National Consumer Disputes Redressal
Bajaj Allianz General Insurance Co. ... vs Harpal Singh & Anr. on 16 October, 2017
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI FIRST APPEAL NO. 1516 OF 2017 (Against the Order dated 10/04/2017 in Complaint No. 199/2014 of the State Commission Punjab) 1. BAJAJ ALLIANZ GENERAL INSURANCE CO. LTD. REGIONAL OFFICE, 7TH FLOOR, 1, DLF INDUSTRIAL AREA, MOTI NAGAR, NEW DELHI-110 015. 2. M/S BAJAJ ALLIANZ GENERAL INSURANCE CO. LTD, THROUGH ITS BRANCH MANAGER, HEAD OFFICE AT G.E. PLAZA, AIRPORT ROAD, YERWADA, PUNE-411 006, MAHARASHTRA 3. M/S BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED THROUGH ITS BRANCH MANAGER, OFFICE AT SCF-12-13, 2ND FLOOR, GURUDWARA, DUKHNIWARAN SAHIB, MARKET, PATIALA PUNJAB ...........Appellant(s) Versus 1. HARPAL SINGH & ANR. S/O SHRI BHAGWAN SINGH, R/O VILLAGE-DANDRALA KHAROR, TEHSIL NABHA DISTT, PATIALA, PUNJAB 2. SHRI HARJOT SINGH S/O SHRI HARPAL SINGH (MINOR), THROUGH HIS NATURE GUARDIAN HARPAL SINGH, R/O VILLAGE DANDRALA KHAROR, TEHSIL NABHA DISTRICT-PATIALA PUNJAB ...........Respondent(s)
BEFORE: HON'BLE MR. JUSTICE V.K. JAIN,PRESIDING MEMBER
For the Appellant : Mr. Pradeep Gaur, Advocate
Mr. Amit Gaur, Advocate For the Respondent :
Dated : 16 Oct 2017 ORDER
JUSTICE V.K. JAIN (ORAL)
Late Smt. Jaswant Kaur who was the wife of the complainant No.1 and mother of complainant No.2 obtained a 'Generic Contingency Policy Schedule' from the petitioner, where-under, the sum named in the policy was payable in case of any mishap or accidental death of the insured. The case of the complainants is that on 26.6.2014, the deceased insured fell on the floor and got injured. A doctor practising in the village was called who declared her to be dead due to head injury. No post mortem, however, was conducted on the dead body of the deceased. The claim lodged by the complainants for payment in terms of the policy was repudiated vide letter dated 20.9.2014 which, to the extent it is relevant, reads as under:-
"On detailed scrutiny of the same, we find that the claim does not fall under the purview of the policy for reasons given below:-
Verification of the claim documents reveal aforesaid claimant has lodged claim to avail death benefit under policy. After scrutiny of documents there is no First Information Report(FIR) & No Post Mortem done, due to which exact cause of death cannot be ascertained. Hence the claim is not admissible under the policy as the accidental death of deceased is not confirmed."
2. Being aggrieved from the repudiation of the claim, the complaints approached the concerned State Commission by way of a complaint. Vide impugned order dated 10.4.2017, the State Commission allowed the complaint and directed the appellant to pay a sum of Rs.25 lakhs that being the sum assured as per the policy along with compensation quantified at Rs.50,000/- and the cost of litigation quantified at Rs.10,000/-.
2. It is contended by the learned counsel for the appellant that it was necessary for the family of the deceased to get a post mortem done on her body and submit the post mortem report to the insurer. According to him no benefit under the policy was payable if the post mortem was not conducted. In support of his contention, he relied upon clause 2(f) of the policy document under the heading 'Safeguard-Personal Accident Policy' which reads as under:-
"2) Making a claim If you meet with any Accidental Bodily Injury that may result in a claim, then as a condition precedent to our liability:
In case of your death, someone claiming on your behalf must inform us in writing immediately and send us a copy of the post mortem report within 14 days."
3. On the other hand in the repudiation letter dated 20.9.2014, the insurer referred to Condition D-4 of the policy which as per the repudiation letter, to the extent it is relevant reads as under:-
"f. In case of your death, someone claiming on your behalf must inform us in writing immediately and send us a copy of the post mortem (if performed) report within 30 days "note : Waiver of conditions (a) and (f) may be considered ......."
4. It would thus be seen that though the document relied upon by the learned counsel for the appellant which is available on page 74 of the paper-book, does require submission of a post mortem report, it is evident from the term as reproduced in the repudiation letter itself that the post mortem report had to be submitted only if the post mortem 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.
5. The next question which arises for consideration is as to whether the deceased had died due to an accident. It cannot be disputed and has not been disputed that if in fact someone accidentally falls in his/her house and dies, it will be an incidental death, entailing payment of the benefit available under the insurance policy. In order to prove that the deceased had died on account of an accidental fall, the complainants, besides filing their own affidavit by way of evidence, also filed the affidavit of one registered medical practitioner. Dr. Dharampal Sharma who expressly stated that he had examined Jaswant Kaur and found her dead due to catastrophic brain injuries by falling on the floor. There is no evidence of the appellant having even made a request for cross-examination of Dr. Dharampal Sharma. The learned counsel for the appellant submits that Dr. Dharampal Sharma was not a qualified doctor he having been issued a certificate by Board of Ayurvedic & Unani System of Medicine, Punjab & Chandigarh. I however, cannot accept the contention. The Board is authorised by law to issue certificate allowing a person to practise and it was on the strength of the certificate issued by the Board that Dr. Dharampal Sharma was practising in the village in which the death of the deceased happened. There is no evidence to even suggest that Dr. Dharampal Sharma was not qualified enough to verify the cause of death in an incident of this nature. No medical evidence was produced by the insurer to prove that Jaswant Kaur not had died due to catastrophic brain injuries due to falling on the floor.
6. The insurer engaged an investigator who reported that the deceased had died a natural death. I have perused the report submitted by the investigator. Admittedly, he was not present at the time the deceased died. No statement was recorded by him to prove that the deceased had died due to a cause other than falling in her house. In fact, this is the contention of the learned counsel for the appellant himself that no one was present in the house at the time the deceased is alleged to have fallen. In these circumstances, absolutely no reliance can be placed on the report of the investigator, the same being based on no evidence at all.
7. For the reasons stated hereinabove, I find no ground to interfere with the view taken by the State Commission. The appeal being devoid of any merit is hereby dismissed with no order as to costs.
8. The statutory amount deposited by the appellant shall be refunded to it after it has complied with the order passed by the State Commission.
......................J V.K. JAIN PRESIDING MEMBER