IN THE KODAGU DISTRICT CONSUMER DISPUTES REDRESSAL FORUM MADIKERI

SRI. C.V. MARGOOR,PRESIDENT

O R D E R

1. This complaint is filed by Sri.K.M. Kalappa s/o. late K.G. Muthappa, resident of Arji Village, Virajpet Taluk, Kodagu District with a prayer to direct the opponents to deposit Rs.4,00,000/- in lump sum out  of the insured amount of Rs.10,00,000/- and the balance of Rs.6,00,000/- in monthly installments of Rs.10,000/- in 60 months to him, a sum of Rs.25,000/- as compensation for mental agony, loss and hardship and cost of this proceedings.

2. The opponent No.1 is the Manager, ICICI Lombard General Insurance Company Limited, Mumbai and opponent no.2  the Manager, ICICI Lombard Health Care, P.A. Claims, Hyderabad.  The complainant has got dismissed the claim against the opponent no.1.

3. The wife of the complainant by name late Smt. K.K. Prema was insured under the policy with the opponents bearing policy No.4111/MPC/ 67861060/00/000 with effect from 18/11/2011 to 17/11/2016.  As per the terms and conditions of the policy on the death or permanent disablement of the insured, the nominee would get insured amount of Rs.10,00,000/-.  The complainant is the nominee under the said policy.  The wife of the complainant had a accidental fall from the first floor of her house on 16/05/2016 and sustained severe head injury.  The wife of the complainant was taken to Government Hospital, Virajpet where she was declared dead.  Since the death was occurred due to accidental fall there was no suspicious circumstance to report the death to police.

4. The complainant has submitted claim form with all the relevant documents including policy bond to the opponents for settlement of his claim, but the opponents delayed the settlement on one pretext or the other.  Hence this complaint.

5. Notice was issued to the opponent No.2 and it was served on it on 30/05/2018 as per the postal endorsement dated 26/07/2018.  The opponent No.2 despite the service of notice sent by registered post has failed to appear hence, it is set exparte. 

6. The complainant filed his affidavit in lieu of evidence and got marked exhibits P1 to 7 documents.  We heard the arguments advanced by the learned counsel representing the complainant and the points that would arise for determinations are as under.

1. Whether the complainant proves that the act of opponents not settling the claim of complainant amounts to deficiency in service?

2. To what order?

7. Our findings on the above points is as under;

• Point No.1:- In the Affirmative
• Point No.2:- As per final order for the below

R E A S O N S

8. Point No.1and 2:- The learned counsel for the complainant submitted that the opponent has not disputed issue of policy in the name of late Prema  wife of the complainant during the year 2011.  First information report is not registered since there was no suspicious circumstances with regard to the death of late Smt.K.K. Prema. 

9. The complainant produced exhibit P1 policy issued by the opponents and according to this the complainant has submitted the proposal of the policy and his wife has insured by mentioning the complainant as beneficiary / nominee.  According to exhibit P1 it covers the death resulting from accident or permanent disablement resulting from accident.  Benefit amount is Rs.4,00,000/- lump sum on claim settlement and monthly installments of Rs.10,000/- for pay out period of 60 months.  Exhibit P2 is out patient receipt dated 16/05/2016 of Government Hospital, Virajpet and according to this the wife of complainant was brought dead with history of head injury.  Exhibit P3 is admission/ discharge card of Smt. Prema.K.K issued by Government Hospital, Virajpet, Kodagu District.  Exhibit P3 indicates that on 16/05/2016 at 7 a.m Smt. Prema K.K was brought to the hospital and the Doctor reported that Cardio pulsate failure due to head injury.  The cause of death mentioned in P3 is that head injury due to self-fall. Exhibit P4 certificate issued by the doctor who examined the dead body of Smt. Prema.K.K on 16/05/2016 and opined that she declared dead due to head injury.

10. The complainant has sent exhibits P5 and P6 dated 22/10/2016 and 12/10/2017 legal notice through his lawyer to the opponent no.2 for delay in settling the claim inspite of submitting claim application along with documents.  The opponent No.1 has given exhibit P7 reply dated 26/10/2017 that in case the complainant provides FIR/MLC/policy diary report copy then they would process the claim application.  The doctor who examined the dead body of Smt. Prema K.K. wife of complainant has issued exhibits P3 and P4 that the cause of death due to accidental fall from the floor of the house and death is due to head injury.  By seeing the report and opinion of the doctor there was no suspicious circumstances with regard to the death of the wife of complainant as such there was no occasion for the complainant to report to the police to register FIR.  The death of the wife of complainant is due to accidental fall in the house as such the claim of complainant covers the policy condition.  The opponent would not have insisted for FIR since already the Medical Officer, Government Hospital, Virajpet has issued exhibits P3 and P4 documents after examining the dead body which was brought with history of head injury.  Therefore, repudiating the claim of complainant by the opponent amounts to deficiency in service since the complainant is nominee in exhibit P1 policy.  Hence, the complainant is entitled claim for a sum of Rs.10,00,000/- as mentioned in exhibit P1 policy.  Further the complainant is entitled for a sum of Rs.10,000/-towards mental agony and hardship as he was compelled to approach this Forum inspite of submitting relevant documents to the opponents along with claim application.   In addition to that complainant is entitled to a sum of Rs.10,000/- towards cost of this proceedings.  Accordingly we proceed to pass the following;

O R D E R

1. The complaint filed by Sri. K.M. Kalappa s/o. late K.G. Muthappa is allowed directing the opponent no.2 shall pay a sum of Rs.10,00,000/- insured amount to the complainant within two months from the date of order.  In case the opponent fails to pay the said amount within the stipulated period of two months it carries interest at the rate of 10% per annum from 09/05/2018 till payment.
2. Further the opponent shall liable to pay Rs.10,000/- compensation for mental agony and hardship plus Rs.10,000/- cost of this proceedings.
3. Furnish copy of order to the complainant and opposite party free of cost.

(Dictated to the Stenographer, got it transcribed, corrected and pronounced in the open Forum on this 05^thday of JANUARY, 2019)

                                                      (C.V. MARGOOR)

                                                          PRESIDENT 

                                                     (M.C. DEVAKUMAR)

                                                             MEMBER