A consumer can approach a forum even if his claim has been rejected by the Insurance Ombudsman

‘Death due to fall after slipping is an accident’

    A fall at home due to slipping of foot is an accident and claim is payable under an accident policy.

    Background: When an old person slips at home, resulting in subsequent death, can the insurance company reject a claim on the presumption that the fall was age-related and hence the death was due to a natural cause? In a recent judgment delivered by S M Ratnakar, along with member S S Patil, the South Mumbai district consumer forum ruled that a claim cannot be rejected on such a pretext.

    Case Study: Dr Shirish Vakil had taken Janata Personal Accident Insurance Policy from National Insurance Co when he was 69 years old for a period of 12 years (November 12, 1997-November 11. 2009) with a sum insured of Rs 5 lakh.
    Shirish, though retired, was in good health. On November 3, 2009, he slipped and fell at home. The fall impacted the rear portion of his head, making him feel giddy. There was no serious injury visible externally. But at night, his condition deteriorated and he was taken to Bhatia Hospital, where a CT scan was done. Due to want of beds, he was shifted to Harkisandas Hospital, which registered a medico-legal case and informed the police. He was diagnosed to be having an introcerebral or intracranial bleed. On November 6, Shirish succumbed to injuries.
    His son, Sunil, then claimed the sum insured. But the firm rejected it, contending that the fall was due to giddiness, an age-related problem, and hence the death could not be termed as accidental. Sunil moved the Insurance Ombudsman, which upheld the firm’s contention. He then filed a complaint through
the Consumer Welfare Association. The firm said a claim under the policy would be payable if the insured sustains bodily injury, resulting solely and directly from the accident caused by outward violent and visible means.
    The forum observed it would require to consider whether Shirish’s case amount to an “accident” as interpreted by the National Commission in the case of Reeta Devi v/s National Insurance Co. Ltd. [IV (2007) CPJ 355 (NC)]. The forum noted that the CT scan mentions subdural hematoma of 0.8cm, also seen in left frontoparietal lobe region. The hospital records clearly show “intracerebral bleed”. Statement of the domestic servant present at the time of incident, as recorded by the police, also showed that Shirish’s foot had slipped in the bedroom. The forum said the records establish that the fall was accidental. Hence, the forum ruled that the claim was payable, and that its wrongful rejection constituted a deficiency in service and also an unfair trade practice.
    The forum held that the Insurance Ombudsman order would not act as an impediment to the proceedings before it, as this question had already been settled by the National Commission. Accordingly, it directed the firm to pay the sum insured along with interest at 6% pa from December 7, 2009, till payment. In addition, Rs 20,000 compensation was awarded for harassment and Rs 3,000 as costs.

    Conclusion: A consumer can approach a forum even if his claim has been rejected by the Insurance Ombudsman. Under an accident policy, a claim for any injury or untoward incident caused by outward violent and visible means is payable.