Insurance claims for accidental death require strict adherence to policy definitions. Claimants bear the burden of proving that death resulted from external, violent, and visible means through cogent medical evidence, such as post-mortem reports, rather than relying on non-medical documentation.

ORDER

Present appeal is preferred against the order dated 20.12.2023 of learned District Commission, Chamba, H.P. in consumer complaint No.23/2022 titled Virender Kumar Vs. The Religare, Health Insurance Company Ltd. & Anr. whereby the complaint filed by the complainant was allowed.

Brief facts of the Case:

2. Briefly, case of the complainant is that father of the complainant Sh. Narain Singh (since deceased) during his life time had taken finance of Rs.5.00 lac under the KCC scheme against his landed property from the opposite party No.2/Himachal Pradesh Gramin Bank and the opposite party No.2/Himachal Pradesh Gramin Bank provided Health Insurance Policy bearing No.1483126 from the opposite party No.1/insurance company in the name of Narain Singh, which was valid from 07.09.2019 to 06.09.2022. During the existence of the said policy, father of the complainant Narain Singh died due to sudden fall in bathroom who had sustained head injuries. After death of Narain Singh, the complainant submitted all necessary documents to the opposite parties, but they lingered on the matter on one pretext or the other and are not interested to pay the claim on account of death of father of the complainant. Hence, the present complaint.

3. The complaint was contested by the opposite parties by filing separate replies. The opposite party No.1/Insurance company in its reply has stated that they issued Group health Insurance policy No.13039789 to group policy holder Himachal Pradesh Gramin Bank thereby covering its customers i.e. Narain Singh (now deceased) vide certificate of insurance No.1483126. The said policy was effective w.e.f. 07.09.2019 to 06.09.2022 for a sum of Rs.10,00,000/-. As per the terms and conditions of the policy, benefits are provided to the nominee of the insured when the injury or death occurs due to accidental reason and not otherwise. As per the claim form, insured died due to slipping in washroom which is not an accident and as such insured was covered under the policy in question. A prayer for dismissal of complaint was made.

4. The opposite party No.2/Bank in its reply has stated that on receipt of death claim, the opposite party No.2/Bank contacted the opposite party No.1/Insurance company, who told them to submit Post Mortem Report, FIR/panchnama, death certificate and legal heir certificate. However, the complainant only submitted death certificate, legal heir certificate and report of the then Pradhan. The opposite party No.2/Bank sent all the said documents to opposite party No.1/Insurance company. A prayer for dismissal of complaint was made.

5. The complainant filed rejoinder denying the contents of reply filed by the opposite party and reiterated those of the complaint.

6. Thereafter parties led evidence in support of their respective pleadings.

7. After hearing the counsel for the parties, learned District Commission allowed the complaint of the complainant.

8. Feeling aggrieved by the order of learned District Commission, the appellant/insurance company has filed the present appeal before this Commission.

9. Arguments heard on behalf of the parties and perused the record carefully.

10. Learned counsel of the appellant/insurance company has submitted that the impugned order is bad in law and facts. He further submitted that both the parties are governed by the terms and conditions of the insurance policy. He further submitted that as per terms and conditions of the insurance policy, the injury means accidental physical bodily harm excluding illness or