MADHUMITA BOSE Vs. MANAGER RETAIL PA CLAIM TEAM

JUDGEMENT

(1.) THIS appeal has been filed by the complainant against the order dated 24.12.2013 passed by the State Consumer Disputes Redressal Commission West Bengal in CC No. 95/2012, by which the State Commission dismissed the complaint filed by the appellant / complainant.

(2.) THE complainant's mother Sucheta Bose had obtained an Accident Protection Plan HC policy from the opposite party / insurance company with the coverage upto Rs. 25.00 lakhs for the period from 04.01.2011 to 03.01.2012. As per the allegations in the complaint, the said Sucheta Bose met with an accident on 05.05.2011 and was admitted in Medical College and Hospital with injury 'at the back of her head'. FIR dated 06.05.2011 was lodged. She was shifted from the Medical College and Hospital to Saviour Clinic and then to SVS Marwari Hospital for better treatment. Unfortunately, the insured died on 16.05.2011 at the SVS Marwari Hospital. The opposite parties were informed of the death of the insured. The complainant / appellant being the nominee, submitted the claim form alongwith necessary documents. Inspite of several e -mails between the complainant and the opposite party, the claim was not settled, which led to the complainant sending an Advocate's notice dated 03.04.2012 urging upon the opposite party to settle the claim without further delay. Vide their letter dated 21.05.2012, the opposite party intimated 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 and Director, Public Vehicles Department, Kolkata had passed an order for payment of a sum of Rs.25,000/ - for the accidental death of Sucheta Bose. The complainant also approached the Insurance Ombudsman, who vide his letter dated 11.06.2012 showed his inability to admit the complaint because the claim of Rs.25.00 lakhs was beyond the financial limit of the Insurance Ombudsman. Ultimately, the complainant knocked the door of the consumer forum by filing a consumer complaint before the State Commission praying for direction to the opposite parties to make payment of Rs.25.00 lakhs alongwith interest @ 18% p.a. besides compensation of Rs.10.00 lakhs for harassment and mental agony and the litigation cost of Rs.50,000/ -.

(3.) ON being noticed, the opposite parties contested the complaint by filing its written version contending interalia that although the insured had obtained an insurance policy covering risk of accidental death and had expired on 16.05.2011, 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 opposite parties did not accept the death to have occurred on account of accidental injuries. It was also pointed out by the opposite parties 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. Denying any deficiency in service on their part, the opposite parties prayed for dismissal of the complaint.