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Judgment
Late Shri Biseshwar Prasad Yadav, husband of the petitioner/complainant had taken a Janta Personal Accident Insurance Policy for a sum assured of Rs.2,00,000/-. He having died in an accident on 18.06.2004, a claim for payment of the benefit in terms of the policy was submitted by the petitioner/complainant. The claim was rejected vide letter dated 01.08.2007, which to the extent it is relevant, reads as under:
"We would like to inform you that as per the terms of the Policy and the condition enumerated under the certificate provided to you (Condition No. 1) the claim is inadmissible on the ground of limitation. You have submitted the claim after a gap of 11 months 20 days. No reasonable explanation has been provided to us for the delay.
Condition No. 1 - "Upon the happening of any event which may give rise to a claim under this policy, the insured forthwith give notice thereof to the Company. Unless reasonable cause is shown, the insured should within one calendar month after the event which may give rise to a claim under this policy give written notice to the Company with full particulars of the claim."
Condition No.2 - "Proof satisfactory to the Company shall be furnished of all matters upon which a claim is based. Any medical or other agent of the company shall be allowed to examine the person of the Insured on the occasion of any alleged injury or disablement when and often as the same may reasonably be required on behalf of the Company and in the event of death, to make a post-mortem examination of the body of the Insured and such evidence as the Company may from time to time require (including a post-mortem examination, if necessary) shall be furnished within the space of fourteen days after demand in writing and in the event of a claim in respect of loss of sight the insured shall undergo at the Insurer's expense such operation or treatment as the Company may reasonably deem desirable. Provided that in the case of a claim by death or permanent disablement all sums payable only, on the delivery of this Policy cancelled and discharged.
In view of the aforesaid violations and non-compliance and non-submission of required documents from your end we are not able to entertain your claim and treat it as "NO CLAIM".
We would like to mention that Patna High Court has declared vide their Order Ref. C.W.J.C. No.8301 of 2004 that Post Mortem Report is a mandatory document to ascertain the actual cause of death in case any accidental death, even in the case of 'snake bite' also.
This is for your kind Information and necessary record.
It would thus be seen that the claim was rejected solely on the ground that notice to the insurer was not given within the time period prescribed in the insurance policy.
Being aggrieved from the non-payment of the claim, the complainant/petitioner approached the concerned District Forum by way of a Consumer Complaint. The complaint was resisted by the insurer primarily on the ground on which the claim had been rejected. Respondent no.2 is the company which had taken the umbrella policy under which the husband of the complainant was insured.
The District Forum having dismissed the Consumer Complaint, the petitioner/complainant approached the concerned State Commission by way of an appeal. The said appeal having been dismissed, the petitioner is before this Commission.
It is evident from condition no.1 of the policy, as extracted in the letter of the insurer dated 01.08.2007 that a notice to the insurer was required to be given within one calendar month of the event which gave rise to a claim under the policy unless the beneficiary of the insurance policy was able to show reasonable cause for the delay in giving such a notice. In other words, the claim was maintainable even if the notice was given after more than one month from the happening of the event, provided a reasonable cause for the delay in giving the notice was shown.
The petitioner has relied upon a certificate issued by Dr. R.C. Prasad on 05.06.2005, which to the extent it is relevant, reads as under:
"Certified that Ms. Fukani Devi aged about 40 yrs w/o Late Biseshwar Pd. Yadav At Khanpura, Tola Jario, P.S. - Sirdala, District-Nawada (Bihar) was suffering from depressive psychosis since 19.6.04. Since she was under my treatment and was advised rest. Now, she is mentally and physically normal and able to do her daily works from 5.6.05."
It would thus be seen that the petitioner/complainant was under depression on account of the death of her husband and that was the reason she was not able to give the requisite notice to the insurer within one month of the death of her husband. The state of mind of a Hindu wife on the sudden death of her husband can be understood. The complainant/petitioner could never be expecting such a sudden death of her husband. All the human beings do not react uniformly to a similar event in their life. It is quite likely that the complainant was so much overwhelmed with grief on account of the sudden death of her husband that she went into deep depression. Such a person would obviously not be in a position to approach an insurer unless and until she is able to come out of the depression from which she is suffering. Therefore, in my opinion, sufficient cause was shown by the petitioner/complainant for not being able to submit the claim within one month of the death of her husband. The insurer therefore, ought to have considered the claim on merits.
It is evident from a perusal of the letter of the insurer that the claim was rejected solely on account of the delay in giving notice to the insurer. This was not the case of the insurer that the deceased had not died due to an accident. Therefore, the petitioner/complainant, in my opinion, is entitled to the benefit which was available to her under the insurance policy.
For the reasons stated hereinabove, the impugned orders are set aside and the insurer/respondent no.1 is directed to pay a sum of Rs.2,00,000/- to the complainant alongwith interest on that amount @ 9% per annum from the date of institution of the Consumer Complaint till the date of payment. The payment in terms of this order shall be made within three months from today. The Revision Petition stands disposed of.