IN THE CONSUMER DISPUTES REDRESSAL FORUM, ALAPPUZHA
Saturday the 31st day of December, 2016
Filed on 29.09.2014
Present
1.Smt. Elizabeth George (President)
2.Sri. Antony Xavier (Member)
3.Smt.Jasmine.D. (Member)
in
C.C.No.243/2014
between
Complainants:- Opposite Parties:-
- Smt. Nija, W/o late Anilkumar 1. The Commissioner
Mulluparambil, Thottappally P.O. Kerala Fishermen Welfare
Ambalappuzha, Alappuzha Fund Board, Ayyappan Nagar
Poomkunnam, Thrissur
- Nivedya -do- (By Adv. Janardhana Shenay)
- Akshay -do- 2. The Manager, United India
Insurance Co. Ltd., Divisional
Office No.2, Thrissur Trade
Centre, Kuruppam Road
Thrissur – 680 001
(By Adv. C. Muraleedharan)
O R D E R
SMT. ELIZABETH GEORGE (PRESIDENT)
The case of the complainant is as follows:-
The complainants are the legal heirs of the deceased Anilkumar. The deceased Anilkumar was a member of Kerala Fishermen Welfare Fund Board and the 2nd opposite party had issued a policy Tailor-made Group Personal policy to the Kerala Fishermen Welfare Fund Board covering their members. The husband of the first complainant properly remitted his share to the Board and he was covered under the policy issued by the 2nd opposite party. On 20.8.2013 during the course of fishing he slipped from the boat and his head hit on the deck of the boat and got injured seriously and admitted in Medical College Hospital and died on 23.8.2013. Thereafter, the complainants approached for the insurance, but their claim was repudiated by the opposite party stating that the deceased was not covered under the scheme. Alleging deficiency in service on the part of the opposite party, the complaint is filed.
2. The version of the first opposite party is as follows:-
It is true that there exists an insurance policy for accidental death for the members of the Fund with the 2nd opposite party. The Fishermen’s Welfare Fund Board collects applications for insurance claims along with the required documents and forwards it to the 2nd opposite party. The 2nd opposite party pays the insurance amount to the applicants through the first opposite party –Board. The Board forwarded the application submitted by the complainant to the 2nd opposite party. The Board has not made any delay in the said process. The 2nd opposite party informed that the policy amount could not be disbursed since in the Postmortem Report cause of death is recorded as intra cerebellar hemorrhage (Natural) and hence the death of Anilkumar does not come within the purview of accidental death. There is no deficiency in service on the part of the first opposite party.
3. The version of the 2nd opposite party is as follows:-
There is no deficiency in service on the part of the 2nd opposite party. The claim was repudiated on the basis of the policy conditions. The relevant records were submitted along with Postmortem certificate. On perusal of the postmortem certificate the finding is that the death of the above person is of natural intra cerebellar hemorrhage. The policy covers only accidental death or injury, accident by external, violent and visible means. Hence the death of the Anilkumar is not due to any accident but by natural hence the claim was repudiated on the basis of the policy condition and letter was sent on 23.10.2014. Since the death is not covered as per the policy the 2nd opposite party has no other option except to repudiate the claim.
4. Complainant was examined as PW1. The documents produced were marked as Exts. A1 to A10. The 2nd opposite party produced 3 documents and which were marked as Exts.B1 to B3.
5. The points that arose for consideration are as follows:-
1) Whether there is any deficiency in service on the side of the opposite parties?
2) If so the reliefs and costs?
6. It is an admitted fact that the 2nd opposite party issued a policy Tailor-made Group Personal Accident policy to the Kerala Fishermen Welfare Fund Board covering their members for the period from 17,.12.2012 to 16.12.2013. The first complainant’s husband was a member of the above Board. According to the first complainant, her husband sustained serious injuries on 20.8.2013 during the course of fishing he slipped from the boat and his head hit on the duck of the boat and admitted in Medical College Hospital and died on 23.8.2013. When the complainants submitted claim form for the insurance claim, the 2nd opposite party repudiated the claim by stating that the policy amount could not be disbursed because as per the Postmortem report the death was due to Intra cerebellar hemorrhage (Natural). The opposite party further stated that the policy covers only accidental death or injury, accident by external violent and visible means. In order to substantiate the claim of the complainant, they produced the police case document which marked as Ext.A9series and Ext.A10 series. Ext.A10(1) is the FIR and it is clearly mentioned that, “ A\nÂIp-amÀ 20.8.2013 XobXn aI-c-hn-f¡v F¶ aÂky-_-Ô-\-t_m«v Ad-_n-¡-S-en aÂky-_-Ô\w \S-¯n-h-cth cm{Xn 9.30 aWn-tbm-Sp-IqSn F§-s\tbm ImÂh-gpXn hoWv t_m«v U¡n Xe-b-Sn¨v ]cn-¡p-]än Be-¸pg hm\w saUn-¡Â tImtfPv Bip-]{Xn ICUþ NnInÂkbn Ign-ªp-h-cth Snbm-t\ä ]cn-¡p-I-fpsS ImTn-\y-¯m C¶p (23.8.2013) shfp-¸p\p 6 aWn-tbm-Sp-IqSn ac-W-s¸-«p-t]m-bn-cn-¡p-¶p.” Ext.A10(3) also it is stated that on 20.8.2013 while doing fishing in the Arabian Sea, Anilkumar slipped down in the boat and caused injury by hitting his head on the deck of the boat. It is an admitted fact that he was admitted in the hospital on 20.8.2013 and he died on 23.8.2013. According to the opposite party in the Postmortem report, the finding is that the death of Anilkumar is of Natural Intra cerebellar hemorrhage. The Postmortem report produced by the opposite party is marked as Ext.B3. In the Postmortem certificate under the title opinion and cause of death, it is stated that the deceased died due to Intra cerebellar hemorrhage (Natural). In the said certificate it is also stated that the history given by the investigating officer as per KPF 102 is “fall on to a boat”. So it is clear from the Postmortem certificate that the incident happened due to the fall on to a boat and deceased died due to Intra cerebeallar hemorrhage. “In a similar case of National Insurance Company Vs. Mosumi Bhattacharji RP No.(1270/16) Hon’ble National Commission observed that the policy does not define the term accident.” It relied upon the definition of accident given in Oxford Dictionary wherein it is defined as “an accident is something that happens unexpectedly and not planned in advance and causes injury.” In the instant case it is clear from the document produced that the accident occurred on 20.8.2013 while the first complainant’s husband was doing fishing. He was admitted in the hospital on 20.8.2013 due to the serious injuries sustained during the time of fishing and the died on 23.8.2013. So we are of opinion that the first complainant’s husband died due to the injury sustained in an accident on 20.8.2013. The accident on 20.8.2013 happened unexpectedly and not planned in advance and that caused injury which caused to the death of Anilkumar. The opposite party has no right to repudiate the claim of the complainants on the ground that the death of Anilkumar is not due to any accident but by natural. The repudiation of the claim by the opposite party amounts to deficiency in service.
In the result, complaint is allowed. The 2nd opposite party is directed to pay an amount which the complainants are eligible and entitled to get as per the policy. The 2nd opposite party is further directed to pay Rs.2,000/- (Rupees two thousand only) towards compensation and Rs.1,000/- (Rupees one thousand only) towards costs of this proceedings to the complainants. The order shall be complied within one month from the date of receipt of this order.
Dictated to the Confidential Assistant transcribed by her corrected by me and pronounced in open Forum on this the day 31st day of December, 2016.
Sd/- Smt.Elizabeth George (President) :
Sd/- Sri. Antony Xavier (Member) :
Sd/- Smt.Jasmine.D. (Member) :
Appendix:-
Evidence of the complainant:-
PW1 - Nija (Witness)
Ext.A1 - Copy of the Fishermen Welfare Fund Board passbook of Anilkumar
Ext.A2 - Copy of the Receipt Book of Fishermen Welfare Fund Board passbook
Ext.A3 - Copy of the certificate dated 24.9.2013
Ext.A4 - Copy of the letter from the first opposite party
Ext.A5 - Copy of the letter dated 5.4.2013
Ext.A6 - Copy of the postmortem certificate dated 23.8.2013
Ext.A7 - Copy of the Death certificate
Ext.A8 - Copy of the paper cutting
Ext.A9 - Copy of the report from Police
Ext.A10series - Copy of the notice u/s 157(2) and 173(1) (b) Cr. P.C., FIR., Deposition
Evidence of the opposite parties:-
Ext.B1 - True copy of the policy schedule
Ext.B2 - Copy of the letter dated 7.12.2014
Ext.B3 - Copy of the Postmortem report
// True Copy //
By Order
Senior Superintendent
To
Complainant/Opposite parties/S.F.
Typed by:- pr/-
Compared by:-
