DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

BATHINDA

C.C. No. 325 of 28-11-2018

Decided on : 29-11-2021

Manjeet Kaur aged about 48 years, widow of Sh. Pal Singh R/o Village Kaureana, Tehsil Talwandi Sabo, Bathinda. ........Complainant

Versus

1. State of Punjab, through Deputy Commissioner, Bathinda.

2. Director Health & Family Welfare, Punjab, Mini Secretariat, Sector 9, Chandigarh.

3. United India Insurance Co. Ltd., SCO 72, Phase IX, Mohali, through its Branch Manager.

.......Opposite parties

Complaint under Section 12 of the Consumer Protection Act, 1986

QUORUM

Kanwar Sandeep Singh, President

Sh. Shivdev Singh, Member.

Smt. Paramjeet Kaur, Member

Present

For the complainant : Sh. A S Chahal, Advocate.

For opposite parties : Sh. Lachman Kumar, Advocate, for OPs No. 1&2.

Sh. Sunder Gupta, Advocate, for OP No. 3.

ORDER

Kanwar Sandeep Singh, President

1. The complainant Manjeet Kaur (here-in-after referred to as omplainant) has filed this complaint U/s 12 of Consumer Protection Act, 1986 (Now C.P. Act, 2019, here-in after referred to as 'Act') before this Forum (Now Commission) against State of Punjab and others (here-in-after referred to as opposite parties).

2. Briefly stated, the case of the complainant is that she is a poor lady and is living under below poverty line, having no immovable property and is also holding blue card issued by the Govt. of Punjab for getting Atta/Dal under the control rates. The husband of complainant namely Pal Singh was also holding Card issued under Bhagat Puran Singh Sehat Bima Yogana vide Card No.9304 6000 0960 35922. As per the aforesaid Bhagat Puran Singh Yogana, in case of the accidental death of the head of the family or in case of the 100% disability to the head of the family, a sum of Ras.5,00,000/- is payable by the opposite parties as compensation to the family.

3. It is alleged that Sh. Pal Singh husband of the complainant was murdered by Dewal Singh@ Kewal Singh son of Gurdev Singh, resident of Vill.Pakka Shaheedan, P.S. Kelianwall, Distt. Sirsa by throwing him in Bhakhra Canal on the intervening night of 10/11.7.2017. In this regard, a case FIR No. 194 dated 12.7.2017 under section 302 IPC has been registered against the aforesaid Dewal Singh @ Kewal Singh in P.S. Kalianwali, Distt. Sirsa and the challan in the aforesaid case has already been presented against Dewal Singh @ Kewal Singh in the said case which is still pending trial. Since the husband of the complainant was the head of the family and has been murdered, the complainant, being nominee of the deceased Pal Singh, is entitled to Rs.5,00,000.00 as compensation under Bhagat Puran Singh Sehat Bima Yogana from the opposite parties. The complainant applied for the aforesaid amount of claim with the opposite parties and furnished requisite documents but the opposite parties have failed to pay even a single penny to the complainant rather the opposite parties kept on putting the matter off under one or the other false pretext and ultimately the opposite party no 3. repudiated the claim of the complainant vide letter dated 3.9.2018 with the observation “You have submitted the chemical report and final opinion of the doctor performing the PMR, wherein the chemical examination report shows the presence of alcohol, which is exclusion under the policy/tender documents. Accordingly, we hereby repudiate the claim". The complainant alleged that repudiation letter dated 3.9.2018 is totally wrong, illegal, null and void, arbitrary and is unilateral one as the opposite party No. 3 has repudiated the claim of the complainant on the basis of totally false facts in order to avoid their liability to pay the amount of insurance claim of Rs. 51acs. This case is not a case of death by drowning into the canal under the influence of alcohol rather it is a case of murder of Pal Singh and the death of Pal Singh is unnatural who was robbed by Dewal Singh @ Kewal Singh and was murdered and was ultimately thrown into the Canal by Dewal Singh @ Kewal Singh and as such the complainant is entitled to the amount of claim under Bhagat Puran Singh Sehat Bima Yogana and the impugned repudiation letter dated 3.9.2018 is having no binding effect upon the rights of the complainant. Due to the above said act on part of the opposite parties, the complainant is suffering from great mental tension, agony, botheration, harassment, humiliation.

4. On this backdrop of facts, the complainant has prayed for direction to the opposite parties to pay her insurance claim/ compensation of Rs.5,00,000/- under Bhagat Puran Singh Sehat Bima Yogana alongwith upto date interest @ 12% per annum w.e.f. the date of death of Pal Singh till payment besides costs of Rs. 11,000/-.

5. Upon notice the opposite parties appeared through their respective counsel and filed written reply.

6. The opposite parties No. 1 & 2 in their joint reply raised legal objections that opposite parties have got no relationship with the present claim; that the application is not maintainable in its' present form; that the complainant does not fall under the definition of a consumer as he has not paid any premium for availing facility under the scheme; that the claimant has got no pre-existing right to file the present claim against the opposite parties under the 'Act'; that the complainant has no cause of action and locus standi to file the present claim and that this Commission has no jurisdiction to entertain and decide the present claim as the complainant does not fall under the definition of the consumer.

7. On merits, the opposite parties No.1 and 2 have pleaded that no claim whatsoever was payable on behalf of the opposite parties No. 1 & 2. Claim if any was payable by Opposite Party No. 3. The said Bhagat Puran Singh Sehat Bima Yojna (BPSSBY) is a cashless mass health policy for smart card holders of this scheme. The state government has issued a notification dated: 02.05.2016 vide which District Grievance Redressal Committee (DGRC) has been constituted at district level to settle the disputes between all the stake holders. The complainant has failed to make any representation before the said DGRC. Moreover, the complainant was bound to seek necessary sanction from Punjab Health Systems Corporation (PHSC) before filing the present suit as per the provisions of Punjab Health Systems Corporation Act, 1996. Therefore, the complainant is not entitled to any claim whatsoever. The role of the opposite parties on behalf of the PHSC was only limited to entertain and decide any dispute arising between the stake holders. Any claim whatsoever was payable only by opposite party No. 3. Still the opposite parties No. 1 & 2 are ready to take up the matter under DGRC. The claim claim is vague, false & baseless. No claim is payable to the complainant. After denying all other averments of the complainant, the opposite parties No. 1 & 2 prayed for the dismissal of the complaint.

8. Opposite party No. 3 filed separate written statement by raising legal objections that opposite party entered into agreement with Govt. of Punjab (Nodel Officer, Punjab Health System Corporation), Mohali, as per tender dated 17.08.2016 issued by State of Punjab Department of Health and Family Welfare to insure Blue Cards holders under BPSSBY Scheme w.e.f. 01.11.2016 to 31.10.2017 only and Pal Singh son of Kaur Singh was insured under Bhagat Puran Singh Sehat Bima Yojna, vide Card No.9304 6000 0960 3592 2 and terms and condition of insurance policy was duly supplied to State of Punjab and Director Health and Family Welfare Punjab; that claim of the complainant has rightly been repudiated vide letter reference No.DOM:2017, dated 03.09.2018. on the ground that as per chemical examination report and Forensic Science Laboratory Report regarding viscera shows the presence of alcohol, which is violation of terms and conditions of insurance policy as well as tender dated 17.08.2016 issued by State of Punjab Department of Health and Family Welfare to insure Blue Cards holders under BPSSBY Scheme w.e.f. 1.11.2016 to 31.10.2017, as such claim of the complainant is not payable; that as per complaint and as per copy of FIR No.194 dated 12.07.2017 recorded in PS Kalanwali, Distt. Sirsa. u/s 302 IPC. recorded on the statement of Hardeep Singh son of Pal Singh, insured Pal Singh has been murdered by Dewal Singh@ Kewal Singh son of Gurdev Singh and as per post-mortem report and viscera reports deceased/insured was under the influence of alcohol as per chemical examination report; that the present complaint is bad for non-joinder of necessary party, as all the legal heirs of deceased Pal Singh have not been impleaded as party ; that complainant has not come to this Commission with clean hands, rather has intentionally concealed the material facts from this Commission and that the complaint is false, frivolous and vexatious to the knowledge of the complainant and is liable to be dismissed with special costs.

9. On Merits, the opposite party No. 3 has admitted that under BPSSBY head of the family holding BPSSBY Card is insured for Rs.5,00,000/- in case of accidental death, However, as stated earlier, Pal Singh has not died due to any accident, rather he has been murdered. The complainant is not entitled for any compensation as insured /deceased has not died due to any accident, rather as per complaint and as per aforesaid FIR, he has been murdered so the claim of the complainant do not fall within the purview of aforesaid tender issued by Punjab Government and as per terms and conditions of insurance policy.

10. It has been pleaded that the claim of the complainant has rightly been repudiated by opposite party No. 3, vide letter dated 03.09.2018 as per terms and conditions of insurance policy as chemical examination report of deceased shows presence of alcohol, which is an exclusion under the policy/tender documents. The complainant herself admits in para No. 3 and para No.5 of the complaint that insured has been murdered and thrown into Canal by Dewal Singh @ Kewal Singh. Complaint is not entitled for any compensation. After denying all other averments of the complainant, opposite party No. 3 prayed for dissmissal of complaint.

11. In order to prove this complainant, learned counsel for the complainant tendered into evidence affidavit dated 27-11-2018 ( Ex.C1), photo copy of card ( Ex.C2), photo copy of FIR(Ex.C-3), photocopy of death certificate ( Ex.C-4) and photocopy of letter ( Ex.C-5).

12. In order to rebut the evidence of complainant, opposite party No.1 and 2 tendered into evidence photocopy of notification (Ex. OP-1/1) affidavit of Dr. Sukhbirinder Singh Romana dated 6-3-2019 (Ex. OP-1/2) .

13. The opposite party No. 3 also tendered into evidence affidvit of Baldev Singh dated 06-02-2019 (Ex.OP-3/1), photcopy of letters (Ex. OP-3/2 to OP-3/4), photocopy of e-mail ( Ex.OP-3/5), photocopy of applicaton ( Ex.OP-3/6), photocopies of reports (OP-3/7 & Ex.OP-3/8), photo copy of letter (Ex.OP-3/9), photocopy of investigation report ( Ex.OP-3/10), photocopy of claim form ( Ex.OP-3/11), photo copy of police investigation (Ex.OP-3/12), photocopy of FIR (Ex.OP-3/13), photocopy of forensic medicine report (Ex.OP-3/14), photocopy of notice inviting tender (Ex.OP-3/15) and closed the evidence.

14. We have heard learned counsel for the parties and gone through the record.

15. These are undisputed facts between the parties that husband of complainant namely Pal Singh was holder/insured under Bhagat Puran Singh Sehat Bima Yojna vide Card No. 9304 6000 0960 3592 2 (Ex. C-2). As per Notification dated 2-5-2016 (Ex. OP-1/1), this insurance provides cashless health insurance upto Rs. 50,000/- per family per year and Accidental Death & Permanent disability cover of Rs. 5,00,000/- per HoF (Head of Family). Pal Singh, husband of complainant was murdered on 10-07-2017 and copy of death certificate is on the file as Ex.C-4. The said Pal Singh was head of the family. After death of Pal Singh, complainant filed application under aforesaid Yojna/Insurance for compensation of Rs.5,00,000/- with opposite party No. 3. The claim of the complainant was repudiated vide letter dated 3-9-2018 (Ex. C-5).

16. A perusal of repudiation letter (Ex. C-5) reveals that claim of complainant was repudiated on the ground that chemical examination report shows the presence of alchohal which is exclusion under the policy/tender document.

17. Ex. OP-3/8 is the report of the Chemical Examiner for the Haryana which shows that :“Content of the exhibit No. 1,2 & 3 gave positive test for Ethyl alcohol was estimated at 34.5 mg % in exhibit No. 3.” As per said report, blood alcohol concentration in the body of the deceased Pal Singh was 34.5 mg per 100 ml. of blood.

    Hon'ble National Commission in the case titled Life Insurance Corporation of India Vs. Ranjit Kaur (2011 (3) CPJ 232) has held that :

    “Chemical Examiner in his report had stated that the blood alcohol concentration in the body of the deceased was 86.25 mg per 100 ml. of blood – That this by itself is not adequate proof that the deceased was intoxicated at the time of his death – Specific clinical picture of alcohol intoxication also depends on the quantity and frequency of consumption and duration of drinking at that level and, therefore, mere presence of alcohol even above the usually prescribed limit is not a conclusive proof of intoxication. - There is also no evidence that there was a nexus between the death caused by electric shock and consumption of liquor – Insurance Corporation was not justified in repudiating the double accident benefit insurance claim of the Respondent.”

18. Therefore, keeping in view the opinion of Hon'ble National Commission in above cited cases, deceased Pal Singh cannot be said to be under the influence of liquor at the time of his death. Moreover, there is no evidence that there was a nexus between cause of his death (murder) and consumption of liquor.

19. Further the contention of learned counsel for the opposite party No. 3 that that deceased has not died due to any accident rather he has been murdered, so he has violated the terms and conditions of the insurance policy, is not tenable.

    Hon'ble National Commission in First Appeal No. 1357 of 2016 decided on 25-9-2018 in the case Royal Sundaram Alliance Insurance Co. Ltd., Vs. Pawan Balaram Mulchandani, while discussing the case Maya Devi Vs. LIC of India has referred Halsbury's Laws of England Vol. 25 Pg 311 para 575, 4^th Edition (2003 reissue) wherein it is stated that :

    “575 Injury caused by a willful act. An injury caused by the willful or even criminal act of a third person, provided the insured is not a party or privy to it, is to be regarded as accidental for the purpose of policy.”

20. It was also held in the aforesaid judgement that :

    “It may further be stated that Contra Proferentem Rule applicable to insurance policies says that in case of ambiguities in the insurance policy, the interpretation has to be done in favour of the insured. In the present case it is nowhere stated that even for murder simplicitor the claim is not payable and hence the action of the insurance company in repudiating the claim cannnot be justified.”

21. Thus, keeping in view facts, circumstances, evidence and the aforesaid opinion rendered by Hon'ble National Commission, this Commission is of the considered opinion that there is deficiency in service on the part of opposite parties in repudiating the genuine claim of the complainant.

22. In the result, this complaint is partly allowed with Rs. 10,000/- as cost and compensation against opposite party No. 3 and dismissed qua opposite parties No. 1 & 2. The opposite party No. 3 is directed to pay Rs. 5,00,000/- (Rupees Five Lacs only) with interest @9% p.a. w.e.f. 3-9-2018 (date of repudiation) till payment to complainant.

23. The compliance of this order be made within 45 days from the date of receipt of copy of this order.

24. The complaint could not be decided within the statutory period due to heavy pendency of cases.

25. Copy of order be sent to the parties concerned free of cost. File be consigned to the record room.

    Announced :

    29-11-2021

    (Kanwar Sandeep Singh)

    President

     

     

    (Shivdev Singh)

    Member

     

    (Paramjeet Kaur)

    Member