Personal Accident Insurance Policy
Sd/- Sd/-
MEMBER PRESIDENT
Forwarded by Order
Assistant Registrar
JJ/
