National Consumer Disputes Redressal
Anjali Prasad vs The New India Assurance Company Ltd. on 1 September, 2017
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI FIRST APPEAL NO. 727 OF 2012 (Against the Order dated 13/05/2012 in Complaint No. 27/2010 of the State Commission Andhra Pradesh) 1. ANJALI PRASAD W/O. LATE RAMESH PRASAD, R/O. 37, RAAIN BASERA, MANJHI TOLA, ADITYAPUR, JAMSHEDPUR JHARKHAND ...........Appellant(s) Versus 1. THE NEW INDIA ASSURANCE COMPANY LTD. REPT. BY THE DIVISIONAL OFFICER-III, 49-1-9, II FLOOR, DALRAJU, SUPER MARKET, SANGAM OFFICER, BUS STOP, AKKAYYAPALEM, MAIN ROAD, VISAKHAPATNAM ...........Respondent(s)
BEFORE: HON'BLE MR. DR. S.M. KANTIKAR,PRESIDING MEMBER
For the Appellant : Mr. Himanshu Shekhar, Advocate For the Respondent : Mr. Salil Paul, Advocate
Dated : 01 Sep 2017 ORDER 1. This first appeal has been filed under Section 19 of the Consumer Protection Act, 1986 against the order dated 30.05.2012 passed in consumer complaint No. 27 of 2010 by A. P. State Consumer Disputes Redressal Commission, Hyderabad ( in short, 'the State Commission') whereby the State Commission dismissed the complaint.
2. The brief facts are that complainant's husband, Mr. Ramesh Prasad, since deceased, (hereinafter referred as 'the patient') was employee of Visakhapatnam Steel Plant. He was insured under Group Personal Accident Death Insurance Policy through his employer, who was tied up with New India Assurance Co. Ltd./OP. During the subsistence of the insurance policy, on 15.9.2008, the patient suddenly fell down while parking his vehicle at about 11 p.m. at his residence and sustained head injury. He was immediately taken to Visakha Steel Plant General Hospital (in short, 'VSPGH') and thereafter shifted to Apex Hospital, where he died on 17.9.2008. The complainant registered a FIR at Steel Plant Police Station. The post mortem report revealed that death was due to head injury. The complainant approached the insurance company/OP for the claim of insured amount but the OP repudiated the claim without any reasons. The legal notice was also issued by the complainant claiming compensation but no response come from the OP. Hence, the complainant filed a complaint before A.P. State Consumer Disputes Redressal Commission, Hyderabad.
3. The OP filed a written version opposing the claim of the complainant and denied allegations. OP submitted that the deceased was covered under personal accident policy and liability of OP would arise only as per the terms and conditions of the policy. In case of accidents only and deaths caused by other ways or other means, are not covered under the policy. The OP submitted that as per investigator's report, the deceased was suffering from hypertension. The same was evident from the documents of Apex Hospital where the deceased was treated on 16.9.2008. the condition was diagnosed as Intra-cerebral hemorrhage, Hypertensive bleed, Aneurysm bleed. Hence, the death of insured was on account of massive intra cranial hemorrhage due to a possible rupture of an artery.
4. The State Commission dismissed the complaint. Being aggrieved, by the order of State Commission, the complainant preferred first appeal before this Commission.
5. Heard learned counsel for both the parties. Learned counsel for the appellant/complainant submitted that the insured deceased fell down in the night around 11.00 p.m. and suffered head injury. Due to severe headache in the early hours, he was taken to VSGPH at 8.45 a.m.. The duty doctor examined the patient and said that it was severe injury and the condition of patient was critical, therefore, he was shifted to Apex Hospital for further management, thus, the patient underwent cranial surgery. During the treatment, he died.
6. Learned counsel for the OP vehemently argued that on receipt of claim form from the complainant, the surveyor investigated the matter and obtained past medical record of the insured, for the period from September 2002 to August, 2008. On the basis of said record, it was confirmed that the deceased was suffering from hypertension. Also, as per the discharge certificate issued by Dr. Sridhar of Apex Hospital the deceased was suffering from hypertension, which had caused Intra-cerebral hemorrhage. The patient had aneurysm bleed, which means "localized abnormal dilation of a blood vessel, usually an artery, due to a Congenital defect or weaknesses in the wall of the vessel. Counsel for OP submitted that as per medical record (Ex. B-6) and the opinion of Dr. Durgesh, it was not possible for any person to die of massive intra cranial (intra cerebral hemorrhage) following a fall, as suffered by the deceased. The post mortem report was vague, it is merely an opinion, which observed it as head injury to the brain. There was no ill intention for Dr. Durgesh to issue a wrong certificate. The counsel further submitted that the complainant would have immediately taken her husband to the hospital and at the same time informed the police; but the complainant took him to the hospital on 8.45 a.m. on 16.9.2008 whereas the deceased suffered injury on previous night at 11.00 p.m. Thus, it appears that the complaint was suitably designed and the FIR was lodged on 17.9.2008 after the death of the deceased to claim benefit under the policy.
7. I have perused the medical record of VSGPH and the Apex Hospital. The medical record of VSGPH revealed that the deceased was under regular treatment of hypertension; it was under control and he was hale and hearty. The Apex Hospital record revealed that deceased had fallen in the night on 15.9.2002 and he was taken to Apex Hospital on 16.9.2002 in early hours. The admission record mentioned that the blood pressure (BP) was not recordable. Therefore, he was administered dopamine drip. The BP never recovered throughout the day and patient expired on 17.09.2008 at 4.45 a.m. In the Apex Hospital, emergency Craniotomy surgery was performed, after obtaining the high risk consent from the relative of the patient. As per operative notes there was left temporal hemorrhage but nothing was mentioned about the aneurism of the cerebral vessel. I have perused the certificate issued by Dr. K. Sridhar. It is pertinent to note that it is an undated handwritten certificate/document and appears to be issued on 5.1.2009, the date which was mentioned beneath the signature. I think the last paragraph of the said certificate is more relevant to note. It is reproduced as below:
"Patient had sudden outset loss of ___? Due to sudden brain hemorrhage ? hypertension bleed "
Aneurysm bleed."
8. On bare perusal of the certificate, it clearly indicates that it was issued after pretty long time at the insistence of the insurance company. The doctor did not mention any definite diagnosis, but he had mentioned few differential diagnoses i.e. possibility of intra cranial hemorrhage. The learned counsel for the OP relied upon the judgments of this Commission in the case of United India Insurance Co. Ltd. vs. Prakash Chand III (2016) CPJ 290 (NC), another judgment in New India Assurance Co. Ltd. vs. Laxmi Bai IV (2016) CPJ 364 NC. In my view, in those cases, the facts are different from the instant case.
9. After thoughtful consideration, I have recollected the chronology of events. As per the say of OP, the claim was repudiated on three counts. Firstly, the document of surgeon opined that the patient had sudden loss of consciousness, due to sudden brain hemorrage/tension bile amunirim bleed. Secondly, as per the investigator's report, the claim falls outside the scope of policy, as the insured person died due to hypertensive intra cerebral hematoma and with severe brain edema. Thus, it was not due to accidental fall and thirdly after the referral, the Apex hospital doctor had also opined that there was cerebral damage due to massive hypertensive haemmorhage consequent to long standing hypertension, which caused the death of the person. It is surprising to note that the OP/insurance company relied upon opinion of one surveyor, who is not a medical professional. After investigation, he concluded that "the cause of accident is that the deceased fell down on the road while he suffered with hypertensive brain hemorrhage", it means 'due to hypertension, firstly, the person suffered brain hemorrhage and then he fell down on the road. It is absolutely a misleading report. OP should have consulted their team of doctors before confirming such misleading opinion. I have perused the medical record from 2002 - 2006. The record consists of Out Patient Card (OPD) slips with the clinical notes. I do not find anywhere that the deceased was suffering from high blood pressure. BP recorded in OPD card on regular visit revealed that it was 120/82 mm of Hg. i.e. within normal range and occasionally, it was recorded as 140/100. The variations in BP recordings are usually due to physiological changes. There is no single prescription showing anti-hypertensive medicines prescribed to the deceased.
10. It is an admitted fact that the complainant's husband suffered accidental fall, who was taken initially to VSPGH and due to critical condition, he was referred to Apex Hospital. His blood pressure was not recordable. It was very low. The Craniotomy surgery was performed at Apex Hospital on 16.9.2008 but he could not be saved. The main question in the instant case is whether the insured died due to hypertension or due to accident. The main question to be answered is whether the Intracranial hemorrhage was due to hypertension or by accident (traumatic). The post mortem was performed, the organs did not show any changes of long standing hypertension. Even the post mortem findings showed condition of heart and the coronary vessels as normal, thus, in my opinion, the death of insured was not due to hypertension but it was accidental only.
11. Regarding the opinion of Dr. V. Durgesh about massive intra cranial hemorrhage, was not due to fall in the parking space. I do not agree with the said opinion because any trivial trauma also cause head injury and intra cranial hemorrhage. The patient underwent Craniotomy surgery and the blood clots were removed from the cranium. It itself indicates that there was severe trauma to the head causing rupture of intra cranial blood vessels. There is no evidence produced by OP, that the patient was suffering from uncontrolled hypertension which may cause, intra cerebral bleed. In my view, the insurance company has made unflappable attempts, to co-relate the accidental death to the hypertensive etiology. Now a days, most of the people are living with Hypertension and Diabetes. They are under regular checkups and treatment. Even the doctors at Apex hospital did not come to the definitive diagnosis, whether the bleed was Hypertensive or Aneurysmal or by some other means. Even the operative findings are not suggestive of either AVM ( Arterio Venous Malformation) or Anurysm. The Post Mortem also ruled out hypertensive changes in vital organs like kidney, heart, lungs etc.
12. On the basis of foregoing discussion, I conclude that the husband of complainant had accidental head injury, which caused cerebral hemorrhage and subsequently death. Therefore, I set aside the order, passed by the State Commission and allow this appeal with the direction that the OP shall pay a sum of Rs.26,00,000/- alongwith Rs. 1,00,000/- for mental agony and Rs.20,000/- towards cost. The OP shall comply the entire order within four weeks from the date of receipt of the order failing which the entire amount shall carry interest of 12% per annum till till realization.
...................... DR. S.M. KANTIKAR PRESIDING MEMBER