An insurer cannot repudiate a personal accident claim based on an exclusion clause for intoxication unless it provides cogent, independent evidence—such as a toxicology report—demonstrating a direct proximate causal connection between the intoxication and the accident.

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Order: (Per Smt.Dr.G.Radha Rani, Hon’ble President)

1. This appeal is filed by the Opposite Party Insurance Company aggrieved by the orders of the District Consumer Disputes Redressal Commission, Nalgonda in CC.No.55/2020 dated 26.06.2023 wherein the complaint was allowed in part directing the Opposite Party to pay an amount of Rs.2,00,000/- towards Group Personal Accident Insurance amount and Rs.30,000/- towards compensation for mental agony and deficiency of service besides Rs.10,000/- towards costs of the litigation within 30 days from the date of receipt of the order, failing which an interest @ 9% p.a. on Rs.2,00,000/- shall be paid by the Opposite Party to the Complainant till its realization.

2. For the sake of convenience, the parties are hereinafter referred as arrayed before the District Commission as Complainant and Opposite Party.

3.

(a) The case of the Complainant was that, she was the wife and nominee of the deceased B.Maisaiah and her husband was a member of The Telangana Rastra Samithi Political Party (TRS). The TRS had provided a Group Personal Accident Insurance Scheme to their party members from the Opposite Party Insurance Company vide Master Policy No.604800421610000019 and assured an amount of Rs.2,00,000/- each for party member.

(b) On 01.06.2016 at about 17.00 hours, the deceased Maisaiah slipped from a Toddy Tree and fell down resulting which he sustained severe head injury and was shifted to Government Hospital, Nalgonda for treatment. Thereafter, the deceased Maisaiah was referred to Gandhi Hospital for better treatment and while undergoing treatment in Gandhi Hospital, the deceased Maisaiah succumbed due to injuries on 23.06.2016. The Police Nakrekal registered a case in Crime No.112/2016 under Section 174 of Cr.P.C. and took up the investigation. After death of the deceased, the Complainant approached the TRS, Telangana Bhavan, Hyderabad and submitted her claim intimation and necessary documents for settlement of Group Personal Accident claim of her husband Maisaiah. The TRS, Hyderabad sent the claim intimation of Complainant to Opposite Party office for settlement of Group Personal Accident claim of deceased B.Maisaiah. After a gap of one year, on 15.09.2017, the Opposite Party sent a claim repudiation letter stating the reason that the claim was repudiated as per the exclusion clause under policy condition No.5.1 to 5.10. Vexed with the same, the Complainant approached the District Commission for legal remedy against the Opposite Party claiming that the Opposite Party failed to render service properly inspite of collecting premium from TRS party and that there was deficiency of service on their part and claimed Rs.2,00,000/- towards Group Personal Accident Claim amount, Rs.50,000/- towards mental agony and Rs.50,000/- towards costs of the complaint with interest @ 12 % p.a. from the date of repudiation of the claim on 15.09.2017.

4. The Opposite Party filed written version taking several pleas that the Complainant was not a Consumer as defined under Section 2 (d) of the Consumer Protection Act, the complaint would not come under the purview of Consumer Dispute as envisaged in Section 2(e) of the Consumer Protection Act, the District Commission had no jurisdiction to entertain the complaint. They were not aware that the Complainant was the wife of the deceased and called for strict proof of the same with documentary evidence. They contended that the deceased B.Maisaiah had not paid any insur