STATE INSURANCE And PF DEPTT. vs NANU LAL JAIN

THIS appeal has been filed by the appellants-State Insurance Deptt. against order dated 3.7.2004 passed by the District Forum, Banswara in Complaint No. 92/1998 by which the complaint of the respondent was allowed against the appellants in the manner that the appellants were directed to pay a sum of Rs. 2 lacs in respect of the State Insurance Policy to the complainant along with interest @ 9% p.a.

IT arises in the following circumstances : That the complainant-respondent had filed a complaint against the appellants on 22.4.1998 inter alia stating that her wife Smt. Vibha Rani Jain, now deceased was Headmistress in the Govt. Girls Secondary School, Gari and while she was travelling in a car on 19.4.1997 an accident had taken place. Thereafter she was got admitted in the hospital and thereafter she was taken to Ahmedabad where her operation was got done by Orthopaedic Surgeon, even then no relief was found by the deceased and she was again operated and kept in ICU and ultimately doctor informed that her brain had been damaged and there was no hope for survival and, therefore, in the state of coma while she was coming from Ahmedabad to Banswara and on the way she had died on 8.11.1997. IT was further stated in the complaint that since the deceased was a Government servant and was the member of Group Individual Accident Insurance Scheme (the scheme) initiated by the appellants and as per terms and conditions of that scheme, if the employee had died during service, his/her dependants would be entitled to get Rs. 2 lacs. Therefore, for the death of the deceased claim was preferred by the complainant but that claim was repudiated by the appellants through letter dated 22.1.2004 on the ground that since the deceased had died because of heart attack after the surgery was done, therefore, claim as per term of Clause (2) of Condition No. 8 of the scheme was not payable. Similarly in another letter dated 31.1.2004 issued by the appellants it was further made clear that since after the accident that had taken place on 19.4.1997, treatment of the deceased was started w.e.f. 21.4.1997 and operation in respect of bone was got done and since after the operation the deceased was having respiratory problem and that had developed into Cardiac Respiratory Arrest and thereafter she became unconscious in the Navneet Hospital where she was admitted and in the admission card Drugreaction with respiratory arrest resisted was mentioned and in the record of the hospital it was mentioned that her brain was totally damaged and thus she had died as of heart attack but death was due to surgery and thus as per Clause (2) of Condition No. 8 claim was not payable. Thereafter the present complaint was filed. A reply was filed by the appellants on 8.9.1998 and they have taken the same pleas which were taken by them in the abovementioned repudiation letters. The District Forum after hearing both the parties through impugned order dated 3.7.2004 had allowed the complaint of the respondent inter alia holding that the disease of the deceased had not taken place during the procedure of surgical operation but it was the direct result of the hospital, therefore, Clause (2) of Condition No. 8 was not applicable in the present case. Aggrieved from the said order of the District Forum, this appeal has been filed by the appellants.

In this appeal the main contention of the learned Counsel for the appellants is that since in this case complications had developed after the surgical operation and thereafter deceased had died, therefore, the present case was fully covered under Clause (2) of Condition No. 8 of the scheme. Hence, the findings recorded by the District Forum are erroneous one and the impugned order cannot be sustained and liable to be quashed and set aside and this appeal deserves to be allowed.

ON the other hand the learned Counsel appearing for the respondent has supported the impugned order of the District Forum. We have heard the learned Counsel appearing for the parties and gone through the entire materials available on record.

BEFORE proceeding further it may be stated here that there is no dispute on the point that the accident had taken place on 19.4.1997 as a result of which the deceased had received some injuries for which she was got admitted in the hospital where operation was done and she was taken to Ahmedabad where she was got admitted in the Kruti Orthopaedic Hospital where she was admitted on 21.4.1997 and discharged on 30.4.1997. It is further clear from the record that she was also got admitted in Navneet Memorial Hospital, Ahmedabad where she was got admitted on 11.10.1997 and was discharged on 7.11.1997 and her disease was diagnosed as Drugreaction with respiratory arrest resistated. There is also no dispute on the point that thereafter she was being taken back from Ahmedabad to Barmer as mentioned in the discharge ticket of Navneet Memorial Hospital and she had died on 8.11.1997.

AS per Clause (2) of Condition No. 8 of the scheme the claim is not payable if death had taken place during undergoing operation.

THE question for consideration is whether in the facts and circumstances just narrated above, findings of the District Forum are liable to be confirmed one or not, especially though the cause of death of deceased had been shown by concerned doctor as head injury while in bed head ticket, immediate cause of death was cardiac arrest. In this case the immediate cause of death of the deceased was cardiac respiratory arrest and that was due to brain damage as supply of blood from the heart was not passing, but the main cause of death of the deceased was injuries which she had received in an accident that had taken place on 19.4.1997.

In this case the death of the deceased was the simple result of surgical operation done to the deceased could not be said but the death was the direct result of the accident that had taken place on 19.4.1997. Therefore, the District Forum had rightly observed that the benefit of Clause (2) of Condition No. 8 of the scheme could not be given to the appellants.

IN view of the discussion made above, no interference is called for with the impugned order of the District Forum, Banswara dated 3.7.2004 and this appeal deserves to be dismissed. Accordingly, this appeal filed by the appellants is dismissed. Appeal dismissed.