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Madhya Pradesh High Court · body

2008 DIGILAW 1310 (MP)

ORIENTAL INSURANCE CO LTD v. INSURANCE OMBUDSMAN

2008-11-10

SANJAY YADAV

body2008
Judgment ( 1. ) CHALLENGE put fourth in the present writ petition filed under Article 226/227 of the Constitution of India is to an order dated 8-7-2003, passed by Insurance Ombudsman respondent No. 1; whereby, the claim put forth by respondent No. 2 has been allowed and the petitioner was directed to settle the claim for a sum insured i. e. , Rs. 80,000/- along with 9% per annum from 1-4-1994 till the date of full and final payment. ( 2. ) THE facts in nut shell are that respondent No. 2-Smt. Archana chourasiya filed a complaint to the Insurance Ombudsman, respondent No. 1 on 29-7-2002, seeking the claim of Rs. 80,000/- in lieu of death of her husband shri Ashok Chourasiya, who was working as Assistant Grade II in the Office of executive Engineer, M. P. Electricity State Board (for short referred to as "mpseb") City Division, North, Bhopal. The said Ashok Chourasiya met with an accidental death on 24-11-1993. The claim put forth by Smt. Archana chourasiya respondent No. 2, was on the anvil that MPSEB respondent No. 3 and the petitioner Oriental Insurance Company Ltd. had entered into a contract of insurance on 18-11-1986 for implementation of the Group Personal Accident policy in accordance whereof an amount of Rs. 80,000/- was to be paid to the family members of Class III and Class IV employees, in the event of death of such employee. ( 3. ) THE ombudsman while entertaining the claim put forth by respondent No. 2, issued notices to the petitioner in response whereof claim put forth by respondent No. 2 was denied. However, no notices appear to have been issued to MPSEB. The Ombudsman, thereafter, by impugned order dated 8-7-2003 directed the petitioner Oriental Insurance Company to settle the claim of respondent No. 2. The said claim of respondent No. 2 was allowed on the basis of finding that the policy was first issued on 18-11-1986 and was continuously renewed with insurer every year on expiry till the year 1995 when renewal order was passed to other insurer. It was also noted by Ombudsman that one Ashok chourasiya a Class III employee working as Assistant Grade II in City Division (North) MPSEB, Bhopal died in an accident on 25-11-1995. It was also noted by Ombudsman that one Ashok chourasiya a Class III employee working as Assistant Grade II in City Division (North) MPSEB, Bhopal died in an accident on 25-11-1995. An intimation was given to the insurer and the claim was not allowed and despite of repeated reminders no heed was paid by petitioner/oriental Insurance Company. It is on the anvil of these facts, Ombudsman directed to settle the insured claim as noted above. ( 4. ) ASSAILING the order, it is contended by learned Counsel for the petitioner that impugned order is a nullity in the eyes of law. It is urged, that it was beyond the powers of Ombudsman to pass such an order. It is further contended that relevant rules of Redressal of Public Grievance Rules, 1998 stipulates that beyond the period of limitation prescribed under the Rules of 1998 no claim could have been entertained by Ombudsman. Learned Counsel for the petitioner relies on Rule 12 and Rule 13 of the Rules of 1998 to bring home his submission that Ombudsman entertained a time barred claim which, was beyond his power thus rendering the award a nullity in the eyes of law. ( 5. ) FURTHERMORE, while placing reliance on Group of Personal accident Policy, Annexure R-2, and a letter dated 8-5-2002 filed by respondent no. 2 MPSEB, it is contended by learned Counsel for the petitioner that even if it is assumed that the Ombudsman could have entertained the claim, the respondent No. 2 was not entitled for settlement in her favour as the husband of respondent No. 2 was found to have died in an accident while he was under, influence of intoxication of liquor. The learned Counsel for the petitioner placed reliance on Clause 5 of the said policy. It is further contended that mpseb had rejected the claim of respondent No. 2 on the anvil that the death of said Ashok Kumar Chourasiya was not a natural death but was due to accident which occurred while said Ashok Kumar Chourasiya was under the influence of liquor. It is thus on these grounds, the petitioner seeks quashment of impugned order dated 8-7-2003 passed by Insurance Ombudsman. ( 6. ) LEARNED Counsel for respondent No. 2/claimant has filed the return whereby order passed by Insurance Ombudsman has been supported. It is thus on these grounds, the petitioner seeks quashment of impugned order dated 8-7-2003 passed by Insurance Ombudsman. ( 6. ) LEARNED Counsel for respondent No. 2/claimant has filed the return whereby order passed by Insurance Ombudsman has been supported. It is contended by learned Counsel for respondent No. 2 that there is no perversity of finding by Insurance Ombudsman, and therefore, it is urged, that the same cannot be interfered with. ( 7. ) LEARNED Counsel for respondent No. 3 on his turn submits that ashok Kumar Chourasiya, who was working in (City Division, North, Bhopal) in the Office of Executive Engineer, MPSEB as Assistant Grade II suddenly died by falling from roof on 24-11 -1993 at mid night. The post-mortem was conducted in Medical College, Bhopal and as per viscera report, it was found that Ashok kumar Chourasiya had in his liver 80 mg % and 70 mg % Alcohol respectively, immediately at the time of the accident and was under intoxication of alcohol. The respondent No. 3 while relying upon Clause 5 of Group Personal Accident policy contends that since the death of Ashok Kumar Chourasiya was due to accident while he was under influence of intoxicating liquor, the claim put forth by respondent No. 2 (wife of Ashok Kumar Chourasiya) was turned down vide letter dated 8-5-2002 (Annexure R-3 ). Thus, in a way respondent No. 3 has supported the petitioner to the extent that respondent No. 2 was not entitled for settlement of any claim in her favour. ( 8. ) HEARD learned Counsel for the parties at length and perused the respective pleadings. ( 9. ) THE exception clause of Group Personal Accident Policy is in following terms:-Provided always that: the company shall not be liable under this policy for: "5. Payment of compensation in respect of Death Injury or disablement of the Insured (1) from intentional self injury, suicide or attempted suicide (b) whilst under the influence of intoxicating liquor or drugs, (c) whilst engaging in Aviation or whilst mounting into, dismounting from or travelling in any aircraft other than as a passenger (fare paying or otherwise) in any duly licensed standard type of aircraft anywhere in the world, (d) directly or indirectly caused veneral disease or insanity, (e) arising or resulting from the insured Person committing any breach on the law with criminal intent. " (Emphasis supplied)In the case at hand, as borne out from record that, Ashok Kumar chourasiya suddenly died by falling from the roof on 24-11-1993 at mid night and the post-mortem was conducted and as per Viscera report 80 mg % and 70 mg % alcohol was found in his liver and he was under intoxication of Alcohol. The nature of death occurred brings him in the exception category, dis-entitling the claimant from any claim under Group Personal Accident Policy. The ombudsman as the impugned order reflects, ignores the aforesaid fact while awarding the claim. ( 10. ) TRUE, it is that Rule 12 of 1998 empowers the Ombudsman for receiving and considering delay in settlement of claims but this clause does not empower the Insurance Ombudsman to grant or settle the claim in favour of a person who otherwise is not entitled for a claim under a policy. Moreover, in the wake of the claim having been declined by the. employer MPSEB, it was incumbent upon the Insurance Ombudsman to have considered the said facts before passing the order of settlement of claim in favour of respondent No. 2. ( 11. ) IN the considered opinion of this Court and keeping in mind aforesaid facts culled out from the respective pleadings, the Insurance ombudsman exceeded the powers vested in him under Rules, 1998, therefore, the order cannot be given a stamp of approval and it is liable to be quashed. ( 12. ) IN result the petition is allowed and the impugned order dated 8-7-2003 (Annexure P-1) passed by Insurance Ombudsman is hereby quashed. However, no costs.