STATE CONSUMER DISPUTES REDRESSAL COMMISSION UTTARAKHAND, DEHRADUN Date of Admission : 05.10.2018 Date of Final Hearing : 21.01.2026 Date of Pronouncement : 10.02.2026 SC/5/CC/32/2018 Mrs. Rachi Rajendra C/o Mr. Rajendra Prasad R/o 75/6, Rajpur Road, Ex-CMO, Dehradun 248001 (Through: Sh. Sahil Gulati, Advocate)

…..Complainant VERSUS Royal Sundaram General Insurance Co. Ltd.

(Formerly known as Royal Sundaram Alliance Insurance Company Ltd.)

Corporate Address: Vishranthi Melaram Towers No. 2/319, Rajiv Gandhi Salai (OMR)

Karapakkam, Chennai – 600 097 Registered Office: 21, Patullos Road, Chennai – 600002 Branch Office: First Floor, Building No. 44^th Cross Road, Dehradun, Uttarakhand 248001 (Through: Smt. Anjali Gusain, Advocate)

…..Opposite Party Coram:

Ms. Kumkum Rani, President Mr. C.M. Singh, Member

ORDER

(Per: Mr. C.M. Singh, Member):

This complaint under Section 12 of The Consumer Protection Act, 1986 has been filed on behalf of the complainant seeking satisfaction amount the claim of Rs. 20 Lacs together with interest @ 18% per annum; Rs. 5 Lacs for compensation for causing mental pain, trauma, shock, anguish and sufferings; Rs. 1 Lac as litigation costs and any other relief from the opposite party.

2. Brief facts of the case are as such that the complainant (Mrs. Rachi Rajendra) is a nominee under an accidental insurance policy “Accidental Shield” bearing No. PCS0000997000106 valid from 22.08.2015 to 21.08.2016 for a sum of Rs. 20 Lacs towards accidental death obtained by her father for himself and his wife Late Smt. Vedwati Prasad from the opposite party. The present complaint has been filed by the complainant seeking payment of insured sum of following death of her mother (co- insured) Late Smt. Vedwati Prasad. The deceased (co-insured) sustained injuries due to accidental fall in the bathroom on 08.07.2016 and underwent a hip surgery and consequently developed post-operative complications leading to severe infection and expired on dated 21.08.2016. The complainant duly intimated the opposite party - insurance company and submitted a claim form alongwith hospital records, discharge summary etc. Despite full compliance with policy conditions and reminders sent to the opposite party, the opposite party failed to settle the claim and instead repudiated the claim on the ground that alleged pre-existing illness and absence of post-mortem report, which according to the complainant was neither required nor relevant. The policy remained valid yet the claim was not paid. The complainant alleged that such repudiation and delay amount to deficiency in service and unfair trade practice constrained the complainant to file the present complaint.

3. The opposite party – Insurance Company has filed written statement and denied all the allegations made in the complaint case. The answering opposite party has contended that there was no deficiency in service on its part. It is also stated that after the claim was intimated, the insurer registered the claim, obtained the medical records, scrutinized the documents and conducted due investigation. According to the opposite party, the discharge of first Hospital recorded that the patient was stable at the time of discharge and subsequent death was attributed in medical records through Cardiopulmonary Arrest with metabolic encephalopathy with sepsis which is due to pre-morbid systemic illness and not solely resultant of alleged accidental fall. The answering opposite party asserted that there is no direct and proximate nexus between the accidental fall and death. It is further pleaded that as per policy terms and conditions, the post-mortem report is mandatory requirements in accidental death claims, which was not furnished by the complainant and therefore, the claim was rightly repudiated. On this ground, the answering opposite party prayed for dismissal of the complaint, contending that the complainant is not entitled to any claim amount, compensation or costs from the answering opposite party.

4. Le