The Tamil Nadu State Consumer Disputes Redressal Commission affirmed a lower forum's ruling that favored the wife and two daughters of a deceased pensioner who died following an April 2022 road accident. While the insurer cited an alcohol exclusion based on a 106.1 mg/dL reading, it failed to produce an original lab report or prove the sample belonged to the victim. The commission also noted that the insurer's relied-upon death summary erroneously recorded the date of death as April 11 rather than April 18. Consequently, the insurer was ordered to release the full claim along with interest and additional financial compensation for the family's mental agony.
Key points
Insurers cannot rely on policy exclusion clauses without producing authentic, verified la…: Insurers cannot rely on policy exclusion clauses without producing authentic, verified laboratory documentation linking the deceased to alleged intoxication.
Deficiencies and factual contradictions in an insurer's submitted evidence undermine appe…: Deficiencies and factual contradictions in an insurer's submitted evidence undermine appeals against unfavorable consumer commission orders.
The ruling mandates additional financial penalties for mental agony and legal costs along…: The ruling mandates additional financial penalties for mental agony and legal costs alongside statutory interest on delayed payouts.
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Insurance payouts can sometimes be tricky if the insurer denies claims. In one such case, a pensioner died following a road accident and his wife and two daughters turned to the accidental death insurance cover associated with his pension account for financial assistance.
However, the insurer declined their claim, citing a policy clause excluding certain injuries linked to alcohol consumption. The family challenged the insurer's decision and won relief.
What the case is about
A pensioner held coverage under a group personal accident/salary package/pension account policy issued by the insurer through the man’s bank account.
The insurance policy covered the period from January 4, 2022, to January 3, 2023. On April 9, 2022, the man was involved in a motor accident and suffered severe head injuries. He was taken to a hospital, where he died on April 18, 2022.
His wife and two daughters filed a claim for the insured amount of Rs 30 lakh on December 5, 2022. The insurer however, rejected their request on January 9, 2023, relying on a policy exclusion concerning injuries sustained under the influence…
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