Versus
- Universal Sompo General Insurance Co. Ltd., Crystal Plaza, Opp. Infiniti Mall, Link Road, Andheri (West), Mumbai-400058 (Regd. Office), through its Managing Director/CEO/Authorized Signatory.
- Universal Sompo General Insurance Co. Ltd., SCO-10,11, Feroze Gandhi Market Road, Jila Kacheri Area, Model Gram, Ludhiana, Punjab-141001 through its Branch Manager
- Indian Overseas Bank, 763, Anna Salai, Chennai-600002, through its Managing Director/Authorized Signatory.
- Indian Overseas Bank, Near Bus Stand, Sihar, Tehsil Payal, Distt. Ludhiana, through its Branch Manager. PIN-141117. …..Opposite parties
Complaint U/s. 35 of the Consumer Protect Act (amended upto date).
QUORUM:
SH. SANJEEV BATRA, PRESIDENT
MS. MONIKA BHAGAT, MEMBER
COUNSEL FOR THE PARTIES:
For complainant : Sh. Abhay Pal Bector, Advocate.
For OP1 and OP2 : Sh. R.K. Chand, Advocate.
For OP3 and OP4 : Sh. S.K. Chawla, Advocate.
ORDER
PER SANJEEV BATRA, PRESIDENT
1. Shorn of unnecessary details, the facts of the case are that the complainant is a labourer i.e. Raj Mistri, having three children namely Gurpreet Singh, Harpreet Kaur and Manpreet Singh (now deceased). Manpreet Singh was also working with the complainant. On 10.04.2021, the complainant along with his son Manpreet Singh were working of shuttering at second floor at Village Sihar, Tehsil Payal, Distt. Ludhiana in someone’s house from where Manpreet Singh fell down and hit with a tree. His neck was broken and blood started oozing from his neck, ears, mouth and other parts of the body. The complainant with the help of some persons, took Manpreet Singh in alive condition to Village Butari where doctor refused to attend him and referred him to Civil Hospital. On reaching Civil Hospital, Dehlon, the doctor checked him and declared him brought dead. The complainant stated that he took dead body of Manpreet Singh to his house where police came and asked to get postmortem of Manpreet Singh, but on refusing the same they got recorded his statement and got their signatures on some papers and allowed to cremate the body. A DDR No.11 dated 10.04.2021 at P.P. Sihar was also recorded regarding accidental death of son of the complainant.
The complainant further stated that Manpreet Singh was maintaining an account with Indian Overseas Bank in their village and the bank officials also opened a personal accidental insurance policy for him having sum insured of Rs.5,00,000/- with annual premium of Rs.118/- which was regularly deducted by the bank from his account. Thereafter, the complainant approached the office of OP4 with respect of policy of his son. The officials of bank took original documents from the complainant and his family along with documents of his son and assured to send the same to OP1 to OP3 for verification. They also obtained signatures of the complainant on blank papers. However, in October, 2021, the bank officials called the complainant and returned the original documents along with a claim rejection letter stating that the claim for death of Manpreet Singh could not be passed as the death was natural rather the same was accidental. According to the complainant, he also received rejection letter dated 28.09.2021 through registered post from OP1 and OP2 mentioning that the cause of death of his son was natural death so the claim cannot be passed and it is hereby rejected. In fact, the son of the complainant was died due to accidental death. The complainant claimed to have suffered mental and physical harassment on account of deficiency in service on the part of the OPs. In the end, the complainant has prayed for directing the OPs to pay the insurance amount of the policy for death of his son along with compensation of Rs.2,00,000/-.
2. Upon notice, OP1 and OP2 appeared and filed joint written statement and assailed the complaint by taking preliminary objections on the grounds of maintainability; lack of jurisdiction; the complainant has not come with clean hands; suppression of material facts etc. OP1 and OP2 stated that the complainant lodged the claim regarding death of Manrpeet Singh and immediately on receipt of claim, it was duly registered and entertained. The complainant was called upon to submit the documents in support of his claim. After going through the documents available in the claim file and after scrutinizing the file by their officials, the claim of the complainant was found not payable and same was repudiated vide repudiation letter dated 28.09.2021 as per terms and conditions of the policy, which are self explanatory. According to OP1 and OP2, the claim of the complainant is not payable as per terms and conditions of the policy and same has been rightly repudiated by them.
On merits, OP1 and OP2 reiterated the crux of averments made in column brief facts of the case. OP1 and OP2 have denied that there is any deficiency of service and have also prayed for dismissal of the complaint.
3. OP3 and OP4 appeared and filed joint written statement and assailed the complaint by taking preliminary objections on the grounds of maintainability; the complainant is bound by his act, conduct and admission; concealment of true and material facts; the complaint has been filed for squeezing money from them; lack of cause of action; the complainant is not their Consumer etc. OP3 and OP4 stated that they have nothing to do with the claim of the complainant and they are not liable for any alleged damages, harassment, mental pain, agony etc.
On merits, OP3 and OP4 reiterated the crux of averments made in column brief facts of the case. However, OP3 and OP4 admitted the opening of savings account by son of the complainant with them and also obtaining personal accidental insurance policy for sum insured of Rs.5,00,000/- on annual premium of Rs.118/-. But the same was paid by him twice i.e. 05.12.2019 and 22.04.2020. OP3 and OP4 further admitted that they took the original documents from the complainant and his family members along with documents of his son for sending the same to OP1 and OP2 for verification. In October 2021 they called the complainant and returned the original documents along with claim rejection letter mentioning the death of son of the complainant being natural. OP3 and OP4 have denied that there is any deficiency of service and have also prayed for dismissal of the complaint.
4. In evidence, the complainant tendered his affidavit as Ex. CA and reiterated the averments of the complaint. The complainant also placed on record documents i.e. Ex. C1 is the copy of personal accidental claim form, Ex. C2 is the copy of rejection letter dated 28.09.2021, Ex. C3 is the copy of account statement of Manpreet Singh with Indian Overseas Bank, Ex. C4 is the copy of certificate dated 10.04.2021 issued by Dr. Jasneev Sandhu, Medical Officer, PCMS-1, CHC Dehlon, Ludhiana, Ex. C5 is the copy of death certificate of Manpreet Singh, Ex. C6 is the copy of DDR No.11 dated 10.04.2021, Ex. C7 is the copy of Enrollment Form for Group Personal Accident Insurance and closed the evidence.
5. On the other hand, the counsel for OP1 and OP2 tendered affidavit Ex. RW1/A of Ms. Anita Raghuwanshi, Senior Executive of OP1 and OP2 along with documents Ex. R1 to Ex. R28 and closed the evidence.
The counsel for OP3 and OP4 tendered affidavit Ex. RW3/A of Sh. Rajesh Kumar, Senior Manager, Indian Overseas Bank, Siahar Branch, District Ludhiana along with documents Ex. RW3/1 to Ex. RW3/5 and closed the evidence.
6. We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents as well as written statements, affidavits and documents produced on record by the parties.
7. One Manpreet Singh (now deceased) son of the complainant was holder of a savings bank account No.06880100021912 with OP3 and OP4 and by virtue of being an account holder with OP3 and OP4 he was enrolled in IOB Suraksha, a Group Personal Accident Insurance Policy of OP1 and OP2. The policy was valid from 03.08.2021 to 13.04.2022 and it extended a personal accident cover up to Rs.5,00,000/-. Unfortunately, on 10.04.2021, when deceased Manpreet Singh was working at a construction site along with the complainant and co-workers, he had a sudden fall from the second floor of the under construction building and he sustained serious injuries which proved fatal for him. He was declared brought dead at Civil Hospital, Dehlon, District Ludhiana vide certificate Ex. C4. The personal accident claim Ex. R8 was preferred which was rejected by the OPs and OP2 vide rejection letter dated 28.09.2021 Ex. C2 mainly on the ground that the insured felt vertigo/dizziness and this act falls in the exclusion clause of the policy in question.
8. Now point of determination arises before this Commission for consideration whether the rejection of claim regarding death of insured Manpreet Singh was justified or not?
9. Before adverting to the merits of the case, reference can be made to Civil Appeal No.4769 of 2022 in National Insurance Company Ltd. Vs The Chief Electoral Officer & Others 2023 LiveLaw (SC) 90 whereby the Hon’ble Supreme Court has made the following observations:-
“32. We have benefit of elucidation in this behalf arising from the judgment of this Court in Smt. Alka Shukla Vs Life Insurance Corporation of India (2019) 6 SCC 64. The Court noted the divergence of opinion of courts between courts across international jurisdictions making a distinction between “accidental means” and “accidental result” while deciding insurance claims. Thus, an unexpected accident and unforeseen consequence or result from a normal or routine activity may constitute an accident but it would not qualify as “accidental means”. Two illustrative examples given are: (a) a fatal heart attack while dancing would be called “accidental” but would fail to attract insurance cover as not due to “accidental means”; (b) heart attack suffered as a result of over-exertion on being chased by a ferocious dog the death might attract the insurance cover as it was caused by “accidental means”. In the first example it was a normal activity while in the second it was an unintended activity and not a normal activity. The given type of injury may thus, fall within or outside the policy according to the event which led to the death and it is this particular cause which is required to be examined. The accident, thus, per se postulates a mishap or untoward happening, something which is unexpected or unforeseen.
33. The aforesaid judgment also emphasises the importance of a plain reading of the policy as a guiding principle. A proximate causal relationship between the accident and the body injury is a necessity.”
10. In the present case, undeniably, the fall was sudden, unintended causing bodily injury which resulted into death of Manpreet Singh. The only exception provided in the clauses mentioned in the rejection letter that the said accidental death should not be from any illness. It is not the case of OP1 and OP2 that Manpreet Singh was suffering from some pre-existing medical conditions which resulted into dizziness at the construction site. This fact has not been pleaded or proved by the insurance company. Even the contents of DDR were not interpreted as whole and only few words were selectively picked. It can be further noticed that the deceased, the complainant father and co-worker belong to labour class and “Chakkar AA Gya” are used in common parlance and it does not mean that the deceased was suffering from any medical condition like vertigo/dizziness. Further the deceased succumbed to bodily injuries immediately and injuries are the only proximal cause of death. As such, by applying ratio of the above said citation and keeping in view the facts and circumstances of the case, this Commission is of the view that OP1 and OP2 were not justified in repudiating the claim of the complainant and as such, it would be just and appropriate if OP1 and OP2 are directed to settle and reimburse the claim of the complainant regarding death of the insured Manrpeet Singh as per terms and conditions of the insurance policy along with composite costs of Rs.20,000/-. The complaint as against OP3 and OP4 is hereby dismissed.
11. As a result of above discussion, the complaint is partly allowed with an order that OP1 and OP2 shall settle and reimburse the claim of the complainant regarding death of the insured Manpreet Singh as per terms and conditions of the insurance policy within 30 days from the date of receipt of copy of order. OP1 and OP2 shall further pay a composite cost of Rs.20,000/- (Rupees Twenty Thousand only) to the complainant, failing which OP1 and OP2 shall be liable to pay interest @8% per annum from the date of order till its actual payment. Compliance of the order be made within 30 days from the date of receipt of copy of order. However, the complaint as against OP3 and OP4 is hereby dismissed. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.
12. Due to huge pendency of cases, the complaint could not be decided within statutory period.
(Monika Bhagat) (Sanjeev Batra) Member President
Announced in Open Commission.
Dated:12.12.2024.
Gobind Ram.
