National Consumer Disputes Redressal
Oriental Insurance Co. Ltd. vs Tara on 2 March, 2015
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI REVISION PETITION NO. 3630 OF 2013 (Against the Order dated 11/07/2013 in Appeal No. 05/2012 of the State Commission Rajasthan) 1. ORIENTAL INSURANCE CO. LTD. INSIDE AJMERI GATE, BEAWER, DISTRICT : AJMER RAJASTHAN ...........Petitioner(s) Versus 1. TARA W/O LATE RAMESH KUMAR, BY CASTE MALI, R/O 17, SHIV COLONY, POLICE LINES PALI RAJASTHAN ...........Respondent(s)
BEFORE: HON'BLE MR. JUSTICE AJIT BHARIHOKE, PRESIDING MEMBER HON'BLE MRS. REKHA GUPTA, MEMBER For the Petitioner : Mr.Vishnu Mehra, Advocate For the Respondent : already ex-parte Dated : 02 Mar 2015 ORDER JUSTICE AJIT BHARIHOKE, PRESIDING MEMBER (ORAL) This revision petition is directed against the order of Rajasthan State Consumer Disputes Redressal Commission, Circuit Bench at Jodhpur (in short, "State Commission") dated 11.7.2013 whereby State Commission allowed the appeal No.05/2012 of the respondent/complainant and set aside the order of the District forum and directed the petitioner/opposite party to pay a sum of Rs.1 lakh with interest @ 9% thereon from the date of filing of the complaint till its realization of the amount and also to pay litigation cost of Rs.5,000/-.
2. Briefly put facts relevant for the disposal of the revision petition are that the respondent/complainant filed a consumer complaint in District Forum, Pali alleging that her late husband, Ramesh Kumar obtained Janta Personal Accident Insurance Cover for sum assured of Rs.1 lakh on payment of premium of Rs.240/-. The insurance cover was effective from 19.05.2006 till mid night of 18.05.2011. It is the case of the petitioner that on 25.06.2006 the car of the insured collided with a train at the railway crossing resulting injuries on his backbone, chest and left thigh. The insured remained under treatment for those injuries till his death on 26.07.2007. It is further alleged that because of death of her husband, the complainant went into shock. When the complainant recovered from the shock, she checked the documents of her husband and came across the cover note. Thus, the complainant submitted the insurance claim. The petitioner / opposite party, however vide letter dated 15.07.2008 repudiated the claim. It is alleged by the complainant that insurance policy was never provided by the petitioner opposite party and that repudiation of claim amounts to deficiency in service.
3. The petitioner opposite party resisted the complaint. It was alleged that the complaint was rightly repudiated because no proof was produced by the respondent complainant that cause of death of the injured was the injuries suffered in the accident. The petitioner also took the plea that repudiation was justified in view of the terms and conditions of the insurance policy.
4. District Forum on consideration of the pleadings and the evidence took the view that there was no deficiency in service on the part of the petitioner/opposite party and dismissed the complaint.
5. Being aggrieved by the order of the District Forum, respondent/complainant filed an appeal before the State Commission which was allowed and directed the respondent as noted above.
6. Learned counsel for the petitioner, Shri Vishnu Mehra has contended that the impugned order of the State Commission is not sustainable for the reason that the State Commission has committed a grave error in failing to appreciate that the complainant failed to file insurance claim within stipulated period of one month from the date of incident. It is also contended that otherwise also, there is no evidence to show that the death of the insured took place as a result of the injury sustained in the accident.
7. We have considered the submissions made on behalf of the petitioner and perused the record particularly the terms and conditions applicable to the Janta Personal Accident Insurance policy. The relevant provisions of this policy describing the insurance cover provided to the insured reads as under:
"NOW THE POLICY WITNESSETH that subject to the terms exclusions definitions and conditions contained therein or endorsed or otherwise expressed hereon the company will indemnify the insured as herein mentioned.
If the insured shall sustain any bodily injury resulting solely and directly from Accident caused by outward, violent and visible means and/or death/disablement due to sterilization risk the company shall pay to the insured the sum hereinafter set forth that is to say If such injury shall within twelve calendar months of its occurrence be the sole and direct cause of the death of the insured the capital sum insured stated in the schedule. The amount payable under this clause shall be paid to the nominee shown in the schedule.
If such injury shall within twelve calendar months of its occurrence be the sole and direct cause of the total and irrecoverable loss of sight of both eyes or total and irrecoverable loss of use of two hands or two feet or of one hand and one foot or of such loss of sight of one eye and such loss of use of one hand or foot, the capital sum insured stated in the schedule hereto :
If such injury shall within calendar months of its occurrence be the sole and direct cause of the total and irrecoverable loss of sight of one eye or total and irrecoverable loss of use of a hand or a foot fifty percent of the capital sum insured stated in the schedule hereto.
If such injury shall within twelve calendar months of its occurrence be the sole and direct cause of permanently totally and absolutely disabling the insured from engaging being occupied with or giving attention to pay employment or occupation of any description whatsoever the capital sum insured stated in the schedule."
8. On reading of the above, it is clear that in a death case, the insured shall get the policy amount provided the death is caused by a bodily injury / injuries resulting from an accident caused by outward, violent and visible means provided such injury results in death within 12 months of its occurrence and is sole and direct cause of the death of the insured. Thus, in order to succeed in this claim, the complainant was required to show that the insured died because of the injury sustained in the accident within 12 months of the sustaining the injury. From the pleadings, it is evident that insured Ramesh Kumar sustained injuries in an accident on 25.06.2006 and he died on 6.07.2007 i.e. after the expiry of period of 12 months. Therefore, in view of the above noted covenant of the insurance policy, the insurance company was justified in repudiating the claim.
9. Further, condition no.2 of the insurance policy reads as under:
"Proof satisfactory to the company shall be furnished of all matters upon which a claim is based. Any medical or other agent of the company shall be allowed to examine the person of the insured on the occasion any alleged injury or disablement when and so often as the same may reasonably be required on behalf of the company and in the event of death to make a post mortem examination of the body of the insured and such evidence as the company may from time to time require (including a post mortem examination, if necessary) shall be furnished within the space of fourteen days after demand in writing and in the event of a claim in respect of loss of sight the insured shall undergo at the insurers expense such operation or treatment as the company may reasonably deem desirable. Provided that in case of valid claim arising under sub-clause (a), (b), (c.) or (d) all sums payable hereunder shall be payable only on the delivery of this policy cancelled and discharge."
10. On reading of the above, it is clear that complainant in order to succeed was under obligation to prove that cause of death of the insured was the injuries sustained in the unfortunate accident. Post mortem report which could have proved the cause of death has not been produced. Even otherwise no cogent evidence has been produced by the complainant to establish that death of her husband was the direct result of injuries sustained in the accident. Thus, in view of the above condition in the insurance contract, petitioner opposite party was justified in repudiating the claim.
11. Respondent in her complaint has pleaded that only cover note was given to the insured and the terms and conditions of the insurance policy were not supplied. This version of the complainant is not reliable for the reason that stand of the complainant in para 5 of the complaint is that she came across cover note pertaining to the insurance of her husband when she was looking the documents of her husband after the death. From this, it can be safely inferred that insured had not even told the respondent complainant hat he had taken the insurance cover. That being the case, the complainant could not have any knowledge whether or not her husband had received the terms and conditions of the insurance policy. It appears that this plea that has been taken on an after-thought in order to wriggle out of condition no.1 of the insurance contract which reads as under:
"Upon the happening of any event which may give rise to a claim under this policy the insured shall forthwith give notice thereof at the company unless reasonable cause is shown the insured should, within one calendar month after the event which may give rise to claim under the policy give written notice of the company with full particulars of the claim".
12. The State Commission while reversing the order of the District Forum has totally ignored the aforesaid aspects of the case. Therefore, impugned order cannot be sustained.
13. In view of the discussion above, we allow the revision petition; set aside the impugned order and dismiss the complaint.
......................J AJIT BHARIHOKE PRESIDING MEMBER ...................... REKHA GUPTA MEMBER