Coming down heavily on Shriram Life Insurance Co Ltd for unnecessarily seeking a comprehensive post-mortem report and other medical records from the claimant, the national consumer disputes redressal commission (NCDRC) directed the insurance company to pay Rs22.50 lakh to the wife of the deceased life assured (DLA).
In an order, the NCDRC bench of Justice Ram Surat Ram Maurya (presiding member) and Bharatkumar Pandya (member) says, "Copies of the first information report (FIR), inquest as conducted by the police, post mortem report, police investigation report were already submitted by the complainant before Shriram Life Insurance. We failed to understand the comprehensive post-mortem report, which was demanded by the insurer. These documents were prepared by public authorities in the discharge of their statutory duties. It was not possible for the complainant to get any other record to prove accidental death of the deceased life assured."
"Similarly, if the deceased life assured had no previous ailment or was ever admitted to any hospital, then no document could be produced by the complainant. From the documents produced by the complainant, it was fully proved that the DLA had a valid insurance policy issued by the appellant, his death was accidental and the complainant was a nominee in the policy. Closing the insurance claim was illegal and arbitrary. The order of the state commission does not suffer from any illegality. The appeal has no merit and is liable to be dismissed," the bench says.
In March 2009, Guntur district-based Chenna Kesava Rao bought a 'Shri Plus Insurance Policy' from Shriram Life Insurance. The 15-year policy had an annual premium of Rs1.50 lakh, covering an accidental shield benefit of Rs11.25 lakh and an accidental death benefit of Rs22.50 lakh. While driving a tractor, Chenna Kesava Rao met with an accident on 31 July 2009 and died on the spot. The Marcheria rural police station registered an FIR and conducted an inquest and post-mortem of the dead body, mentioning the cause of the death as ruptured.
Namasani Venkata Lakshmamma, the wife of Chenna Kesava Rao and nominee of the insurance policy, filed an insurance claim seeking Rs22.50 lakh. However, the claim was rejected by Shriram Life Insurance for not producing the post-mortem report and the medical documents and reports about liver ailments of the DLA, Chenna Kesava Rao. Ms Lakshmamma, however, had submitted all the necessary documents.
She then gave a legal notice to the insurer. In its reply, Shriram Life Insurance told her that she did not submit a comprehensive post-mortem report and the medical documents and reports of liver ailments of her husband.
Ms Lakshmamma then filed a complaint before the Andhra Pradesh state consumer disputes redressal commission. During the hearing, the state commission found that the insurance company raised a plea that the DLA was suffering from chronic liver disease and had taken treatment before taking the insurance policy. Still, no evidence has been produced in this respect by the insurer.
It says, "Medical records of Hitech Trauma and Critical Hospitals Ltd at Guntur as produced by the insurer, relating to the treatment of the DLA (Chenna Kesava Rao) were suspicious documents inasmuch as the investigator, in his report stated that initially the nurse, who had attended the patient, informed that he was a drunkard and had run away with hospital record. Later on, photostat copies of medical records were produced, stating that it were obtained from the record section of the hospital as such, these records were not reliable documents. The claim was repudiated on irrelevant consideration."
While allowing the complaint of Ms Lakshmamma, the state commission directed Shriram Life Insurance to pay Rs22.50 lakh with 9% interest.
Shriram Life Insurance challenged the order before NCDRC.
During the hearing, the NCDRC bench observed that the repudiation letter by the insurer did not record any finding that the deceased had concealed a previous ailment relating to his liver disease. However, the investigator appointed by Shriram Life Insurance in his report on 10 November 2009 mentioned that the DLA was a drunkard, chronic alcoholic or smoker and had taken treatment for liver problems and liver disease.
The bench, while referring to the copies of medical records submitted by the insurer before the state commission, noted that neither the date of discharge of the patient had been given nor was a discharge summary prepared. "If these two facts are considered with the report of the investigator that initially the nurse, who had attended the patient, informed that he was a drunkard and had run away with hospital record, then grave doubt is created upon the genuineness of these documents. If the patient had run away with hospital records, then from where these records were procured? If these records were with the hospital, then why was endorsement not made in it that the patient had run away without discharge or if discharged, then why discharge summary was not mentioned?"
"A photostat copy of the affidavit of Dr Vutukuri Suresh has been filed in the appeal, which shows that the entire contents of the affidavit were typed and particulars of Dr Vutukuri Suresh were filled up in handwriting. Had this affidavit been drafted on the instruction of Dr Vutukuri Suresh, there was no reason not to type his name. This affidavit does not contain the name and seal of any oath commissioner. In these circumstances, we do not find any reason to take the contrary view as taken by state commission raising grave doubt in respect of genuineness of these records and ignoring these documents," it added.
NCDRC says there is no evidence that the deceased life assured was suffering from any ailment on 3 February 2009 or before it, when the proposal form was filled up by him or had taken any treatment in any hospital. "As such, the plea taken by Shriram Life Insurance that the deceased had concealed his ailment relating to liver disease is not proved."
Dismissing the appeal, the bench directed Shriram Life Insurance to pay Rs22.50 lakh with an interest of 9%pa to Ms Lakshmamma.
(First Appeal No1225 of 2014 Date: 20 September 2023)
