National Consumer Disputes Redressal
Saryuben B Shah vs Life Insurance Corporation Of India on 4 March, 2016
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI REVISION PETITION NO. 2462 OF 2014 (Against the Order dated 14/02/2014 in Appeal No. 926/2010 of the State Commission Gujarat) 1. SARYUBEN B SHAH "GOVIND", 26, MILL PARA, RAJKOT-360 002 GUJARAT ...........Petitioner(s) Versus 1. LIFE INSURANCE CORPORATION OF INDIA HAVING ITS BRANCH OFFICE AT, JEEVAN PRAKASH BUILDING, RELIEF ROAD, THROUGH ITS MANAGER AHMEDABAD - 380 001 GUJARAT ...........Respondent(s)
BEFORE: HON'BLE MRS. M. SHREESHA, PRESIDING MEMBER
For the Petitioner : Ms. Sushila Ram, Mr. Satish Kumar and
Mr. Sahil Asthana, Advocates For the Respondent : MR. RAJESH K. GUPTA
Dated : 04 Mar 2016 ORDER
Challenge in this Revision Petition under Section 21 (b) of the Consumer Protection Act, 1986 (for short "the Act") is to the order, dated -2- 14.02.2014, passed by the Gujarati State Consumer Disputes Redressal Commission at Ahmedabad (for short "The State Commission") in Dispute no.926/2010. By the impugned order, the State Commission allowed the Appeal preferred by the Insurance Company and set aside the order of the District Forum.
The brief facts as set out in the Complaint are that the Complainant's husband Dr. B. P.Shah was holding the following policies with the Opposite Party Insurance Company:-
Fifteen Year Money Back Policy with Profits (With Accident Benefit) of Rs.50,000/- bearing Policy No.811128809 for the period from 28/03/1991 to 28/03/2006.
Fifteen Year Money Back Policy with Profits (With Accident Benefit) of Rs.50,000/- bearing Policy No.811137832 for the period from 28/03/1992 to 28/03/2007.
Endowment Assurance Policy with Profits (With Accident Benefit) of Rs.1,00,000/- bearing Policy No.811149058 for the period from 28/05/1993 to 28/05/2008.
Endowment Assurance Policy with Profits (With Accident Benefit) of Rs.50,000/- bearing Policy No.811151192 for the period from 28/10/1993 to 28/10/2008.
Twelve Year Jeevan Sanchay Plan without Profits/with Accident Benefit of Rs.1,00,000/- bearing Policy No.811190454 for the period from 09/10/1997 to 09/10/2008.
Jeevan Anand (with Profits) with Accident Benefit of Rs.2,00,000/- bearing policy No.812410567 for the period from 23/04/2002 to 23/04/2016.
The Insured was a practising Doctor and had fallen down in the lobby from the stairs on 24.12.2003 and received injuries. He was shifted to Madhuram Hospital where he was treated for his accidental injuries. The Complainant submitted that her husband's X-rays showed fractures for which he was treated and discharged on 06.01.2004 and was advised bedrest. His condition deteriorated and subsequently, he was shifted to Prarthana Hospital where he was treated by Dr.Vidyut Shah who diagnosed the injured as suffering from Multi Trauma with Septicaemia and Acute Renal Failure. Thereafter, on the advice of the Nephrologists, the injured was shifted to Nephrological Care in Harilal Jechand Doshi Sarvajanik Hospital where Dr. Kamal R. Doshi treated the patient and diagnosed him to be suffering from Upper GI Bleeding with Anaemia and Hypoprotienaemia; with Septicaemia; Left Renal Calculus; Hydronephrosis; and Hydroureter; Uareamia with Acidosis. The Complainant averred that her husband was admitted there on 12.01.2004 and had expired on 15.01.2004. The Post Mortem examination was not advised by the Doctor as it was clinically established that the death was caused on account of accidental injuries which resulted in Multiple Trauma, Septicaemia and Acute Renal Failure.
The Complainant pleaded that the Insurance Company paid her the single benefit of Rs.7,90,950/- but did not settle the double accident benefit on the ground that the death was not due to accidental injuries.-4-
The Complainant pleaded that despite correspondence and several requests, the Opposite Party did not settle the double accident benefit as per the terms of the contract. The deceased had also given a statement on 01.01.2004 to the police which established the accident and the injuries. Hence, the Complaint seeking direction to the Opposite Party to pay the double accident benefit of all the policies totalling to Rs.5,50,000/- with interest @ 18% p.a., compensation of Rs.50,000/- and costs of Rs.10,000/-.
The Opposite Party filed their reply admitting the issuance of the policies and averred that only the double accident benefit was not paid as the accidental death was not established by way of any documentary evidence. It is pleaded that the deceased had given a statement to the police on 01.01.2004 in which he had submitted that he was injured in both hands, left leg and jaw and he had never mentioned that he was also injured on the stomach or on the kidneys on account of the fall. Even the Discharge Summary dtd.06.01.2004 shows that he was discharged in good condition. The Opposite Party had written a letter to Dr. Ujjval Hathi on 09.08.2004 and asked him in detail about the treatment and condition of the deceased to which Dr. Ujjval Hathi certified as follows:-5-
(3) He underwent X-ray examination for ........ He was also investigated for blood chemistry and Haemoglobin which was within normal limits including blood ura.... We did not have a case to suspect damage to kidney.
(4) Patient was cathererized on 25.12.203 but no adversity was noted.
(5) During the stay he did not complain regarding kidney or urine problem.
(6) The patient was recovering at the time of discharge and was on oral diet, oral supportive drugs.
Dr. Vidyut Shah in his Medical Certificate dtd. 28.04.2004 certified that Sh. B. P. Shah, the insured, was admitted in his Hospital with diagnosis of Multiple Trauma and Septicaemia. During the course of illness, he developed Acute Renal Failure and the opinion of a Nephrologist was asked for.
The Opposite Party pleaded that the Insured was admitted to Dr.Vipul Shah's Hospital on 08.01.2004 and later, Doshi Hospital on 12.01.2004 and Dr. Manr had visited the deceased at Dr. Vipul Shah's Hospital and opined that there was nothing for orthopaedic treatment or surgery. The Opposite Party relying on the Certificate given by H. J. Doshi on 29.09.2004 that the patient had upper bleeding anaemia with hypoproteinaemia, pleaded that the deceased suffered Renal complications due to collection of urine in Renal track and therefore, their repudiation of the double accidental benefit is justified.
-6-The District forum based on the evidence adduced, allowed the Complaint directing the Opposite Party to pay Rs.5 Lac with interest @ 9% p.a. from the date of filing of the Complaint till the date of realization together with compensation of Rs.10,000/- and costs of Rs.2,000/-.
Aggrieved by the said order, the Opposite Party Insurance Company preferred an Appeal before the State Commission. The State Commission while allowing the Appeal observed as follows:
"In the present case, it is not proved that the death was caused due to the injury and the exact cause of death has not been declared and so the above case does not help the applicant, and so the arguments of the above case are not accepted. Apart from this, the respondent applicant has presented several other decisions, but she has not given any proper reason for the same and has not proved that they had any direct relation with the present case and the death of the deceased insured was caused after bone fractures in his leg and while his treatment was going on Previous to that for conditions of hypotension septicaemia and renal failure and kidney stone and he died about 22 days after the incident and the cause of his death is not proved by any treatment or by an affidavit sworn by doctors treating him, and so the decision of the defect in service by L.I.C. held by the District Consumer forum remains unproved. Moreover, he was injured due to falling down and treatment for this was going on for 22 days and together with this the treatment for hypotension septicaemia and kidney was also going on but in absence of P.M. note, the exact cause of his death remains unproved and specifically, even though he was seriously injured on the legs, accidental death is not proved for the purpose of giving double accident benefit and so it is resolved to accept the representations made by the appellant party and to consider -7- their points in a positive manner and to cancel the judgment at the District Consumer Forum.
Heard Counsel for both the parties.
Learned Counsel for the Petitioner/Complainant submitted that it is only on account of accidental fall on 24.12.2003 that the injuries had occurred which necessitated the admission of the insured in the Madhuram Hospital where he was treated for multiple fractures and was discharged on 06.01.2004. It is the Petitioner's case that after discharge, the injured had developed breathlessness, chills and high fever, for which treatment he was shifted on 08.01.2004 to Prarthana Hospital.
It is not in dispute that the treating Doctor Vidyut Shah had suggested that a Nephrologist should see the injured as he was suffering from symptoms of Septicaemia and Acute Renal Failure. Hence, the patient was shifted to H. J. Doshi Hospital for further treatment on 12.01.2004 and ultimately expired on 15.01.2004. Learned Counsel for the Respondent Insurance Company submitted that the injured died after 22 days after the fall and there is no direct nexus between the accident and the death of the injured.-8-
The affidavit of the treating Doctor Kamal R. Doshi reads as follows:
That I had gone through the objections and Witten Statement dtd. 20/03/2006 filed by the Opponent, Life Insurance Corporation of India, Rajkot and Affidavit dtd. 16/05/2006 of Shri Ashwin Prabhulal Adhvaryu, Manager (Legal), Divisional office, life Insurance corporation of India , Rajkot. That I am sorry to state that they had wrongly mis-interpreted the Medical Certificate issued by me and so there had arisen a need to file this Affidavit for further clarifications which may kindly be considered as under:-
A ) That deceased B. P. Shah had got multiple fractures due to self accidental fall at his home and due to it he had multiple fractures and blood loss which in turn had created hypotension. That the patient was admitted and operated at Madhuram Hospital, Rajkot by Dr. Maru on dtd 24/12/2003. After discharge from Madhuram Hospital, Rajkot there was a need to admit him under Dr. Vidyut Shah for Anaemia, Uraemia and Septicaemia and after that the patient was referred to H. J. Doshi Hospital for further management.
B) That the deceased Dr. B P. Shah was treated with the Antibiotics, I/v Fluids, Blood Transfusion, Coagulants and Supportive Therapy which clearly suggests that there was a Medicinal line of Treatment in which there is no surgery.
C) That it is absolutely not true that the deceased B P. Shah had suffered the Renal Complications i.e. Acute Renal failure due to kidney stone. Further that Dr. Sanjay popat's (Urologist) opinion was taken for -9- Renal Stone and according to his opinion small doubtful stone in ureter and renal stone is not the cause of impaired renal function and other kidney was functioning normally.
d) In this case, there was Hypotension with Fever which indicated Septicaemia which was due to Multiple Trauma which had turned into Pre-Renal Failure and that had deteriorate and damaged the Kidney Function and this all had ultimately caused Renal Failure which had caused the death of the deceased. That every problem had only and only started because of the Self Accidental Fall and that had ultimately caused the death of the deceased.
e) That there was Acute Renal Failure and not the Chronic Renal Failure. The Acute Renal Failure happens within the short span of period which can be 6 days to 6 weeks and so there was Renal Deterioration and then Failure within the short period of span. That in fact there was no Chronic Renal Failure as it takes months and years and the patient should have a symptomatic history and here in this case there was no any history of the same. Dr. Praful Gajjar's (Nephrologist) was taking care of renal failure. He had certified that the opposite kidney function was normal and the renal failure was not due to the small stone.
f) That the death of the deceased B. P. Shah has occurred solely directly and independently of all other causes i.e. septicaemia, acute renal failure, anaemia. Further that renal stone was the coincidental finding and was not the cause of death and that cause of death is due to Self Accidental Fall. That injury due to fall are Accidental Injury and death resulting from it is Accidental death. That as the Cause of Death was singularised and so the Post Mortem was not advised. That in fact there is a nexus between the death and the injuries suffered.
That the above said facts are true and correct to the best of my knowledge and belief which I do declare and affirm it on oath.
-10-The aforementioned affidavit given by the treating Doctor clearly establishes that the death of the insured was only on account of the accidental fall and that Septicaemia and Acute Renal Failure all occurred on account of the injuries and the finding of the Renal stone is only coincidental. In the light of this affidavit, the contention of the Respondent Insurance Company that there were no injuries to the kidney or stomach and injuries were only to the hands and legs, is unsustainable. The Insurance Company has placed reliance on the Certificate issued by Dr. Vidya Shah in which he had stated that at that point of time, no orthopaedic treatment or surgery was noted i.e. 08.01.2004. In the very same Certificate, the Doctor had stated that the injured was admitted on 08.01.2004 with Septicaemia, infection and three Renal deceases and therefore, the opinion of Nephrologist was sought for. Merely because he stated that no orthopaedic treatment was needed at that point of time, it cannot be construed that the accidental injuries did not have any nexus with the occurrence of Septicaemia. The Hon'ble Supreme Court in New India Assurance Company Limited vs. Zuari Industries Limited, (2009) (9) SCC 70 held as under:
"that the proximate cause is not the cause which is nearest in time or place but the active and efficient cause that sets in motion a train or chain of events which brings about the ultimate result -11- without the intervention of any other force working from an independent source. (Page 7, Para 14) The expression "proximate cause" is defined in the 5th Edn. of Black's Law Dictionary as under:
"Proximate cause" - that which, in a natural and continuous sequence, unbroken by any efficient intervening cause, produces injury and without which the result would not have occurred.
The Hospital treatment record shows Multiple Trauma, Septicaemia and Acute Renal Failure which all arose on account of accidental injuries as certified by the treating Doctor himself. In view of this evidence on record the repudiation of the Insurance Company with respect to double accidental benefit is totally unjustified.
For all the abovementioned reasons, the Revision Petition is allowed and the order of the State Commission is set aside affirming the order of the District Forum which has allowed the accidental death benefit and rightly limited it to Rs.5 Lakhs as per clause 10 (b) of the terms and conditions of the policy. The direction given by the District Forum with respect to the death benefit amount, interest, compensation and costs is confirmed.
...................... M. SHREESHA PRESIDING MEMBER