Vijay Rajesh.S.S v. The Insurance Ombudsman
BEFORE THE MADURAI BENCH OF MADRAS HIGH COURT DATED: 18.11.2025
CORAM
THE HONOURABLE MS.JUSTICE P.T.ASHA Writ Petition(MD)No.25560 of 2023 and W.M.P(MD)No.21735 of 2023 S.S.Vijay Rajesh ..Petitioner Vs 1.The Insurance Ombudsman, For the State of Tamil Nadu & Puducherry, 4th Floor, Anna Salai, Teynampet, Chennai - 600 018.
2.The Manager, Claims Department, Regional Office, SBI General Insurance Company Limited, 3rd Floor, Good Shepherd Square, A block, Kodambakkam High Road, Chennai - 600 034.
..Respondents Prayer: Writ Petition filed under Article 226 of the Constitution of India, praying this Court to issue a Writ of Certiorarified Mandamus to call for the records on the file of the 1st respondent pertaining to its Award No. IO/CHE/A/GI/0015/2023-2024 dated 31.05.2023 and quash the same as illegal, consequently direct the respondents to settle the Insurance Claim of Rs.20,00,000/- to the petitioner in accordance with law within a time frame fixed by this Court.
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For Petitioner : Mr.S.Selva Aditya for Mr.K.Sathishkumar For Respondents : Mr.N.Shyllappa Kalyan for R2 No appearance for R1
ORDER
This writ petition has been filed seeking issuance of a Writ of Certiorarified Mandamus to call for the records pertaining to Award No. IO/CHE/A/GI/0015/2023-2024 dated 31.05.2023 passed by the first respondent, quash the same as illegal and arbitrary, and consequently direct the respondents to settle the personal accident insurance claim for a sum of Rs.20,00,000/- in accordance with law.
2. The petitioner is the son of the deceased insured, Smt.V.Shantha, aged about 64 years. On 31.10.2022, the insured had an accidental slip and fall in the bathroom of her residence, resulting in head injury and bodily trauma. She was immediately taken to Velammal Medical College Hospital & Research Institute, Madurai, where she was admitted in the ICU. Intimation of the accident was duly given to the police, and a CSR was registered. As her condition deteriorated, she was referred to Government Rajaji Hospital, Madurai, where she remained under treatment until her demise on 08.11.2022. At the time of the accident, the deceased was covered under a 2/7
Personal Accident Insurance Policy bearing No.31016502 for a sum assured of Rs.20,00,000/-, valid up to 24.10.2023. The petitioner lodged a claim with the second respondent. However, the claim was repudiated on the ground that the insured allegedly died due to natural causes, namely acute pulmonary edema and heart failure. The complaint preferred before the Insurance Ombudsman was also rejected by Award dated 31.05.2023. Challenging the same, the present writ petition.
3. The learned counsel for the petitioner contended that the death occurred only due to injuries and complications arising from the accidental fall. From the date of accident till the date of death, the insured was under continuous hospitalization and ventilator support. CT Brain conducted at Government Rajaji Hospital revealed hemorrhagic contusions and depressed fracture, clearly establishing traumatic injury. The Treatment Summary issued by Government Rajaji Hospital dated 12.06.2023 categorically certifies that the original cause of hospitalization and death was the accidental fall. The insurer and the Ombudsman ignored vital medical evidence and mechanically rejected the claim.
4. The learned counsel for the second respondent by relying upon the echo-cardiography findings and hospital notes indicating LVH, and pulmonary edema, contended that death was due to medical illness beyond policy coverage.
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5. I have considered the rival submissions of both the learned counsels and perused the records.
6. The issue for consideration is whether the petitioner has established that the death of the insured occurred solely and directly due to an accidental fall, so as to entitle him to claim benefits under the Personal Accident Insurance Policy.
7. On a careful perusal of the pleadings and the medical records placed before this Court, it is evident that though the insured sustained a slip and fall on 31.10.2022, the medical documents disclose that she was suffering from pre-existing cardiac condition, including Left Ventricular Hypertrophy, dilated cardiac chambers, valvular thickening, and cardiomegaly. The treatment summary issued by Velammal Medical College Hospital records that the patient was admitted with breathlessness and shock, and that she was treated with diuretics and inotropes to stabilize cardiac function. The echo-cardiography report indicates structural heart disease. The records further show that the patient developed acute pulmonary edema and respiratory failure, which are recognized complications of cardiac decompensation.
8. Further, the insurer obtained a medical opinion, which concluded that the insured died due to acute pulmonary edema and respiratory failure 4/7
in a case of decompensated cardiomyopathy and concentric Left Ventricular Hypertrophy. These findings indicate that the death occurred due to medical illness and natural causes, and not as a direct consequence of accidental injury. Though the petitioner contends that the fall was the cause of death, the medical records do not conclusively establish that the injuries sustained in the fall were the proximate and dominant cause of death. In the absence of a postmortem examination and in view of the medical evidence pointing towards cardiac failure, the causal nexus between the accident and death remains unsubstantiated.
9. The Insurance Ombudsman, upon examining the claim and medical records, arrived at a reasoned conclusion that the death was not accidental within the meaning of the policy. No material has been placed before this Court to demonstrate that the impugned Award suffers from illegality, irrationality, or procedural impropriety warranting interference.
10. In view of the above discussion, this Court finds no merit in the writ petition. Accordingly, this writ petition is dismissed. No costs. Consequently, connected miscellaneous petition is closed. 18.11.2025 NCC : Yes/No Index : Yes/No Internet:Yes skn 5/7
To 1.The Insurance Ombudsman, For the State of Tamil Nadu & Puducherry, 4th Floor, Anna Salai, Teynampet, Chennai - 600 018.
2.The Manager, Claims Department, Regional Office, SBI General Insurance Company Limited, 3rd Floor, Good Shepherd Square, A block, Kodambakkam High Road, Chennai - 600 034.
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P.T.ASHA, J.
skn Writ Petition(MD)No.25560 of 2023 and W.M.P(MD)No.21735 of 2023 18.11.2025.
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