National Consumer Disputes Redressal
The United India Insurance Co. Ltd. vs Smt.Potru Vijaya Lakshmi on 5 May, 2010
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI FIRST APPEAL NO. 312 OF 2004 (Against the order dated 07.06.04 in Complaint No. 133/01 of the State Commission Andhra Pradesh, Hyderabad) The United India Insurance Co. Ltd. Narasaraopet, Guntur Distt. ( A.P.) ........ Appellant Through: Regional Office No.1 Kanchanjunga Building, 8th Floor, Barakhamba Road, New Delhi-110001 Vs. Smt. Potru Vijaya Lakshmi W/o Late Ramulu c/o A.Siva Ramaiah Vinukonda-522 647 Guntur Distt. ( A.P.) ......... Respondent BEFORE: HON'BLE MR. JUSTICE R.C. JAIN, PRESIDING MEMBER HONBLE MR. ANUPAM DASGUPTA, MEMBER For the Appellant : Mr.S.M. Tripathi, Advocate For the Respondent : Ms. K. Radha Rao, Advocate : Dated 05th May,2010 ORDER
JUSTICE R.C. JAIN, PRESIDING MEMBER This appeal arises from an order dated 07.06.2004 passed by A.P. State Consumer Disputes Redressal Commission Hyderabad ( in short, the State Commission) in C.D No. 133/2001. By the impugned order, the State Commission has allowed the complaint filed by Smt. Potru Vijaya Laxmi, respondent herein with a direction to the opposite party appellant to pay the amount of policy viz. Rs. 5,00,000/- together with interest @ 9% p.a. w.e.f. 02.07.2001 ( the date of award of the Insurance Ombudsman) till the date of realization together with cost of Rs.2000/-. Aggrieved by the said order, the opposite party M/s United India Insurance Limited has filed the present appeal for setting aside the impugned order.
2. In view of the disputed factual position and the controversy raised, it seems necessary to note the facts and circumstances of the case in some greater details. Ramulu, the late husband of complainant Potru Vijaya Lakshmi, had taken Janta Personal Accident Insurance Policy No. 150904/51/57852 dated 21.11.97 in the sum of Rs.5,00,000/-. The policy was to remain in force till 20.11.2010. The complainant was shown as nominee in the said policy. The case of the complainant is that she alongwith her husband Ramulu had gone to Ramagundam and on the night of 10.05.1999 while the insured Ramulu was walking alone on the road in Ramagundam, an unknown scooterist came in a rash and negligent manner and knocked down Ramulu who, as a result, received head injury. Ramulu returned home and informed the complainant about the accident and that he could not observe the scooter number and the identity of the scooterist since it was night time. The complainant herself noted a small external injury near the right ear of Ramulu.
However, after some time, the insured Ramulu collapsed and the complainant took her to the NTPC hospital at Ramagundam where the daughter of the complainant was employed. The duty doctor at the hospital examined the insured and declared him dead. Since the incident had happened at Ramagundam where the complainant did not have any acquaintance, she could not make any police complaint immediately but a report was made later on at the Ramagudam Traffic Police Station and police registered the crime no. 69/99 under section 304A IPC. Post mortem was conducted on the body of Ramulu and the insurance company was informed about the death of Ramulu on 27.5.99 i.e., after 16 days of the death. Vide communication dated 01.06.99, the insurance company asked the complainant to submit the claim papers which she did on 09.06.99. After several months the complainant submitted additional supporting documents to the insurance company. However, vide communication dated 31.10.2000, the insurance company repudiated her claim on the ground that the NTPC authorities had not registered a medico-legal case and that the police was not informed immediately and further that there was expert medical opinion to the effect that there was no corroboration as to the injury narrated by the complainant and as reported in the post mortem examination report. Besides, the repudiation letter stated that there were several discrepancies as to the entries made in the emergency ward register and the ambulance log book which carried Ramulu from the place of his residence to the NTPC hospital.
3. According to the complainant, the repudiation of the insurance claim by the insurance company was wholly unjustified. She wants to explain the grounds / circumstances on the basis of which the insurance company had repudiated the claim in the following manner:
a. The NTPC hospital is not a Government hospital and there is no legal duty cast upon it to register medico-legal cases, much less, in respect of a patient who is not an employee of that Corporation, and was not injured while on duty therein.
b.
Because the daughter of the deceased was an employee in that hospital, the deceased was taken there and the incident not registered as medico legal case by the said hospital authorities is not an omission or latch.
c. The post mortem certificate states that the deceased had a lacerated wound of 3 x bone deep on the frontal scalp on the right side vertically irregular and the injury is ante mortem.
d. The police report as well as the complainants statement dated 15.6.99 given to the opposite party identically show that the insured had a vertical injury on the right side of his head. Therefore, the ground that the statement of the complainant are not corroborating with what is reported in the post mortem certificate is not correct.
e. The insured was brought dead at the hospital at 1.00 AM and the original entry regarding the time of the death can be perused in the Register and the previous entry was entered at 4.00 AM on 11.5.99.
The time of death is only around the midnight of 10/11.5.99, as per the post mortem conducted at the Government hospital, Ramagundam.
f. There is a news item dated 12.5.99 published in VAARTHA newspaper that her husband died in a road accident caused by an unknown scooterist. The delay in registering the FIR was clearly explained by the complainant stating that she was new to the place Ramagundam, was a lone woman there and she waited till the arrival of her relatives to complete the formalities.
g. The insured had a credit card no 50000 2510 from the Andhra Bank having insurance coverage from the New India Assurance Company who also appointed an Enquiry Officer who enquired into the matter and sent up his report to the company stating that the instant case was a genuine one. Even the LIC of India, Vinukonda Branch, found the case of her husbands death as genuine and admitted her claim.
4. It would appear that before filing the complaint, the complainant had also approached the Insurance Ombudsman, Hyderabad for seeking payment of the insurance claim but the Insurance Ombudsman dismissed the complaint vide order dated 02.07.2001. Consequently, the complainant filed the complaint before the State Commission seeking the insurance claim of Rs. 5,00,000/- with interest @ 18% p.a. from 11.02.2000 till the date of realization together with compensation of Rs. 25,000/- for mental agony and Rs.3000/- as cost of the proceedings.
5. The opposite party contested the complaint and filed written version refuting the claim on grounds similar to those on which it had earlier repudiated the insurance claim. It was sought to be explained that the insurance company was liable to indemnify under the policy if the insured sustained any bodily injury resulting solely and directly from an accident caused by outward, violent and visible means. It was also stated that immediately after the receipt of the information that the insured had sustained injuries in a scooter accident and died on 11.05.99, the insurance company appointed an investigator, who in his report opined that the insured did not receive injuries in an accident, much less in an accident with a scooter as was claimed. It was also pleaded that there was no direct evidence to the occurrence of the alleged accident and that the NTPC hospital authorities had not registered a medico legal case and had not informed the police about the deceased having been brought dead to the said hospital. The insurance company justified the grounds on which it had earlier repudiated the claim and prayed for dismissal of the complaint.
8. In support of the complaint, the complainant filed her own affidavit as also certain documents while the insurance company relied upon the order of the Insurance Ombudsman as also the report of the investigator. The State Commission, on its own reading of the evidence and material produced on record more particularly the version of the complainant in her affidavit as also the cause of death of the deceased given in post mortem examination that it was on account of shock and haemorrhage due to the head injury, viz., lacerated vertical wound 3 x bone deep on the right frontal scalp, found the grounds on which the claim had been repudiated as untenable and unjustified and accordingly accepted the case of the complainant that the insured Ramulu had died on account of the bodily injury caused to him in the scooter accident on the night of 10.05.99. It accordingly allowed the complaint and awarded compensation in the above terms.
7. We have heard Mr. S.M. Triptahi, Advocate, learned counsel for the appellant insurance company and Ms. K. Radha Rao, learned counsel representing the respondent and have perused the entire material produced on record. Mr. Tripathi would assail the impugned order and justify the repudiation of the claim by the insurance company mainly on the ground that the complainant had miserably failed to establish on record that the deceased Ramulu had sustained bodily injury, having been hit by a scooterist, on the night of 10.05.99 at about 11.30 pm. In this connection he has relied upon the following circumstances which according to him cast grave doubts about the said incident and the circumstances in which the complainant had, in fact, died:
i. According to the claim form, the time of the incident was 11.30 p.m. on 10.05.99 whereas the time and date as reported to the police (as per FIR) was 1200 noon on 12.05.99, i.e., after 36 hours.
ii. The original time of dispatching the dead body from NTPC hospital to government hospital at Ramagundam for post mortem was 1630 hours. Subsequently it was altered as 1530 hours in the inquest report whereas according to the post mortem report, the body was at Govt. Hospital, Ramagundam at 1600 hrs and post mortem completed at 1810 hrs. iii. According to the written statement given by the complainant, the wife of the insured, the cremation was done at 1730 hours at Ramagundam i.e., well before the time of completion of the post mortem (1810 hrs.).
Iv. According to the post mortem report, the cause of death of the insured was shock and hemorrhage due to head injury. The size of the wound was found 3 x bone deep.
But according to the written statement given by the wife of the deceased, the wound was very small and there was only sweat of blood ( no bleeding) and the insured was watching TV after the incident, i.e., at mid-night.
v. According to the post mortem report, the wound was very large and as per the medical expert opinion. The post-mortem finding will not correlate directly with the description of the wound having been sustained by the insured, as stated by his wife, before his death because such a large wound as reported in the post-mortem will force the blood out.
vi. At the same time, there was a complaint from the brother of the deceased carried by the news paper, Vaartha, dated 17.05.99 who was said to have attended the cremation at Ramagundam and the contents of the complaint were contrary to the statement given by the complainant, the wife of the insured and also contrary to the records submitted in support of the claim.
vii According to the complainant/wife of the insured, the incident occurred at 11.30 P.M. on 10.05.99 and she found her husband in unconscious state at 1 A.M. on 11.5.99 in toilet and rushed to the NTPC hospital to bring the ambulance. However, according to the records of the NTPC hospital, the ambulance was dispatched at 10 P.M. on 10.5.99 itself, i.e., one and a half hours prior to the alleged time of the incident and three hours prior to the actual reported time of calling the ambulance.
viii. According to the NTPC hospital, it was not a medico legal case but a brought-dead case and hence the body was kept in the mortuary without referring to the police, as natural death.
ix. According to the inquest report, the inquest was conducted at 1630 hrs. at NTPC hospital and the body sent for post mortem to Govt. Hospital Ramagundam. The travel time between the NTPC Hospital and the Govt. Civil hospital, Ramagudam, was about half an hour. However, according to the post mortem report, the body was seen by the medical officer there at 1600 hours itself and the post mortem commenced at 1610 hours and concluded at 1810 hrs. on 12.5.99 x. According to the wife of the deceased, the cremation concluded at 1730 hours at Godavarikhani, which is at about 40 to 50 minutes away from Ramagundam hospital.
xi. According to NTPC hospital records, where the body was kept in the mortuary since 1 A.M. on 11.5.99 till the completion of the inquest said to have been done at NTPC hospital on 12.5.99. The dead body was actually handed over to a family friend of the deceased, i.e. M. Prabhat Kumar at 17.40 hrs. on 12.5.99 and not to the police as the inquest report speaks.
xii. The above details show that on 17.30 hrs. on 12.5.99, the dead body of the insured was present at three places at the same time, i.e., first at the NTPC hospital, second at Govt. hospital Ramagundam and the third at the banks of river Godavari for cremation.
8. In support of his submissions, Mr. Tripathi, placed reliance upon the documents, reports and record of the hospital produced on record. On careful perusal of the same, we have no manner of doubt that most of the above circumstances can be said to have been reasonably established. There was undue delay of about 36 hours in reporting the matter to the police which in our opinion remained unexplained. The explanation of the appellant that the delay was due to the reason that she had no acquaintances at Ramagundam and that no medico legal case was made at the NTPC hospital does not appear to be satisfactory. Report of the post mortem examination had put the time of death between 36 to 40 hours when the post mortem was conducted between 1610 to 1810 hrs. at 12.05.99. The most intriguing part is that as per the certificate dated 22.10.99 issued by the NTPC hospital, the ambulance was sent to quarter no. A-6/22, i.e., the house of the daughter of the complainant on 10.05.99 and the insured was brought in dead condition to the hospital only at 1.00 A.M. on 11.5.99.
According to this certificate, the body was sent to the mortuary and was handed over to the police on 12.05.99 at 5.40 P.M. ( 17.40 hrs) to Prabhat Kumar. If the ambulance had been summoned and sent to the house where the complainant and her husband were putting up at Ramagundam at 10 P.M., the entire case of the complainant that her husband had met with an accident at about 11.30 P.M. will fall to the ground. In any case, it raises grave doubt about the time at which the deceased had received injuries and the circumstances in which he received the injury noted in the post mortem examination report. It may also be noticed that the post mortem examination report notices a single injury only, i.e., a head injury ( lacerated wound of 3 x bone deep on the frontal scalp) and no other injury on the body of the deceased.
If the deceased had really met with a road accident caused by a scooter, it is very unlikely, almost impossible in fact, that he would not have received any other external injury by way of abrasions etc., on any other part of his body because, due to the impact of the scooter, he must have fallen on the road and in that situation not only the head of the deceased would have been injured but some other parts of the body like knees and elbows must have received some injuries. These factors make the case of the deceased having received the said single head injury on account of a scooter accident very much doubtful.
9. Mr. Tripathi then submitted before us that the insurance company had appointed an investigator, viz., Spy Eye Detective Agency to investigate in the alleged accidental death of the deceased Potru Ramulu. Report of the said investigator has been placed on record. We have carefully gone through the report of the investigator and on doing so we find that the investigator in this case has done a thorough job by examining in detail the material obtained by him as also various other circumstances. On doing so, the investigator has concluded as under:
After having been investigated the case from all corners it is concluded without prejudice or bias that the cause of death of the insured Sri Potru Ramulu s/o Nagaiah, aged about 52 years of Vinukonda was not due to scooter accident as alleged by the wife and nominee of the insured Smt. P. Vijaya Laxmi and the following are the primary evidences to prove that the statement given by the wife is false and also the FIR, inquest report and certain contents of the postmortem report are fabricated for unlawful gain to the parties concerned to the case and also to screen the offenders:
1. The time of calling of ambulance as per the records of the NTPC hospital was 10 PM on
10.05.99 where as according to the statement of the wife, it was about 1 AM on 11.5.99.
2. The post-mortem was conducted at the banks of river Godavari in the presence of co-employee of the deceased as reported by the brother of the deceased through the newspaper dated 17.05.99 but not at the government civil hospital, Ramagundam at 4.10 PM on 12.05.99 as certified by the Medical Officer, Government Hospital, Ramagundam since the body was at NTPC hospital till 17.40 hours on 12.05.99.
Both the above points will clearly proves that the FIR, inquest and post mortem report are nothing but creature of after though.
3. The expert medical opinion clearly speaks that the statement given by the wife of the deceased do not corroborate with the injury as certified in post mortem report.
4. The rest of circumstantial evidence furnished in this report proves the motive of the parties concerned to the case.
10. Learned counsel for the appellant wants to assail the said report on the ground that it is not worthy of credence and in any case cannot form basis for repudiation of claim, more particularly so when the report casts certain aspersions on the character of the complainant. We, however, see no merits in this contention.
11. Having considered the material from all possible angles, we are of the considered opinion that complainant has failed to establish that the insured deceased had died on account of having sustained bodily injury resulting solely and directly from accident caused by outward, violent and visible means. We have, therefore no hesitation in holding that the finding of State Commission is not based on correct and proper appreciation of the evidence and material brought on record. In our opinion, repudiation of the claim by the insurance company based on the above material was fully justified and the insurance company cannot be held guilty of any deficiency in service in repudiating the claim in the present case.
12. For the above stated reasons, the appeal is allowed and the findings and order of the State Commission are hereby set aside.
As a consequence, the complaint is dismissed, leaving the parties to bear their own costs throughout.
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(R.C. JAIN, J) ( PRESIDING MEMBER) Sd/-
(ANUPAM DASGUPTA) MEMBER Am/