The district consumer disputes redressal commission, Mohali, has ordered an insurer to honour a ₹10-lakh group accident insurance claim, ruling that the absence of a post-mortem alone cannot justify rejection when medical records link the death to a road accident.
Event Context
After examining the medical records, the commission held that they established a continuous link between the road accident, the head injuries and the subsequent death. It observed that cardiopulmonary arrest is the final mechanism in most deaths and cannot, by itself, determine the underlying cause.
The commission further held that the insurer had produced no evidence to show that Akshay died due to any illness or cause unrelated to the accident. It ruled that rejecting the claim solely because no post-mortem was conducted amounted to deficiency in service, as the cause of death stood established through continuous treatment records. The commission dismissed the complaint against the employer, holding that no deficiency in service was proved against the company.
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ICONMA, however, admitted before the commission that Akshay was its employee and confirmed that he was covered under the group accident policy for ₹10 lakh. The company stated that it had assisted the family in processing the claim and coordinated with the insurer.
Team Analysis
The commission, comprising president SK Aggarwal and members Paramjeet Kaur and Lt Col Jasbir Singh Bath (retd), also directed the insurer to pay 6% annual interest on the insured amount from November 30, 2022 the date the claim was repudiated along with ₹50,000 towards compensation and litigation expenses.
Complaint Raj Kumar and his wife Kusha, residents of Phase 1, Sector 55, Mohali, approached the commission after their son, Akshay Kumar, died on April 1, 2022. Akshay was employed with ICONMA Professional Services and Solutions and was covered under the company’s group personal accident insurance policy issued by Shriram General Insurance Company for ₹10 lakh.
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According to the complaint, Akshay sustained serious head injuries in a road accident at Dera Bassi on March 6, 2022, and remained admitted to Government Medical College and Hospital, Sector 32, Chandigarh, until March 18. After being discharged with advice for home care, his condition deteriorated on April 1, following which he was taken to Indus Hospital, Mohali, where he died during treatment.
The couple submitted an insurance claim, but the insurer rejected it on November 30, 2022. The company argued that no post-mortem examination had been conducted and that the death certificate mentioned cardiopulmonary arrest, which, according to it, did not establish death due to an accidental injury as required under the policy.
