Page 1 of 14
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN
STATE OF TAMILNADU & PUDUCHERY
(UNDER RULE NO: 17(1) of the INSURANCE OMBUDSMAN RULES, 2017)
OMBUDSMAN – SHRI M VASANTHA KRISHNA
Case of Mr S Anandakumar Vs HDFC Ergo General Insurance Co. Ltd
Complaint Ref: No: CHN-G-018-1718-0102
Award No: IO/CHN/A/GI/ 0103 /2018-19
1.
Name & Address of the Complainant
Mr Anandakumar
1-14-9D2 Salem Main Road
Sankaridurg, Sankari 637301
2.
Policy No:
Type of Policy
Duration of policy/Policy period
2952 2008 0508 1401 000
Sarv Suraksha-Pers. Accident Policy
17/07/2016-16/07/2018
3.
Name of the insured
Name of the policyholder/Proposer
Mr Anandakumar
Mr Anandakumar
4.
Name of the insurer
M/s HDFC Ergo Genl. Ins. Co. Ltd
6
th
Floor, Leela Business Park
Andheri Kurla road, Andheri (E)
Mumbai 400059
5.
Date of Repudiation/Short settlement
Repudiation, 09/03/2017
6.
Reason for repudiation/ short
settlement
Non disclosure of material fact
7.
Date of receipt of the Complaint
09/05/2017
8.
Nature of complaint
Non settlement of claim
9.
Amount of Claim
Rs 137000
10.
Date of Repudiation
09/03/2017
11.
Amount of relief sought
Rs 137000
11.a
Date of request for SCN
09/03/2017
11.b.
Date of receipt of SCN
08/06/2017
12.
Complaint registered under
Rule 13(1)(b) of the Insurance
Ombudsman Rules, 2017
13.
Date of hearing/place
29/06/2018/Coimbatore
14.
Representation at the hearing
a) For the Complainant
Mr Anandakumar
b) For the insurer
Mr Aneesh Bhaskaran
15.
Complaint how disposed
By Award
16.
Date of Award/Order
03/08/2018
Page 2 of 14
17. Brief Facts of the Case:
The complainant has been with HDFC Ergo under their Sarv Suraksha Personal
Accident policy from 2014. He was hospitalized at CMMH Hospital, Chennai on
15/08/2016 and undergone Anterior Cruciate Ligament reconstruction (ACL
reconstruction) of Left Knee subsequent to the injury due to his accidental fall from two
wheeler 22 days before. Cashless Pre authorization was denied since it was mentioned
in the Cashless request form that the insured was having Hypertension (HT) for the
previous 3 years and the same was not disclosed in the proposal. A claim of Rs
1,31,083 being the expenses incurred in the above hospitalization was preferred with
the respondent insurer and the same was repudiated under policy condition 10.r.ii which
reads as under, since the insured didn’t disclose the Hypertension (HT) and
Dyslipidemia which he was having for the past 3 years, in the proposal and thus there is
non-disclosure of material fact.
‘’We may terminate this policy on grounds of misrepresentation, fraud, non disclosure of
material facts or non cooperation by you or any insured person or anyone acting on
your behalf or on behalf of an insured person. Such termination of the policy shall be
from the inception date or the renewal date (as the case may be) upon 30 days notice
and by sending an endorsement in this regard at your address shown in the schedule
without refund of any premium’’.
Complainant vide E Mail dt 15/04/2017 represented to the Grievance Dept. of the
insurer to reconsider the claim. Grievance Dept. vide E Mail dt 19/04/2017 reiterated the
earlier decision of repudiation. Not satisfied with Grievance Dept.’s reply, the
complainant has approached this Forum vide letter dt 08/05/2017.
18) Cause of Complaint:
a) Insured’s submission:
Complainant’s claim of Rs 1,31,083 for ACL reconstruction of Left Knee was denied by
respondent insurer on the ground that the complainant was having HT for the past 3
years and the same was not disclosed in the proposal. Complainant stated that his wife
had told the duration of HT as approximately 3 years where as it was only 1 ½ years
and this was confirmed by the certificates issued by Dr D Muthiah Selvakumar. More
over the complainant’s current hospitalization was on account of an accident and was
not even remotely related to HT. In view of the above facts, complainant’s claim is
payable and he requested the Forum’s intervention for settlement of his claim.
b) Insurer’s contention:
Page 3 of 14
The complainant’s policy was underwritten through telephonic proposal. The
complainant had replied ‘’No’’ to the question ‘’ Whether yourself or your wife have any
health problems, accidental injury, surgery, BP, sugar like kind of any complaints?’’ But
in the Cashless Pre Authorization Request form, it was stated that the complainant was
having HT since 3 years. Thus it is proved that HT was in existence prior to 15/07/2014
when the policy was incepted for the first time. But the same was not disclosed by the
insured while proposing for insurance. Thus there is non- disclosure of material fact by
the insured. Hence the claim was repudiated under section 10.r.ii. Since the decision to
repudiate the claim was based on policy condition, the insurer requested the Forum to
dismiss the complaint.
19) Reason for Registration of Complaint: - Rule13 (1) (b) of the Insurance
Ombudsman Rules, 2017, which deals with “Any partial or total repudiation of claims
by the life insurer, General insurer or the health insurer”.
20) The following documents were placed for perusal.
Copy of Sarv Suraksha Personal Accident Policy
Insurer’s repudiation letter dt 09/03/2017
Complainant’s E Mail dt 15/04/2017 to Grievance Dept. of the insurer
Grievance Dept.’s reply vide E Mail dt 19/04/2017
Complainant’s letter dt 08/05/2017 to the Ombudsman
Annexure VI-A submitted by the complainant
Self Contained Note (SCN) from insurer
Discharge summary of Chennai Meenakshi Multispecialty Hospital
Chennai Meenakshi Multispecialty Hospital’s certificate dt 30/12/2016
Certificates issued by Dr D Muthiah Selvakumar
21) Result of hearing with both parties (Observations & Conclusion)
Complainant’s claim was repudiated by the respondent insurer under section
10.r.ii of the policy which allows the insurer to cancel the policy either from the
inception date or renewal date by giving 30 days notice in case of non disclosure
of material fact by insured.
As such a claim can’t be repudiated under the referred clause. If a claim is to be
repudiated by taking shelter under section 10.r.ii then the only way is to cancel
the policy from inception date. Insurer didn’t exercise that option.
Page 4 of 14
Pre-existence of complainant’s Hypertension is also not conclusively
established.. The hospital which initially stated that HT was of 3 years duration
had withdrawn the statement and revised the duration to 1 ½ years (their
certificate dt 30/12/2016). As per this certificate, the diagnosis of HT was in
February, 2015, well after policy inception.
In view of the above Forum concludes that repudiation of the claim by insurer is
not in order.
AWARD
Taking into account the facts & circumstances of the case and the submissions made
by both the parties during the course of hearing, the insurer is directed to settle the
claim of the complainant for Rs. 1,31,083 subject to terms and conditions and
deductibles under the policy if any and in addition pay interest as defined under Rule
17 (7) Insurance Ombudsman Rules, 2017.
Thus the complaint is Allowed.
The attention of the Insurer is hereby invited to the following provisions of the Insurance
Ombudsman Rules, 2017:
a) According to Rule 17(6) of the Insurance Ombudsman Rules, 2017, the insurer shall
comply with the award within thirty days of the receipt of the award and intimate
compliance of the same to the Ombudsman
b) According to Rule 17(7) of the Insurance Ombudsman Rules, 2017, the complainant
shall be entitled to such interest at a rate per annum as specified in the regulations,
framed under the Insurance Regulatory and Development Authority of India Act, 1999,
from the date the claim ought to have been settled under the regulations, till the date of
payment of the amount awarded by the Ombudsman.
c) According to Rule 17(8) of the Insurance Ombudsman Rules, 2017, the award of
Insurance Ombudsman shall be binding on the insurers.
Dated at Chennai on this 3
rd
day of August 2018
Sd/-
(M VASANTHA KRISHNA)
INSURANCE OMBUDSMAN
FOR THE STATE OF
TAMIL NADU AND PUDUCHERRY
Page 5 of 14
OFFICE OF INSURANCE OMBUDSMAN
MUMBAI & GOA
METROPOLITAN REGION EXCLUDING NAVI MUMBAI & THANE
(Under Rule No. 16/17 of Insurance Ombudsman Rules, 2017)
OMBUDSMAN : SHRI MILIND KHARAT
COMPLAINANT - MR. MANAN PANKAJ SHAH
VS
RESPONDENT : STAR HEALTH AND ALLIED INSURANCE CO. LTD.
COMPLAINT REF: NO:MUM-G-044-1718-0499
AWARD NO: IO/MUM/A/GI/ /2018-2019
1
Name & Address of the Complainant
Mr. Manan Pankaj Shah
2
Policy No:
Type of Policy
Duration of Policy/Period
Sum Insured
P/171116/02/2016/002152
Accident Care Individual Insurance Policy
16.03.2016 – 15.03.2017
Rs.10,00,000/- Table A
Rs.10,00,000/- Table C
3
Name of Insured
Name of he policy holder
Mr. Pankaj M. Shah
4
Name of Insurer
Star Health And Allied Insurance Co. Ltd.
5
Date of Repudiation
03.02.2017
6
Reason for repudiation
Death not accidental
7
Date of receipt of the complaint
05.07.2017
8
Nature of complaint
Total Repudiation of claim
9
Amount of claim
Rs.20,00,000/-
10
Date of Partial Settlement
-
11
Amount of relief sought
Rs.20,00,000/-
Page 6 of 14
12
Complaint registered under
Ombudsman Rules, 2017
Under Rule 13(b)
13
Date of Hearing
18.06.2018 – 12.30 p.m.
14
Representation at the hearing
a) For the complainant
Mr. Manan Pankaj Shah
b) For the insurer
Dr. Arvind Thakkar
15
Complaint how disposed
Award
16
Date of Award/Order
21.08.2018
Brief Facts of the Case : Complainant lodged a claim under the policy for the death of his father
Mr. Pankaj M. Shah on 20.07.2016 while undergoing treatment at Global Hospital following a fall at
home on 06.07.2016. Respondent rejected the claim stating that the death was not due to any accident
but only due to pre-existing medical condition/ uncontrolled hypertension.
Contentions of the Complainant : Complainant contended that his father Late Mr. Pankaj M.
Shah had an accidental fall in the bathroom on 06.07.2016 in the morning. As he did not respond to
their call, they broke open the door and found him lying in an unconscious state on the floor. He was
immediately rushed to Global Hospital and was admitted in the ICU. After prolonged treatment for 15
days, he expired on 20.07.2016 while in the hospital. Complainant averred that his father was not
having any problem of HTN or DM in the past. He was fit and had planned Dubai tour from 18.07.2016
to 23.07.2016. His death was caused due to the accidental fall in the bathroom and hence denial of the
claim by the Respondent was not acceptable to them.
Contentions of the Respondent: Dr. Arvind Thakkar submitted that on thorough examination of
the documents submitted including the ICPs, it was observed that the patient was admitted to hospital
and was found to have severe intracranial bleed for which surgery was done to evacuate the clot. There
was no evidence of any external injury in the ICPs. The death summary clearly revealed the cause of
death as “Large Intracerebral Bleed in recently diagnosed hypertension”. Thus the victim had
intracranial bleed due to hypertension. This resulted in blood loss, then shock and he was found
unconscious in the bathroom. He did not die due to fall in the bathroom or by reason of any external
head injuries; instead he was afflicted by uncontrolled hypertension which led to intracranial bleed and
the death.
Page 7 of 14
Observations/Conclusion of the Forum: On scrutiny of the documents produced on record it is
observed that the on admission to the hospital pm 06.07.2016, the patient was diagnosed with Large
Intracerebral Bleed in recently diagnosed hypertension for which Right Frontotemporoparietal
Craniotomy was performed on him. He did not respond to the treatment and passed away on
20.07.2016. The Death Summary states the cause of death as large hypertensive bleed in the right
cerebral parenchyma with subfalcine herniation towards the left and also states that the Cause of Death
as “Large Intracerebral Bleed in recently diagnosed hypertension”.
The hospital papers do not mention any signs of head injury due to fall. The term “Accident” has been
defined under the policy as “Accident/ Accidental means a sudden, unforeseen andinvoluntary event
caused by external visible and violent means”. In view of all the above, the complainant’s contention
that the death of the insured was caused due to an accidental fall, is not substantiated and therefore
does not sustain. The decision of the Respondent therefore to repudiate the claim cannot be faulted
with and the Forum finds no valid ground to intervene with the said decision.
AWARD
Under the facts and circumstances of the case, the complaint of Shri Manan Pankaj
Shah against the Respondent does not sustain.
It is particularly informed that in case the award is not agreeable to the complainant, it would be open
for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate
under the Laws of the Land against the Respondent Insurer.
Dated: This 21
st
day of August, 2018 at Mumbai.
(MILIND KHARAT)
INSURANCE OMBUDSMAN
Page 8 of 14
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF KARNATAKA
(UNDER RULE NO: 17 of THE INSURANCE OMBUDSMAN RULES, 2017)
OMBUDSMAN – Mrs NEERJA SHAH
In the matter of Mr SHESHAGIRI K V/s APOLLO MUNICH HEALTH INSURANCE COMPANY LIMITED
Complaint No: BNG-G-003-1718-0594
Award No.: IO/(BNG)/A/GI/0139/2018-19
1
Name & Address of the Complainant
Mr Sheshagiri K
No. 24, 28
th
Cross, 3
rd
Main,
7
th
Block, Jayanagar
BENGALURU – 560 082
Mob.No. 99004 41906/99864 88502
Mail ID : sheshagiri.krishnamurthy @jbbodamail.com
2
Policy /Cert. No.
Type of Policy
Duration of Policy/ Policy Period
160100/22001/2015/A001994-04
Personal Accident Insurance (Group)
01.12.2015 to 30.11.2016
3
Name of the Insured/ Proposer
Name of the policyholder
M/s J B Boda Insurance Brokers P Ltd.,
Mr Sheshagiri K
4
Name of the Respondent Insurer
Apollo Munich Health Insurance Company Limited
5
Date of repudiation/rejection
Offer letter issued but the Complainant refused
6
Reason for repudiation
NA
7
Date of receipt of Annexure VI A
13.11.2017
8
Nature of complaint
Offered for short settlement
9
Amount of claim
₹.13,50,000/-
10
Date of Partial Settlement
NA
11
Amount of relief sought
₹.13,50,000/-
12
Complaint registered under Rule no:
13 (1) (b) of Insurance Ombudsman Rules, 2017
13
Date of hearing/place
09.08.2018/Bengaluru
14
Representation at the hearing
a) For the Complainant
Self
b) For the Insurer
Dr Yeswant Kumar, Manager
15
Complaint how disposed
Dismissed
16
Date of Award/Order
10.08.2018
17. Brief Facts of the Case: The complaint emanates from the offer for settlement of claim under the
head ‘Temporary Total Disablement’ instead of ‘Permanent Partial Disablement’. The Complainant
approached even the GRO of the Respondent Insurer (RI) and having not satisfied with the offer of the
RI, he has approached this Forum for reconsideration of the claim in full.
18. Cause of Complaint:
a. Complainant’s arguments: The Complainant’s (about 62 years) submission was that he was insured
by his Employer with the above mentioned RI. On 28.03.2016, he slipped on the platform while boarding
metro train resulting in injury to femur right hip causing Permanent Partial Disablement (PPD). He was
admitted into Hosmat Hospital P Ltd., Bengaluru on 28.03.2016 and was diagnosed as Fracture of Neck
of femur right hip. Right hip Bipolar Hemiarthroplasty was done and was discharged on 02.04.2016. The
Complainant stated that the finding was Right hip – Attitude in external rotation shortening present and
at the time of discharge he could not walk without the help of Walker aid. Orthopaedic surgeon had
Page 9 of 14
certified that the injury fell under PPD and the hospital also had issued certificate stating 65% right
lower disability & 22% whole body disability and RI without considering had arbitrarily processed the
claim for Temporary Total Disability (TTD) & offered ₹.13,214/- as settlement. The policy covers the total
loss of Functional use and hence contends that he was entitled for compensation ranging from
₹.2,97,000/- (22%) to ₹.8,77,500/- (65%).
The Complainant further submitted that as per the terms and conditions of policy, if the insured patient
suffers a loss not mentioned in the table 4.1, the Insurer will assess the degree of disablement with their
medical advisors and determine the amount of payment to be made, whereas RI was totally irresponsive
and did nothing independently to assess the percentage of PPD on their own. As his grievance was not
resolved even after taking up with Grievance Cell, he has approached this Forum to order RI to settle the
full claim for ₹.8,77,500/-
b.Respondent Insurer’s Arguments:
The Respondent Insurer submitted their Self Contained Note dated 11.01.2018, whilst admitting the
insurance coverage and preferring of claim for PPD. As per the benefit plan, PPD was payable when
there was a loss of part, a loss of limb above the centre of the femur or total loss of function of that part.
The Complainant in the above case was made to walk on his 2
nd
day of the surgery and hence, it did not
fall under the definition of ‘Total Loss of function’ of that operated part. The doctor certificate issued
after 2 months of surgery mentions disability at ‘65%’ and the same should be ‘100%’ for claiming PPD
and hence, the claim was rightly considered under TTD.
The RI also submitted that the claim had been diligently dealt and moreover, the claim of the
Complainant needed to be strictly construed in the spirit of the terms of the policy. The present
Complainant being devoid of merits and hence, may kindly be dismissed.
19. Reason for Registration of complaint:-
The complaint falls within the scope of the Insurance Ombudsman Rules, 2017.
20. The following documents were placed for perusal.
a. Complaint along with enclosures,
b. Respondent Insurer’s SCN along with enclosures and
c. Consent of the Complainant in Annexure VIA & and Respondent Insurer in VII A
21. Result of personal hearing with both the parties (Observations & Conclusions):
This Forum has perused the documentary evidence available on record and the submissions made
during the personal hearing by both the parties. After analysing the same, this Forum noted that the
dispute is as to whether the claim could be considered under the head of Permanent Partial
Disablement (PPD) instead of Temporary Total Disability, as offered by RI.
The Complainant contended that he has suffered the disablement as defined under the policy for PPD
and hence, the same should be paid as claimed.
Page 10 of 14
The Respondent Insurer once again reiterated their contentions in SCN and submitted that they had
‘offered’ to settle the claim on Temporary Total Disablement basis and are prepared to settle even at
this stage and requested for dismissal of the complaint.
The Benefit 4 under the policy, deals with Permanent Partial Disablement. In the first part it states about
loss of and various percentages are mentioned. In the second part it states that loss means the physical
separation of a body part or the total loss of functional use of a body part or organ.
The Complainant argued that the total loss of Functional use need not be 100%. This Forum does not
accept this argument, as the term used is ‘total’, which means 100%. The medical certificate forming
part of claim form submitted by the Complainant mentions that Hip movements are free and also the
discharge summary stated that at the time of discharge he is healthy and patient was made to walk on
the 2nd day itself and at the time of discharge the insured patient was walking with walker aid.
On examination of various records, this Forum does not dispute the fact that the Complainant had
suffered Permanent Partial Disablement, but finds substance in the arguments put forward by the RI
that the same was not payable as per the terms and conditions of policy. The Forum also noted that the
Complainant came walking without any external support. The physical appearance of the complainant
did not show any glaring disablement as defined under the policy. Accordingly, the Forum directs the RI
to settle the claim under the head Temporary Total Disablement, as agreed by them.
This Forum has gone through the relevant terms and conditions of policy and does not find any flaw
with the decision of the Respondent Insurer as the same is as per the terms and conditions of policy.
A W A R D
Taking into account of the facts and circumstances of the case and the submissions made by both the
parties and documents submitted during the course of the Personal Hearing, the decision of the
Respondent Insurer in repudiating the claim is in consonance with the terms and conditions of the policy
and does not warrant any interference at the hands of the Ombudsman.
Hence, the Complaint is Dismissed.
Dated at Bengaluru on the 9
th
day of August, 2018.
(MRS NEERJA SHAH)
INSURANCE OMBUDSMAN
FOR THE STATE OF KARNATAKA
Page 11 of 14
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF KARNATAKA
(UNDER RULE NO: 17 of THE INSURANCE OMBUDSMAN RULES, 2017)
OMBUDSMAN – Mrs NEERJA SHAH
In the matter of Smt RITHA TRIPATHI V/s SBI GENERAL INSURANCE COMPANY LIMITED
Complaint No: BNG-G-040-1718-0584
Award No.: IO/(BNG)/A/GI/0140/2018-19
1
Name & Address of the Complainant
Smt RITHA TRIPATHI
No. 28/B, 3
rd
Cross, Ramanjappa Layout,
Near Saibaba Temple, Akashnagar
BENGALURU – 560 016
Mob.No.80503 09649
E Mail ID : akashtrapathi@gmail.com
2
Policy No.
Type of Policy
Duration of Policy/ Policy Period
150421-0000-00 – Certificate No. 35832359
Group Personal Accident Policy
28.09.2016 to27.09.2017
3
Name of the Insured/ Proposer
Name of the policyholder
Shri Chandra Bhushan Tripathi (late)
4
Name of the Respondent Insurer
SBI General Insurance Company Limited
5
Date of repudiation/rejection
18.07.2017
6
Reason for repudiation
Death due to heart attack not covered under policy
7
Date of receipt of Annexure VI-A
13.11.2017
8
Nature of complaint
Rejection of claim
9
Amount of claim
₹.20,00,000/-
10
Date of Partial Settlement
NA
11
Amount of relief sought
₹.20,00,000/-
12
Complaint registered under Rule no:
13 (1)(b) of Insurance Ombudsman Rules, 2017
13
Date of hearing/place
09.08.2018/Bengaluru
14
Representation at the hearing
a) For the Complainant
Self
b) For the Respondent Insurer
Mr Akash Jha – Lead - Legal
15
Complaint how disposed
Allowed
16
Date of Award/Order
10.08.2018
17. Brief Facts of the Case:
It is case of denial of claim for the death of the insured person on the ground that the insured died out
of heart attack and the policy covers only accidental death. In spite of contacting the Grievance Cell of
Respondent Insurer (RI), his grievance was not resolved. Hence, the Complainant has approached this
Forum.
18. Cause of Complaint:
a) Complainant’s arguments:
The Complainant is the wife of the deceased, who was insured with the above mentioned RI under
Group PA policy for the SB Account Holders of State Bank of India. The Insured met with a road accident
Page 12 of 14
on 07.12.2016 at about 22.30 hrs and was initially treated at local hospital and then referred to St.
John’s Hospital, Bengaluru where he was admitted on 10.12.2016. Later, he underwent cervical
discectomy and stabilisation on 15.12.2016 after being haemodynamically stable. Post-operative patient
improved symptomatically and neurologically. The patient was continued physiotherapy. The patient
was planned for PMR (Physical medicine and rehabilitation) but on 24.12.2016 at about 5.15 hrs, he
developed sudden respiratory difficulty followed by unresponsiveness and cardiac arrest and
succumbed to death on 24.12.2016 at 6.10 hrs at the same hospital.
The Complainant had submitted the claim with RI, who rejected the claim stating that the insured died
due to heart attack. Her appeal to grievance was also rejected vide their letter dated 21.09.2017.
Aggrieved with the repudiation of claim, she has approached this Forum requesting to look into the
matter as her husband was primarily admitted into the hospital for accidental injuries and he died in the
hospital.
b) Respondent Insurer’s Arguments:
The Respondent Insurer submitted their Self Contained Note dated 27.11.2017 admitting insurance
coverage, preferring of claim and their repudiation as the death was due to illness and the policy covers
accidental death only. It was submitted that it was observed from the PM report that the insured had
died due to massive inferior wall myocardial infarction (heart attack) i.e., medical/natural cause. Hence,
claim was repudiated as per the terms and conditions of policy. Their Grievance department also had re-
examined the matter and they also concurred with the decision of repudiation. The RI stated that the
complaint was not entitled for any amount towards the said claim under the ambit of the said policy
from SBI General. The demand of the Complainant was illegal and not maintainable under law and
hence, denied.
In view of the above facts, the RI prayed that the present complaint should be dismissed.
19. Reason for Registration of complaint:-
The complaint falls within the scope of the Insurance Ombudsman Rules, 2017
20. The following documents were placed for perusal.
d. Complaint along with enclosures,
e. Respondent Insurer’s SCN along with enclosures and
f. Consent of the Complainant in Annexure VIA & and Respondent Insurer in VII A
21. Result of personal hearing with both the parties (Observations & Conclusions):
This Forum has perused the documentary evidence available on record and the submissions made by
both the parties during the personal hearing. After analysing the same, this Forum noted that the
dispute is as to whether the claim is for accidental death or due to heart ailment.
Page 13 of 14
The Complainant submitted that her husband was admitted into the hospital for accidental injury. After
initial treatment from Hosmat Hospital, he was referred to St. John’s hospital. He underwent surgery of
the neck and continued to be in the same hospital till his death. The hospital had given the discharge
summary which RI had not considered.
The RI reiterated their contentions submitted in SCN and stated that they have relied on PM report
which states that death was due to heart attack, independent of accident and the same was not covered
under the terms and conditions of policy.
This Forum has gone through the relevant terms and conditions of policy and the submission made by
both the parties. As the decision of RI is based on PM report, this Forum also has perused the ‘Death
Summary’ of the same hospital. It is stated that during the hospital course, patient underwent cervical
discectomy and stabilisation after being haemodynamically stable. Patient developed sudden onset
respiratory difficulty followed by unresponsiveness and cardiac arrest. Inspite of multiple cycles of CPR
(cardiopulmonary resuscitation) patient did not respond and succumbed to death. It is observed that an
FIR is registered under section 304(A) of IPC (causing death by doing any rash or negligent act not
amounting to culpable homicide).
It is not in dispute that the insured person met with an accident and was admitted to the hospital. The
fact is that the death occurred during the continuity of the treatment in the same hospital. This Forum
having perused the discharge summary of the hospital and other records is convinced that the death
occurred during the continuity of treatment in the same hospital and proximate cause of death was road
accident.
This Forum has also noted that the Complainant has filed a case bearing No. MVC 3498/2017, Bengaluru
claiming compensation for the death of her husband from the website of Karnataka judiciary before the
Chief Judge, Court of Small Causes, Bengaluru. The same would not have been registered had the cause
of action not arisen out of accident. The compensation, if any, likely to be received from the Motor
Accidents Claims Tribunal has no bearing on the present complaint, as this complaint is an independent
one based on the policy obtained from RI, on payment of premium.
Hence, this Forum is not in favour of upholding the contention of Repudiation of claim and the
Respondent Insurer is directed to settle the claim for the sum insured as per the terms and conditions of
policy.
A W A R D
Taking into account of the facts and circumstances of the case, the documents the oral submissions made
by both the parties, this Forum is of the opinion that the decision of the Respondent Insurer is not in
accordance with the terms and conditions of policy.
The Respondent Insurer is hereby advised to settle the claim for the sum insured as per the terms and
conditions of policy along with interest @ 8.5 % p.a. after 30 days from the date of submission of last claim
papers, as per as per Regulation 15 (10) of Protection of Policy Holders’ Interests Regulations, 2017 issued
vide IRDAI notification dated 22.06.2017.
Hence, the complaint is ALLOWED.
Page 14 of 14
22. Compliance of Award:
The attention of the Complainant and the Respondent Insurer is hereby invited to Rule 17(6) of the
Insurance Ombudsman Rules, 2017, where under the Respondent Insurer shall comply with the Award
within 30 days of the receipt of the Award and shall intimate compliance of the same to the
Ombudsman.
Dated at Bengaluru on the 10
th
day of August, 2018.
(NEERJA SHAH)
INSURANCE OMBUDSMAN
FOR THE STATE OF KARNATAKA
