An insurer cannot repudiate an insurance claim based on an exclusion clause for intoxication without producing cogent, scientific evidence proving both the existence of intoxication and a proximate causal connection between the intoxication and the accident, as medical history records based on hearsay are insufficient evidence.

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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.57/2020 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.Balaiah, who was a member of The Telangana Rashtra 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 18.12.2016 at about 16.00 hours, while the deceased B.Balaiah (as a rider) along with his son (pillion rider) was proceeding on motor cycle No.TS 05 EN 2690 from Ghatkesar to Danthur Village and on the way when reached at Pothurajugudem Village, the driver of lorry No.AP 26 W 0689 drove the vehicle in a rash and negligent manner and hit the motor cycle on which the deceased and his son were travelling from its behind, due to which both Balaiah and his son sustained severe injuries. Immediately after the accident, B.Balaiah was shifted to Sai Sanjeevini Hospital, Hyderabad for treatment and after first aid he was referred to Gandhi Hospital, Secunderabad for better treatment and while undergoing treatment in Gandhi Hospital, the deceased B.Balaiah succumbed to injuries on 19.12.2016. The Police Ghatkesar registered a case in Crime No.489/2016 under Section 337 of IPC and took up investigation and after investigation filed charge sheet against the driver of the lorry under Section 304A of IPC in the court of the JFCM, L.B.Nagar. After the death of the deceased, B.Balaiah, the Complainant approached the TRS, Telangana Bhavan, Hyderabad and submitted claim intimation and necessary documents for settlement of Group Personal Accident claim of her husband. The TRS, Hyderabad sent the claim intimation to the Opposite Party office for settlement of Group Personal Accident claim. After a gap of six months on 15.09.2017, the Opposite Party sent a claim repudiation letter of deceased B.Balaiah and other to TRS, Hyderabad giving a 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 contending that there was deficiency of service on the part of the Opposite Party and claimed compensation of Rs.2,00,000/- towards Group Personal Accident claim amount, Rs.50,000/- towards mental agony, Rs.50,000/- toward costs with interest @ 12% p.a. from the date of claim repudiation i.e., 15.09.2017 till realization.

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 co