State Consumer Disputes Redressal Commission
The National Insurance Company ... vs B.Bharathamma on 23 March, 2026
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BEFORE THE TELANGANA STATE CONSUMER DISPUTES
REDRESSAL COMMISSION : HYDERABAD.
FA.NO.541 OF 2023 AGAINST ORDERS IN
CC.NO.55 OF 2020, DISTRICT CONSUMER COMMISSION,
NALGONDA
Between:
National Insurance Company Limited,
Regd & Head Office, 3, Middleton St,
Kolkata - 700 071 Rep. by its Regional Manager
Now rep. by its Regional Manager, Hyderabad
Regional Office, Hyderabad - 500 001.
......Appellant/Opposite Party
And
B.Bharathamma, W/o.Late B.Maisaiah,
Aged 60 years, Occ: Housewife,
R/o.D.No.2-59, Chandupatla (V),
Nakrekal (M), Nalgonda Dist.
PIN: 508211, Phone: 9948352162.
......Respondent/Complainant
Counsel for the Appellant/Opposite Party: M/s.G.N.Venkata Ramana
Counsel for the Respondent/Complainant: Notice served
QUORAM:
HON'BLE SMT.JUSTICE DR.G.RADHA RANI ......PRESIDENT
&
HON'BLE SMT.MEENA RAMANATHAN ......MEMBER (NON-JUDICIAL)
MONDAY, THE TWENTY THIRD DAY OF MARCH
TWO THOUSAND TWENTY SIX
******
Order: (Per Smt.Dr.G.Radha Rani, Hon'ble President)
1.This appeal is filed by the Opposite Party Insurance Company aggrieved by the orders of the District Consumer Disputes Redressal Commission, Nalgonda in CC.No.55/2020 dated 26.06.2023 wherein the complaint was allowed in part directing the Opposite Party to pay an amount of Rs.2,00,000/- towards Group Personal Accident Insurance amount and Rs.30,000/- towards compensation for mental agony and deficiency of service besides Rs.10,000/- towards costs of the 2 litigation within 30 days from the date of receipt of the order, failing which an interest @ 9% p.a. on Rs.2,00,000/- shall be paid by the Opposite Party to the Complainant till its realization.
2. For the sake of convenience, the parties are hereinafter referred as arrayed before the District Commission as Complainant and Opposite Party.
3. (a) The case of the Complainant was that, she was the wife and nominee of the deceased B.Maisaiah and her husband was a member of The Telangana Rastra Samithi Political Party (TRS). The TRS had provided a Group Personal Accident Insurance Scheme to their party members from the Opposite Party Insurance Company vide Master Policy No.604800421610000019 and assured an amount of Rs.2,00,000/- each for party member.
(b) On 01.06.2016 at about 17.00 hours, the deceased Maisaiah slipped from a Toddy Tree and fell down resulting which he sustained severe head injury and was shifted to Government Hospital, Nalgonda for treatment. Thereafter, the deceased Maisaiah was referred to Gandhi Hospital for better treatment and while undergoing treatment in Gandhi Hospital, the deceased Maisaiah succumbed due to injuries on 23.06.2016. The Police Nakrekal registered a case in Crime No.112/2016 under Section 174 of Cr.P.C. and took up the investigation. After death of the deceased, the Complainant approached the TRS, Telangana Bhavan, Hyderabad and submitted her claim intimation and necessary documents for settlement of Group Personal Accident claim of her husband Maisaiah. The TRS, Hyderabad sent the 3 claim intimation of Complainant to Opposite Party office for settlement of Group Personal Accident claim of deceased B.Maisaiah. After a gap of one year, on 15.09.2017, the Opposite Party sent a claim repudiation letter stating the reason that the claim was repudiated as per the exclusion clause under policy condition No.5.1 to 5.10. Vexed with the same, the Complainant approached the District Commission for legal remedy against the Opposite Party claiming that the Opposite Party failed to render service properly inspite of collecting premium from TRS party and that there was deficiency of service on their part and claimed Rs.2,00,000/- towards Group Personal Accident Claim amount, Rs.50,000/- towards mental agony and Rs.50,000/- towards costs of the complaint with interest @ 12 % p.a. from the date of repudiation of the claim on 15.09.2017.
4. The Opposite Party filed written version taking several pleas that the Complainant was not a Consumer as defined under Section 2 (d) of the Consumer Protection Act, the complaint would not come under the purview of Consumer Dispute as envisaged in Section 2(e) of the Consumer Protection Act, the District Commission had no jurisdiction to entertain the complaint. They were not aware that the Complainant was the wife of the deceased and called for strict proof of the same with documentary evidence. They contended that the deceased B.Maisaiah had not paid any insurance premium to their Company. The National Insurance Company Limited, Marathalli branch had issued Group Personal Accident Policy in favour of TRS valid from 10.04.2016 to 09.04.2017 subject to the terms, conditions, limitations, 4 definitions etc., for an amount of Rs.2,00,000/- as compensation for each individual covered under the list provided by the TRS party towards accidental death. The TRS was a necessary and proper party for proper disposal of the case. There was no contract between the deceased and the National Insurance Company Limited, as such, the complaint was not maintainable. The Complainant would need to submit the entire certified copies of the Police record and the medical record with regard to the treatment taken in Gandhi Hospital, Secunderabad. They further contended that as per their Company records, the claim of the deceased B.Maisaiah was repudiated as per policy condition No.5.1 to 5.10 and the same was intimated to TRS, Hyderabad vide letter dated 15.09.2017 on the ground that the deceased B.Maisaiah was under alcoholic intoxication while he was working and the same was a breach of policy condition. The Insurance Company repudiated the claim as per the policy conditions, as such there was no deficiency of service and negligence on the part of the Insurance Company and prayed to dismiss the complaint.
5. The Complainant filed her proof affidavit and got marked Ex.A1 to A5 in support of her contention.
Ex.A1 is the photocopy of the repudiation letter along with list of rejected claims.
Ex.A2 is the photocopy of the FIR in Crime No.112 of 2016 dated 23.06.2016 of P.S.Nakrekal.
Ex.A3 is the photocopy of the Inquest Report dated 24.06.2016.
Ex.A4 is the photocopy of the P.M.E. Report dated 24.06.2016.
Ex.A5 is the photocopy of the Aadhar Card of the Complainant.
The Opposite Party also got examined the Assistant Manager of the Insurance Company and got marked Ex.B1 to B3. Ex.B1 was the 5 attested copy of the Policy along with Terms and Conditions. Ex.B2 was the attested copy of the Death Summary of the deceased B.Maisaiah issued by Gandhi Hospital, Secunderabad dated 23.06.2016 and Ex.B3 was the attested copy of the repudiation letter along with list of rejected claims which was similar to Ex.A1.
6. On considering the material on record, the District Commission allowed the complaint in part as stated supra.
7. Aggrieved by the said order passed by the District Commission, the Opposite Party preferred this appeal contending that:
The order of the District Commission, Nalgonda was against the terms and conditions of the policy and against the rulings and judgments of the Hon'ble Apex Court. The death summary issued by the Medical Officer, Gandhi Hospital, Secunderabad dated 23.06.2016 would clearly show that the deceased was under alcoholic influence. The said document was submitted by the Complainant herself and the Insurance Company has marked as Ex.B2 before the District Commission.
As per the condition No.5.3 of GPA, any injury due to misuse or abuse of drugs/alcohol or use of intoxicating substance are excluded.
In the case of IFFCO Tokio General Insurance Company Limited Vs. Pearl Beverages Ltd., the Hon'ble Apex Court observed that the requirement of breath analyser test or 6 blood test under the Motor Vehicles Act was not necessary to refuse an insurance claim in the matter of drunken drive. The Medical Officer, Gandhi Hospital was an expert, as such the District Commission considering the Medical Officer as a third party was not correct. The Discharge Summary and the MLC record were submitted by the Complainant herself. The PME Report was prepared on 24.06.2016 and the accident occurred on 02.06.2016. As such there would be no scope of determining the cause of death as under alcoholic influence.
It was purely a case of Personal Accident Policy arising out of the contract and the insured/beneficiaries were bound by the terms and conditions of the policy;
and prayed to set aside the impugned order passed by the District Commission, Nalgonda.
8. Heard the learned counsel for the Appellant M/s.G.N. Venkata Ramana. There was no representation for Respondent since service of notice on 06.03.2024 in the appeal.
9. Now the point for consideration is:
Whether the order passed by the District Commission is in accordance with law and facts on record or whether the same is liable to be set aside, modified or interfered with in any manner?
10. Point:
A perusal of the record would disclose that the Complainant filed her proof affidavit stating that her husband B.Maisaiah was a Toddy Tapper and on 01.06.2016 at 17.00 hours, he accidentally 7 slipped from the Toddy Tree at Pedda Muthyalamma Temple, Chandupatla Village, sustained severe head injury and was shifted to Government hospital, Nalgonda for treatment and thereafter he was referred to Gandhi Hospital, Hyderabad and while undergoing treatment in Gandhi Hospital, succumbed to injuries on 23.06.2016. She filed the copy of the FIR and the complaint as Ex.A2. The complaint was lodged by the grandson of the deceased stating that his grandfather was a Toddy Tapper by profession and as part of his professional work, he climbed the Toddy Tree on 01.06.2016 and while getting down from the tree, accidentally fell down and sustained head injury and that he was admitted in the Government Hospital, Nalgonda and from there taken to the Gandhi Hospital, Secunderabad and died on 23.06.2016 at 12.00 hours. Ex.A3, the Inquest Report also would disclose that the deceased sustained head injury due to accidental fall from a Toddy Tree and that he was a Toddy Tapper by profession as per the statements of the witnesses. Ex.A4, the PME Report would disclose the cause of death was due to complications of head injury. Ex.A1 is the repudiation letter given by the Insurance Company along with the list of rejected claims. The name of the deceased Buchala Maisaiah of Nalgonda and his membership number as 6229072 and that the claim was rejected due to alcoholic was recorded in the list. As per Ex.A1, it only stated that the claim was repudiated as per the exclusion clause under policy condition No.5.1 to 5.10.
No specific reason was mentioned in Ex.A1.
11. However, the Assistant Manager of the Insurance Company examined on behalf of the Insurance Company stated that the 8 claim was repudiated on the ground that the deceased Buchala Maisaiah was under alcoholic intoxication and as per the policy condition No.5.3, any injury due to misuse or abuse of drugs/alcohol or use of intoxicating substances was excluded from coverage and due to breach of policy condition by the insured, the claim was repudiated.
12. The terms and conditions of the policy along with the policy document were marked as Ex.B1. Clause 5 of the terms and conditions of the policy deals with exclusions. It covers several reasons under which claim can be repudiated bearing from 5.1 to 5.10. No specific reason was given under Ex.A1. However, the list annexed to Ex.A1 and the affidavit of the officer examined on behalf of the Insurance Company would state that the claim was repudiated on the specific ground mentioned under 5.3 due to drug/alcohol abuse and any injury due to misuse or abuse of drugs/alcohol or use of intoxicating substances was excluded.
13. The burden lies on the Insurance Company when it repudiates the claim based on an exclusion clause to prove that the case squarely falls within the exclusion. The Insurance Company must prove the breach of the policy conditions. Exclusion clauses in insurance policies must be strictly construed and proved by insurer. The insurer must establish the breach of policy conditions with cogent evidence before denying liability. But the only evidence relied by the Opposite Party Insurance Company for denying the liability was based upon Ex.B2, the Death Summary of the deceased B.Maisaiah issued by Gandhi Hospital, 9 Secunderabad dated 23.06.2016 wherein under the column brief history of case, it was recorded that "alleged to have sustained head injury due to accidental fall from tree on 01.06.2016 at 5.00 P.M. near Chandupatla under alcoholic influence." The reference in the death summary that the deceased was under the influence of alcohol appears only in the history portion of the medical record. Such history is normally recorded based on information given by attendants or relatives. It does not constitute a clinical finding of the doctor unless supported by medical examination or laboratory testing. No blood alcohol test or toxicology report was filed by the Opposite Party to prove that the deceased was under the influence of alcohol. No medical record of the deceased at Government Hospital, Nalgonda was filed to prove the history of the case given by the attendants at the time of the admission of the deceased at the said hospital. The accident was said to have occurred on 01.06.2016 at 5.00 P.M. However, the deceased was admitted in Gandhi Hospital on 02.06.2016 at 9.18 P.M. It was also recorded in the brief history of the case itself that the patient was in unconscious state and he was brought by his wife Bharathamma i.e., the Complainant herein. As such the information was given by the attendants but not based upon the clinical finding of the doctor. Except relying upon the entry in the medical record, the insurer had not produced any independent or scientific evidence to establish that the deceased was intoxicated at the time of the incident. The post mortem report does not indicate any intoxication by the deceased. Ex.B2 is not a conclusive proof to hold that the deceased was intoxicated.
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14. Even assuming that the deceased had consumed alcohol, the insurer must further establish that the accident occurred because of intoxication and that there was a proximate causal connection between intoxication and the accident. In the present case, the deceased was a Toddy Tapper by occupation, whose work necessarily involves climbing toddy trees. A fall from a tree by performing such work cannot automatically be attributed to intoxication merely on the basis of a statement recorded in the medical history. The material on record would show that the deceased sustained head injury due to fall from the Toddy Tree and succumbed to those injuries after treatment for about 21 days. Therefore, the proximate cause of death was accidental fall and consequent head injury. Unless it is proved that the accident itself occurred due to intoxication falling within the policy exclusion, the insurer cannot avoid liability.
15. Since the repudiation was made without sufficient proof that the deceased was intoxicated and without establishing that the case falls within the exclusion clause, the repudiation cannot be sustained. Such unjustified denial of a legitimate claim amounts to deficiency in service on the part of the insurer. As such, we do not find any error in the judgment of the District Commission in allowing the claim and holding the Opposite Party Insurance Company liable to pay the Group Personal Accident Insurance amount to the Complainant considering the repudiation as deficiency of service.
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16. In the result, the appeal is dismissed confirming the judgment of the District Commission, Nalgonda in CC.No.55/2020 dated 26.06.2023. The Respondent/Complainant is permitted to withdraw the statutory deposit made by the Appellant at the time of filing the appeal along with accrued interest, towards part satisfaction, after lapse of appeal time.
Dictated to the Stenographer, transcribed and typed by her, corrected by me and pronounced by us in the open Court on this the 23rd day of March, 2026.
Sd/- Sd/-
PRESIDENT MEMBER-NJ
Dt: 23.03.2026
UC*