Page 45 - Insurance Times March 2016 Sample
P. 45
LEGAL
Legal Case Studies - Ombudsman Center -
Individual Personal Accident
CASE NO: GIC/572/OIC/11/12 accident and requirements of 'First Information Report' and
Urmila Devi 'Post Mortem Report' could be waived.
vs.
CASE NO. CHD-G-047-1314-0367
Oriental Insurance Company Ltd. Vinod Siwach
vs.
Facts: This complaint was filed about the non-settlement
Tata AIG General Insurance Company Ltd.
of a personal accident claim that was lodged under a group
Personal Accident Policy about the death of an electrician, Facts: This complaint was filed about a decision of the
who had accidentally come in contact with a live wire while
performing his job. Company to settle a personal accident claim for a lesser
amount, which was not acceptable to the insured. The
Findings: On behalf of the complainant, i. e. widow of the policy provided for the 'in-hospital fixed benefit' of Rs.
10,500/- per day and against a claim for a confinement to
deceased, it was stated that the deceased was repairing a bed of 12 days owing to an accidental injury, Company had
ceiling fan when he was electrocuted. He was immediately decided to settle the claim for Rs. 42,000/- only.
rushed to a nearby hospital, where he was declared brought
dead. In support of a contention about death due to an Findings: The complainant had said that after a fall from
accident, a press cutting of a local daily was provided, which
contained news about the death of the deceased. The rep- a motor cycle, swelling appeared on the body, which ne-
resentative of the Company had explained that claim inti- cessitated hospitalization from 25.02.2013 to 08.03.2013.
mation was given after 10 days and two important docu- Thus on the basis of a confinement in the hospital for 12
ments, i.e., 'First Information Report' and 'Post Mortem days, he was entitled for Rs. 1,26,000/-, whereas Company
Report' were not provided. allowed a claim for Rs. 42,000/- only. The representative
of the Company explained that medical papers of the in-
Thereafter, directions were given to the Company for ar- sured were subjected to examination by an expert, who
ranging a formal investigation into the matter. Finally, a opined that for a minor surgery for the removal of abscess
copy of investigation report was provided, which elaborated from knee, admission for a day or two was essential. Hence,
the entire sequence of events leading to the death of the a hospitalization for four days was considered reasonable/
deceased due to an electric shock. justified and accordingly payable amount was arrived at.
The report specifically mentioned about his receiving inju- Decision: The Company's action to settle a claim for Rs.
ries after a fall on the floor, which proved fatal before he
was brought to the hospital. 42,000/- was held justified because treatment chart did not
record any active line of treatment beyond four days and
Decision: Finally, it was held that it would be in order to Complainant, who was an employee of a Govt. Depart-
ment, was non-committal about providing a supporting
allow a settlement of the claim because circumstantial evidence about leave record from his office to substantiate
evidence collected during the investigation was sufficient 'absence from duty' during hospitalization. Moreover, it was
to ascertain that cause of death of the deceased was an
The Insurance Times, March 2016 45
