State Consumer Disputes Redressal Commission
National Insurance Company Ltd. vs Sh. Naman on 29 January, 2024
Appeal No. National Insurance Co. Ltd. 29.01.2024
350 of 2019 Vs.
Sh. Naman
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, UTTARAKHAND, DEHRADUN
Date of Institution: 11.12.2019
Date of Final Hearing: 16.01.2024
Date of Pronouncement: 29.01.2024
First Appeal No. 350 / 2019
National Insurance Co. Ltd., Dehradun
Through its Regional Manager
Regional Office, Dehradun
(Through: Sh. Avi Nanda, Advocate)
.....Appellant
VERSUS
Sh. Naman S/ Sh. Manoj Kumar
Through Mother and Natural Guardian Smt. Deepmala
R/o Moh. Kotswan, Gandhi Market, Jwalapur, Haridwar
(Through: Sh. Tajendra Kumar Garg, Advocate)
.....Respondent
Coram:
Ms. Kumkum Rani, Judicial Member II
Mr. B.S. Manral, Member
ORDER
(Per: Ms. Kumkum Rani, Judicial Member II):
This appeal under Section 15 of Consumer Protection Act, 1986 has been directed against judgment and order dated 17.07.2019 passed by the learned District Consumer Disputes Redressal Forum, Haridwar (hereinafter to be referred as the District Commission) in consumer complaint No. 130 of 2018 styled as Sh. Naman Vs. National Insurance Co. Ltd. and Another, wherein and whereby the complaint was allowed directing the appellant to pay a sum of Rs. 2,00,000/- alongwith simple 1 Appeal No. National Insurance Co. Ltd. 29.01.2024 350 of 2019 Vs. Sh. Naman interest @ 6% from the date of filing of the complaint on account of death and Rs. 5,000/- as costs of litigation.
2. According to the complaint, the grand-father of the complainant had opened a saving bank account No. 33986513518 in the bank of opposite party No. 2. The grand-father of the complainant has also got an insurance to the extent of Rs. 2 Lacs under the head of 'Pradhanmantri Suraksha Beema Yojna' after paying requisite premium wherein the complainant was shown as nominee, aged about 10 years. The complaint was filed on behalf of minor (complainant) through his mother as legal and natural guardian. An accident took place on dated 28.02.2016 by motorcycle bearing No. UK08-X-8974, when his grand-father alongwith one person was sitting and going from Haripur Kalan towards Valmiki Chowk and nearby Chandipul at about 7 pm., the motorcycle fell down from the bridge in order to save some other vehicle and the above motorcycle was badly damaged. The grand-father of the complainant was also severally hurt; he was taken to Government Mela Hospital, Haridwar where he was declared dead by the concerned medical officer. The Medical Officer of Government Mela Hospital, Haridwar has also intimated about the accident to the policy. With the permission of District Magistrate, the cremation of complainant's grand-father was done. There was no negligence on the part of the deceased. After the accidental death of deceased - insured under Pradhanmantri Suraksha Beema Yojna, the complainant has submitted a claim form alongwith death certificate, discharge certificate, policy information, bank papers, postmortem report and FIR report with the insurance company, but the insurance company has repudiated his claim vide letter dated 27.06.2016 alleging that no cause of action has arisen in favour of the complainant. Thereby the insurance company committed deficiency in service against the complainant, therefore, the complaint was filed against the opposite parties.
2Appeal No. National Insurance Co. Ltd. 29.01.2024 350 of 2019 Vs. Sh. Naman
3. The opposite party No. 1 - insurance company has submitted its written statement alleging that it is true that the complainant - Sh. Naman was the nominee in the relevant papers. That the answering opposite party has inquired about the claim and found that neither the proper FIR was lodged, nor any documents were submitted, nor the reason for accident was mentioned, nor Postmortem report was submitted. Therefore, the claim of the complainant was repudiated. There was no deficiency in service on the part of the answering opposite party, hence the complaint was liable to be dismissed.
4. The opposite party No. 2 - Bank has submitted its written statement alleging that it is correct that the deceased - Sh. Om Prakash had obtained a saving bank account No. 33986513518. It is also true that the account holder - deceased Sh. Om Parkash had taken an insurance policy to the extent of Rs. 2 Lacs wherein the complainant was shown nominee. The complainant has submitted his claim alongwith necessary documents before the insurance company, but his claim was repudiated by the insurance company. There is no negligence act on the part of the answering opposite party, hence the complaint is liable to be dismissed.
5. The District Commission after hearing both the parties and taking into consideration the material available on record, passed the judgment and order on dated 17.08.2019, whereby it is held as under:-
"ifjokn Lohdkj fd;k tkrk gSA foi{khx.k dks vknsf"kr fd;k tkrk gS fd osa vkns"k dh frfFk ls ,d ekg ds Hkhrj ifjoknh dks eqc0&2]00]000@&:0 dh /kujkf"k e; 06 çfr"kr okf'kZd C;kt dh nj ls] okn ;ksftr djus dh frfFk 21&05&2018 ls vafre vnk;xh rd rFkk okn O;; ds :i esa 5000@&:0 vnk djsaA"3
Appeal No. National Insurance Co. Ltd. 29.01.2024 350 of 2019 Vs. Sh. Naman
6. Having been aggrieved by the aforesaid judgment and order of the District Commission, the appellant - opposite party No. 1 has preferred the appeal alleging that the District Commission has committed manifest error of law in wrongly appreciating evidence contrary to the facts; the Commission below has failed to consider this fact that the claim was repudiated on the ground that the claimant had not submitted postmortem report conducted on the body of deceased who had allegedly met with an accident, as the same was mandatory. Hence, such condition was mandatory to be fulfill by the claimant or claimant's legal representative.
7. Learned counsel for respondent - complainant has argued that in various case laws, it is held that if the postmortem was not conducted, then the claim filed before the insurance company on behalf of the claimant cannot be repudiated on the ground of non-submission of postmortem.
8. We have heard learned counsel for the both the party and perused the material available on record.
9. The main question for consideration before us is whether the repudiation order on the ground of non-submission of postmortem report by the respondent - complainant is justified and legal or not.
10. It is an admitted fact that the insured was the account holder of saving bank account in the bank of opposite party No. 2. It is also established on record that the insured had taken the insurance policy to the extent of Rs. 2 Lacs under Pradhanmantri Suraksha Beema Yojna wherein the respondent - complainant was shown nominee. It is also not disputed by both the party that the deceased - insured had expired due to accident.
11. Learned counsel for the appellant has vehemently argued that date of death of deceased is not proved on the record and the Commission shall 4 Appeal No. National Insurance Co. Ltd. 29.01.2024 350 of 2019 Vs. Sh. Naman consider the ground on which basis, the complainant's claim was repudiated.
12. We have perused the records. There are various case laws on this point that the grounds which are not mentioned in the repudiation letter cannot be considered in any Commission / Forum.
13. Repudiation letter is available on record at paper No. 51, wherein the Bank has informed the complainant that his claim was rejected by claim settlement company, i.e. National Insurance Co. due to not providing the post mortem report of the deceased.
14. Learned counsel for the appellant has argued that on account of not providing post mortem report of the insured to the insurer, the claim was repudiated and as per the terms and conditions of the policy, the copy of post mortem report should be filed before the insurance company, otherwise the claim shall stand as repudiated. The appellant - insurance company has filed and strongly relied upon the Annexure-B enclosed with the affidavit (paper Nos. 11 & 12) wherein the claim procedure is mentioned, but such prayer is not within the terms and conditions of insurance policy that the claim shall be rejected due to not providing the post mortem report.
15. Respondent - complainant has submitted extract of PMSBY (paper Nos. 37 to 40) wherein the procedure for claim process in PMSBY (paper No. 39) has been mentioned, which is reproduced as under (in paper No.
39):-
"In the first step, you need to fill up the claim form and submit it alongwith Death certificate, the original document of FIR or Post Mortem report, Discharge certificate and Insurance certificate at the 5 Appeal No. National Insurance Co. Ltd. 29.01.2024 350 of 2019 Vs. Sh. Naman bank where you are supposed to get the Suraksha Bima Yojna in the savings account."
16. Thus, as per the said provision, in the first step, the claimant has to fill up the claim form and then submit alongwith death certificate, original document of FIR or post mortem report, discharge certificate and insurance certificate at the bank where the claimant or insured are supposed to get the Pradhanmantri Suraksha Beema Yojna in the savings account. Thus, as per PMSBY, the claimant has to supply either FIR or post mortem report. But the insurance company has deliberately presented the procedure (which has no signature of the insured), according to which the insurance company has made necessary both the documents to be filed, i.e. FIR and post mortem, wherein the terms and conditions of the insurance policy, the claimant has to submit either FIR or postmortem report.
17. So as per the provisions of PMSBY, it is sufficient either to file postmortem report or FIR with the claim form before the Insurance Company.
18. Learned counsel for respondent - complainant has submitted the following case laws, which are as under:-
1. First Appeal No. 1516 of 2017, Bajaj Allianz General Insurance Co. Ltd. & Ors. Vs. Harpal Singh and Ors., decided on 16.10.2017 (Hon'ble National Commission, New Delhi)
2. First Appeal No. 828 of 2010, Ajmeri Khatun Vs. General Manger, National Insurance Company Ltd., decided on 09.01.2015 (Hon'ble National Commission, New Delhi) 6 Appeal No. National Insurance Co. Ltd. 29.01.2024 350 of 2019 Vs. Sh. Naman
3. Sunita Singh (Mrs.) Vs. National Insurance Co. Ltd. and Others, 2018 (II) D.M.P. 466 (Pat.)
19. In the case of Bajaj Allianz General Insurance Co. Ltd. & Ors. Vs. Harpal Singh (supra) the Hon'ble National Commission has held that "it is evident from the term as reproduced in the repudiation letter itself that the postmortem report has to be submitted only if the postmortem was performed. Obviously, the beneficiary cannot be in a position submit a post mortem report if no post mortem on the dead body of the deceased is performed. It seems to be precisely for this reason that the term as extracted in the repudiation letter provides for waiver of the condition of submitting a copy of the post mortem report. Nowhere does the policy expressly stipulate that in the event of death of the insured due to an accident, benefit under the policy shall not be paid if her body is not subjected to a post mortem test. In the absence of such a specific condition in the policy conditions, it is difficult to accept the contention that a post mortem is necessary in every case including a case of accidental death in the manner it happened in this case. Logically, if a person accidentally falls in his/her house and the said accidental fall results in his/her death, a doctor will be called and he certifies the cause of death, the family members would not take his body for post mortem. In fact the hospital may not even conduct the post mortem on the dead body of the deceased in such a case. Therefore, it is not possible to accept the contention that no claim under the insurance policy taken by the deceased was payable unless the dead body of the insured was subjected to a post mortem."
20. In the case of Ajmeri Khatun Vs. General Manger, National Insurance Company Ltd. (supra) the Hon'ble National Commission has held as under:-
7Appeal No. National Insurance Co. Ltd. 29.01.2024 350 of 2019 Vs. Sh. Naman "3. In this case, it is an admitted fact that the deceased had taken a Long Term Janta Personal Accident Policy for 3 years. For that there is no dispute. There is also no dispute that the present complainant is the nominee of her aunt (the deceased) for receiving the amount as per the policy. Limited question is, whether the complainant is entitled to get the benefit of the said policy, as he failed to produce on record the post- mortem report.
4. In our view, as stated by Dr. N. Prasad Rao, Civil Assistant Surgeon, Govt. Hospital, Anakapalli, post-mortem was not conducted on the dead body, because usually, in snake bite cases postmortem examination is not conducted. Further, there is a certificate on record issued by him on 27.7.1996 that the deceased was admitted in the Community Hospital, Anakapalli on 23.7.1996 at 11 a.m. for snake-bite and the patient expired on the same day at 4 p.m. The certificate is signed by the Civil Assistant Surgeon, Community Hospital.
Thereafter, there is a certificate issued by the Village Administrative Officer of Anakapalli Mandal to the effect that Gorli Appala Narasamma, widow of late Nookaraju, died because of snake bite on 23.7.1996 at about 10 a.m., while she was cutting grass. This information was conveyed to him by the neighbouring farmers. In our view, there is no justifiable ground to disbelieve the Village 8 Appeal No. National Insurance Co. Ltd. 29.01.2024 350 of 2019 Vs. Sh. Naman Administrative Officer and the doctor who treated the deceased."
21. In the case of Sunita Singh (Mrs.) Vs. National Insurance Co. Ltd. and Others (supra) the Hon'ble Patna High Court has held as under:-
"On this basis and in view of the statement of witnesses, injury report and after due enquiry, the investigation was closed and police report submitted finding the case true against the vehicle driver Naresh Sha under sections 279/304A/427 of the Indian Penal Code. Similarly, the injury report of the Primary Health Centre, Bariarpur, the various documents relating to the treatment of the deceased, the death certificated of the Magadh Hospital, all show beyond doubt that the death of the petitioner's husband occurred in course of treatment of grievous injury suffered in a road accident. From the policy report, it was established beyond doubt that no post- mortem had been conducted. There was thus no basis at all for the NICL to keep waiting for the petitioner to produce a post-mortem report which was non-existent. The stand of NICl in the supplementary counter affidavit terming the cause of death of the petitioner's husband as natural death in view of the death certificate issued by Magadh Hospital reveals an attitude which is nothing short of callous and can hardly be accepted as bona fide. The same death certificate records the clinical diagnosis as RTA with head injury. NICL's conclusion that it was a case of natural death is thus completely unfounded and reeks of arbitrariness.9
Appeal No. National Insurance Co. Ltd. 29.01.2024 350 of 2019 Vs. Sh. Naman The petitioner has also filed a supplementary affidavit taking a clear stand that the policy issued by the Oriental Insurance Company Limited which was settled within a year of death was similar in nature to the policy issued by NICL. This fact has also not been controverted by the NICL. This Court, therefore, fails to see any reason whatsoever for not settling the claim of the petitioner on one specious plea or another for almost 14 years, which has resulted in considerable harassment and irreparable injury to the petitioner."
22. Thus, the principles as laid down in the above cited case laws are applicable to the case in hand. Because in the case it is an admitted fact that the deceased has expired. It is also admitted fact that the deceased was brought and admitted to the Government Hospital at Haridwar, wherein after examination the treating doctor has declared that the insured has died. It is also admitted fact that the punchnama of the deceased was also conducted, wherein the competent police office, P.S. Kotwali Nagar, Haridwar has shown the reason of death of the deceased as due to accident of the motorcycle. It is also not disputed that the son of the deceased has given a letter to the District Magistrate to handover the body of his father for cremation without postmortem which was accepted. Thus, it is apparent that the postmortem was never conducted. But the report of Medical Officer and inquest report has clearly proved / depicted that the insured has expired due to road accident.
23. As per the principles laid down in the above cites case laws, it is not justified on the part of the insurance company to repudiate the claim of the complainant on the basis of non-providing of post mortem report of the deceased. Learned counsel has raised other plea which are neither 10 Appeal No. National Insurance Co. Ltd. 29.01.2024 350 of 2019 Vs. Sh. Naman contended in the appeal nor mentioned in the repudiation letter. Hence, such plea regarding the use of different motor cycle at the time of occurrence is not sustainable and tenable.
24. We are of the confirmed view that the District Commission has not misinterpreted the documents and has not discarded the appellant's plea and the impugned judgment is in accordance with the terms and conditions of the insurance policy and there is no violation of any terms and conditions of the insurance policy.
25. In the appeal, nothing is raised alleging the award to be in excessive side. Hence, we are of the definite view that the impugned judgment is perfect, justified and in accordance with law and there is no illegality and infirmity in its passing. Hence, we are not inclined to interfere with the finding of the impugned judgment.
26. Accordingly, the appeal is hereby dismissed. Impugned judgment and order dated 17.08.2019 passed by the District Commission, Haridwar is hereby affirmed. No order as to costs of the appeal.
27. A copy of this Order be provided to all the parties free of cost as mandated by the Consumer Protection Act, 1986 / 2019. The Order be uploaded forthwith on the website of the Commission for the perusal of the parties. The copy of this order be sent to the concerned District Commission for record, information and necessary action.
28. File be consigned to record room along with a copy of this Order.
(Ms. Kumkum Rani) Judicial Member II (Mr. B.S. Manral) Member Pronounced on: 29.01.2024 11