Repudiation of claim on ground that complainant failed to prove that cause of death was a result of accidental injuries, upheld

National Consumer Disputes Redressal Commission (NCDRC): NCDRC has upheld a repudiation of claim by an insurance company on the ground that complainant failed to prove that the cause of death of the insured was the injury caused by the accident. Earlier, complainant’s mother obtained insurance cover from HDFC Ergo General Insurance Co. Ltd. upto Rs. 25.00 lakhs for the period from 04.01.2011 to 03.01.2012. On 05.05.2011, complainant’s mother fell from a bus and was admitted in hospital. Later, on 16.05.2011, she expired. The complainant being the nominee submitted the claim before insurance company but the claim was repudiated on the ground that the claim did not fall within the policy coverage because the death was not as a result of accidental injuries. By that time the Claims Settlement Commissioner, Public Vehicles Department, Kolkata passed an order for payment of a sum of Rs.25,000/- for the accidental death of deceased. Feeling aggrieved by the repudiation of her claim by the insurance company, complainant approached West Bengal State Consumer Disputes Redressal Commission for direction to insurance company to make payment of Rs.25.00 lakhs alongwith interest as the post mortem report described the cause of death as “Cerebral Odema” which is sort of internal brain haemorrhage. Before State Commission, insurance company submitted that no external grievous injuries had been noted in respect of the deceased person either in the treatment case papers or at the time of conducting the post mortem and hence the insurance company did not accept the death to have occurred on account of accidental injuries. It was also pointed out that the treatment documents had not been produced by the complainant and in the absence thereof, the allegation of death due to accident could not be proved conclusively by the post mortem or any other document. After perusing the material on record, NCDRC noted, “Before the claim could be admitted by the insurance company, it was incumbent on the part of the complainant to provide proof to establish that the death was accidental. No doubt, the insured person fell from the bus which obviously would constitute an accident but, it could not be established that the cause of death of the insured was the injury caused by the accident. This aspect is required to be established by clear evidence and the plea taken by the appellant to the effect that Settlement Commissioner of the State Government had sanctioned payment of Rs.25,000/- on account of death of the insured by the accident, cannot provide necessary proof to establish the fact that the death of the insured person could actually be attributed to the accident and the injury caused in that accident, since there was a gap of 11 days between the accident and the death. Under these circumstances, we do not find any basis on which the finding of the State Commission can be faulted with.” (Madhumita Bose v. HDFC Ergo General Insurance Co. Ltd., 2015 SCC OnLine NCDRC 4, decided on February 2, 2015)

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