Insurance Company cannot reject Personal Accident claim based on hospital report

Complaint No. I.O.(HYD) G -11.48.0073 / 2017-18 Mr. Bejjanki Ravi VS. National Ins. Company Ltd. Award No. I.O. (HYD)/A/GI/0037/ 2017-18

Insurance Ombudsman Date of award: 11.08.2017


FACTS Smt. Bejjanki Surekha (Late) w/o Sri Bejjanki Ravi was an SB account holder of the Bank of Baroda, Nizamabad branch and she opted coverage under PMSBY Group Personal Accident Policy from 01.04.2016 to 31.03.2017. She had a fall from a stair case on 25.04.2016 and sustained head injury. She was referred to Gandhi Hospital and while undergoing treatment she died on 30.04.2016. Her husband and nominee under the policy, Sri Bejjanki Ravi filed a claim for payment of the Personal Accident benefit under PMSBY Group PA policy. The respondent insurer rejected the claim stating that the claim was not due to accidental injuries and it was due to heart attack and not covered under the policy. FINDINGS The insured person slipped from stair case and sustained head injury and other injuries on her back, legs etc. Due to blood clot in brain she was shifted to a Govt. General Hospital and while undergoing treatment she died on 30.04.2016. After death police complaint was lodged and it was registered by the police on 01.05.2016. The insurer contended that as per the death certificate issued by Gandhi Hospital, Secunderabad, the provisional diagnosis was ‘frontal contusion’ instead of rear side which was contrary to the narration given in the claim form and police complaint lodged by the complainant. In the death certificate it was recorded by the hospital against cause of death – cardiac arrest. The FIR was lodged on 01.05.2016 after lapse of 6 days, i.e. after death of insured person. The PME report submitted by the complainant was blank about the cause of death. A medical opinion was obtained from in-house medical officer who opined that the case appears to be suspicious and the cause of death as evident from the death summary being cardiac arrest, the claim was not admissible in terms of the policy. Since cause of death is not an accidental in nature, the claim is repudiated. DECISION As per Police Records and inquest report the death took place due to head injury sustained at home while getting down from stairs. The Post-Mortem was also conducted. The Insurer rejected the claim based on the death summary issued on 30.04.2016 by Gandhi Hospitals, Secunderabad which stated the cause of death as cardiac arrest but ignored the case history, i.e. the insured person had a fall from stairs on 25.04.2016 at her house in Nizamabad. The hospital records state that there was loss of consciousness and provisional diagnosis was frontal contusion. The representatives of the insurer stated that the PM report submitted by the complainant was blank and it did not specify any cause of death and hence relied upon Gandhi Hospital document in deciding the admissibility of the claim. However, the respondent insurer has not followed the basic principle of a “proximate cause”. There is a chain of event starting with an accident at home which finally resulted in the death of the insured person. The claim of accident has not been denied or disputed by the respondent insurer. Therefore, the Forum is inclined to give the benefit of doubt to the claimant that the death resulted from an accidental fall and its resulting complications only. The insurer is directed to pay the claim of Rs. 2 lacs with interest in terms of Rule 17(70 of the Insurance Ombudsman Rules, 2017.

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