A consumer forum has held that when the terms of an insurance policy are vague, benefits should be given to the insured. The forum brought to book an insurance company that denied the accidental death claim of a South Mumbai resident on the ground that the death of his father, a senior citizen and a doctor, due to a fall at home, was not accidental and was caused by disease-related giddiness.
National Insurance Co Ltd will have to pay the victim's son, Dr Sunil Vakil, the insured sum of Rs 5 lakh along with an interest of Rs 1.20 lakh. It will also have to pay Rs 23,000 as compensation for an unfair trade practice and towards the costs of the complaint.
The forum cited a national commission order which said it was an accidental death even if an insured person suffered a fit and drowned or fell in front of a train and was killed.
The national commission ruling said that "it is settled law that when two reasonable interpretations of the terms of the policy are possible, the interpretation which favours the insured is to be accepted and not the interpretation which favours the insurance. Further, the terms of the insurance policy are drafted one-sided by the insurance company. Therefore, in case the terms of the policy are vague, benefits should be given to the insured and not to the insurer."
The commission order added: "...death, which does not occur in the usual course or natural course of events or causes which could not be reasonably anticipated, is considered accidental."
Dr Shirish Vakil was covered under the Janata Personal Accident Insurance Policy from November 1997 to November 2009.
In a complaint filed before the South Mumbai District Consumer Disputes Redressal Forum on February 9, 2011, Sunil said his father had retired and was in good health. On the evening of November 3, 2009, Shirish slipped on some tiles at home and fell. He suffered an injury to the back of his head and was admitted to hospital, where he underwent treatment for two days but succumbed to injuries on November 6, 2009. Sunil then filed the claim under the policy.
In December 2009, the insurance firm repudiated the claim and informed Sunil that on the basis of documents filed, it was observed that "the insured fell down due to giddiness, causing injuries to head and due to internal blood flow the death has occurred". The insurance firm stated that it was evident there was no accident due to which the death had occurred and hence the claim was inadmissible.
At the forum, the insurance firm denied the allegations and contended that as per the policy's terms and conditions, if the insured sustained bodily injury resulting solely and directly from the accident caused by any outward violent and visible means, only then was the company liable to pay.
The forum said in the document issued by the hospital, cause of death was attributed to "intracerebral bleed". The forum also took into consideration a statement of the domestic help recorded by the police. The help revealed that on the night of the incident, after Shirish spoke to him and was returning to his room, he slipped and fell. "Considering the eye-witness' statement, the repudiation communicated is improper as in the policy there is a specific clause that if the insured sustained bodily injury resulting solely and directly from an accident caused by outward violent and visible means, the company shall pay," the forum said.
Article referred: http://articles.timesofindia.indiatimes.com/2013-07-23/mumbai/40748141_1_insured-sum-consumer-forum-insurance-policy
National Insurance Co Ltd will have to pay the victim's son, Dr Sunil Vakil, the insured sum of Rs 5 lakh along with an interest of Rs 1.20 lakh. It will also have to pay Rs 23,000 as compensation for an unfair trade practice and towards the costs of the complaint.
The forum cited a national commission order which said it was an accidental death even if an insured person suffered a fit and drowned or fell in front of a train and was killed.
The national commission ruling said that "it is settled law that when two reasonable interpretations of the terms of the policy are possible, the interpretation which favours the insured is to be accepted and not the interpretation which favours the insurance. Further, the terms of the insurance policy are drafted one-sided by the insurance company. Therefore, in case the terms of the policy are vague, benefits should be given to the insured and not to the insurer."
The commission order added: "...death, which does not occur in the usual course or natural course of events or causes which could not be reasonably anticipated, is considered accidental."
Dr Shirish Vakil was covered under the Janata Personal Accident Insurance Policy from November 1997 to November 2009.
In a complaint filed before the South Mumbai District Consumer Disputes Redressal Forum on February 9, 2011, Sunil said his father had retired and was in good health. On the evening of November 3, 2009, Shirish slipped on some tiles at home and fell. He suffered an injury to the back of his head and was admitted to hospital, where he underwent treatment for two days but succumbed to injuries on November 6, 2009. Sunil then filed the claim under the policy.
In December 2009, the insurance firm repudiated the claim and informed Sunil that on the basis of documents filed, it was observed that "the insured fell down due to giddiness, causing injuries to head and due to internal blood flow the death has occurred". The insurance firm stated that it was evident there was no accident due to which the death had occurred and hence the claim was inadmissible.
At the forum, the insurance firm denied the allegations and contended that as per the policy's terms and conditions, if the insured sustained bodily injury resulting solely and directly from the accident caused by any outward violent and visible means, only then was the company liable to pay.
The forum said in the document issued by the hospital, cause of death was attributed to "intracerebral bleed". The forum also took into consideration a statement of the domestic help recorded by the police. The help revealed that on the night of the incident, after Shirish spoke to him and was returning to his room, he slipped and fell. "Considering the eye-witness' statement, the repudiation communicated is improper as in the policy there is a specific clause that if the insured sustained bodily injury resulting solely and directly from an accident caused by outward violent and visible means, the company shall pay," the forum said.
Article referred: http://articles.timesofindia.indiatimes.com/2013-07-23/mumbai/40748141_1_insured-sum-consumer-forum-insurance-policy
Comments
Post a Comment