State Consumer Disputes Redressal Commission
The Oriental Insurance Co. Ltd vs Managing Director, Shri Vitthal ... on 4 January, 2013
BEFORE THE HON'BLE STATE CONSUMER DISPUTES REDRESSAL
BEFORE THE HON'BLE STATE CONSUMER DISPUTES
REDRESSAL
COMMISSION, MAHARASHTRA, MUMBAI
First Appeal No. A/11/285
(Arisen out of Order Dated 07/12/2010 in Case
No. 467/09 of District Solapur)
1. THE ORIENTAL
INSURANCE CO. LTD.,
GANDHI CHOWK, AT PST
AKLUJ, TAL. MALSHIRAS, SOLAPUR.
...........Appellant(s)
Versus
1. MANAGING DIRECTOR,
SHRI VITTHAL SAHAKARI SAKHAR KARKHANA LTD.
VENU NAGAR, TAL.
PANDHARPUR,
SOLAPUR.
2. SMT. PARVATI
SHANKAR GANDULE,
R/AT. RANJANI, TAL.
PANDHARPUR,
SOLAPUR.
...........Respondent(s)
BEFORE:
HON'BLE Mr. S.R.
Khanzode PRESIDING MEMBER
HON'BLE MR. Dhanraj
Khamatkar Member
HON'BLE MR. Narendra
Kawde MEMBER
PRESENT:
Adv.R.P.Bafna
......for the Appellant
Adv.A.G.Koandikonda
......for the
Respondent
ORDER :- (Per Shri Narendra Kawde, Honble Member ) (1) This appeal takes an exception to an order dated 07/12/2010 in Consumer Complaint No.467/09, (Managing Director, Shri Vitthal Sahakari Sakhar Kharkhana Ltd. & ors. Vs. Manager, The Oriental Insurance Co.Ltd.), passed by District Consumer Disputes Redressal Forum, Solapur (District Forum in short).
District Forum allowed the consumer complaint filed by the present respondents/original complainants for settling the insurance claim directed to the appellant/original opponent to pay an amount of `1 lakh to the respondent No.2 together with interest @9% p.a. effective from 05/09/2009 within a period of 30 days. District Forum further directed to pay costs of `1,000/- and to pay 12% p.a. interest on the amount payable for non-compliance of the order within the subscribed period. Aggrieved and dissatisfied thereby, the appellant/original opponent preferred this appeal stating that as per the terms and conditions of the policy, the complaint was barred by limitation as was not filed within 12 calendar months from the date of disclaiming liability i.e.30/03/2006 amongst other grounds.
(2) Heard learned advocate for the parties. Perused record. Admitted facts are that :-
The respondent No.1 (complainant No.1) subscribed to Group Janata Personal Accident Insurance Policy bearing No.16263/000/375/06/1898 for the period effective from 11/03/2006 to 10/03/2007 to extend insurance cover to its members. During the validity of the insurance period, husband of respondent No.2 (complainant No.2) died on 22/10/2006. Intimation of death and claim was preferred immediately.
However, required papers together with documents were not submitted by the respondents, though informed by Registered Post Acknowledgement Due on 13/03/2007. The appellant/opponent insurance company repudiated the insurance claim on 30/03/2007 on multiple reasons stating that the death of the insured occurred due to Tuberculosis/due to slipping down/beaten by bullock. Aggrieved by the repudiation, the respondents/original complainants filed consumer complaint before the District Forum, Solapur which came to be allowed on the terms referred to above (supra).
(3) The learned advocate of the appellant/opponent insurance company submitted that the insured died natural death due to gangrene of scrotum with pulmonary tuberculosis as per the post mortem report and therefore this event leading to death of the insured is not covered under the insurance policy.
Further, it was pleaded that the insurance claim was foreclosed as it was not filed within 12 calendar months from the date of disclaimer. Such a disclaimer was intimated by registered post acknowledgement due on 30/03/2007 and the consumer complaint came to be filed on 05/09/2009 (after 12 months). This contention of the appellant/opponent has been considered by the District Forum appropriately and held that the condition incorporated to foreclose claim as incorporated in the terms and conditions of the policy was part of Janata Personal Accident Insurance Policy whereas the subject policy issued covering the insurance to the insured i.e. husband of the respondent No.2 (complainant No.2) was under
Group Janata Personal Accident Insurance Policy. Such a policy condition of foreclosing or disclaiming the insurance claim has not been incorporated in the policy issued in the case on hand as observed by District Forum. Secondly, the police record i.e. statement of enquiries of police available on record i.e. statements of Arun, Suresh and Ramchandra-three sons of the deceased insured recorded during investigation process of the police revealed that the insured sustained injury at sensitive part (scrotum - not mentioned) of the body while going for answering natures call.
Deceased insured was admitted on 12/10/2006 and operation was carried out. However, died on 22/10/2006. As rightly held by the District Forum, there is no rebuttal to the hospitalization and treatment taken by the insured and subsequent death due to reasons narrated in the finding at the time of post mortem.
The post mortem report concluded cause of death as gangrene of scrotum with pulmonary tuberculosis.
Moreover, as can be seen from the record available before us, the appellant/opponent insurance company failed to adduce any documentary evidence to establish that the insured died only due to pulmonary tuberculosis, especially when the cause of death was recorded as gangrene of scrotum with pulmonary tuberculosis.
District Forum has rightly observed that the accident due to slipping down occurred and insured was hospitalized for treatment for the injury sustained to the private part of the deceased. The hospitalization continued and operation was carried out. However, the insured expired on 22/10/2006 i.e. during the course of treatment. District Forum further has rightly relied on the case law 200 CTJ 1145 (CP) (NCDRC) - (Life Insurance Corporation of India Vs. Hiralal) where the National Commission has observed that An accident can be either a sudden happening or a slowly evolving process like percolation of harmful substances affecting human body. In the instant case on hand, the death occurred almost after a week from the date of accidental slipping down leading to hospitalization immediately and operation.
(4) The contention of the appellant/opponent insurance company that the claim is foreclosed or appellant/opponent insurance companys liability to decide claim ceased in view of letter dated 30/03/2007 is not acceptable as letter dated 22/02/2008 issued by the opponent states that the claim was kept alive requesting for submission of required documents in the pending claim of the insured. Moreover, there is no penal provision in terms and conditions to endow upon powers to forfeit claim in case requirements not submitted in prescribed period.
(5) District Forum has considered all the aspects of the case in detail. We, therefore, do not find it necessary to invoke appellant jurisdiction of the Commission and take different view than what has been taken by District Forum. We hold accordingly and pass the following order.
ORDER (1) Appeal stands dismissed.
(2) Under the given circumstances, parties to bear their own costs.
(3) Inform the parties accordingly.
Pronounced on 04th January, 2013.
[HON'BLE Mr. S.R. Khanzode] PRESIDING MEMBER [HON'BLE MR. Dhanraj Khamatkar] MEMBER [HON'BLE MR. Narendra Kawde] MEMBER