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NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DELHI
V.K. Jain, Presiding Member
Bajaj Allianz General Insurance Co. Ltd. and Ors. —Appellants
versus
Harpal Singh and Anr. —Respondents
First Appeal No.1516 of 2017
(Against the Order dated 10/04/2017 in Complaint No. 199/2014 of the State Commission Punjab)
Decided on 16.10.2017
For the Appellants:Mr. Pradeep Gaur and Mr. Amit Gaur, Advocates
IMPORTANT POINT
FIR and Post-Mortem report is not mandatory in all cases of accidental death.
Headnote:Consumer Protection Act, 1986—Sections 17, 19 and 21—Insurance—Generic Contingency Policy Schedule—Repudiation of accidental death claim on ground of lack of FIR and Post-Mortem report—State Commission allowed complaint and directed appellant to pay a sum of Rs.25 lakhs that being sum assured as per policy along with compensation quantified at Rs.50,000/- and cost of litigation quantified at Rs.10,000/-—Logically, if a person accidentally falls in his/her house and said accidental fall results in his/her death, a doctor will be called and he certifies cause of death, family members would not take his body for post mortem—In fact hospital may not even conduct post mortem on dead body of deceased in such a case—If in fact someone accidentally falls in his/her house and dies, it will be an incidental death entailing payment of benefit available under insurance policy—In order to prove that deceased had died on account of an accidental fall, complainants, besides filing their own affidavit by way of evidence, also filed affidavit of one registered medical practitioner—Absolutely no reliance can be placed on report of Investigator same being based on no evidence at all—No ground to interfere with view taken by State Commission—Appeal dismissed. (Paras 4 to 8)
Result: Appeal dismissed.
V.K. Jain, Presiding Member—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:
1. 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. Lo
