LIC OF INDIA , LIC OF INDIA BRANCH MANAGER vs KAMLESH

THIS revision is directed against the order of the State Commission dated 30.07.2012 whereby State Commission Haryana Panchkula dismissed the appeal preferred by the petitioners opposite parties against the order of the District Forum Jind dated 09.08.2011.

BRIEFLY put, the facts relevant for the disposal of this revision petition are that complainant respondent purchased an insurance policy worth Rs.25000/ - from the petitioner on 10.05.2001 with half year premium of Rs.904/ -. The complainant respondent dutifully paid the insurance premium. The complainant unfortunately developed complaint of severe headache in the month of November 2003. On 25.12.2003, the complainant became unconscious and she was taken to All India Institute of Medical Sciences, New Delhi. There she remained under treatment w.e.f. 02.01.2004 to 27.01.2004 as an impatient. Her treatment is still going on and she has become 100% disabled. The complainant filed the claim under the insurance policy alongwith 100% permanent disability certificate issued by the Board of Doctors of General Hospital Jind on 02.06.2008. The opposite party, however, repudiated the claim. This led to the filing of the consumer complaint by the complainant Ms. Kamlesh through her husband and nominee Jai Bhagwan. The petitioners opposite parties contested the complaint by filing written statement wherein opposite parties took the plea that the complaint was barred by limitation. On merits, it was alleged that disability suffered by the complainant was not a consequence of an accident. As such, the petitioners opposite parties was not bound to pay the claim as per terms and conditions of the insurance policy.

THE District Forum on perusal of the pleadings and evidence accepted the complaint with following observations: ''''The medical certificate of All India Institute of Medical Sciences, New Delhi has issued a certificate in respect of the complainant, Kamlesh, which clearly mention that ''''sudden onset severe headache and loss of consciousness on 25.12.2003, dysphagia from 30.12.2003, weakness of right side of body -1.1.2004. K/C/O of Dm/Hypertension on irregular treatment. The disease was sudden unexpected and unfortunate which may be covered under definition of accident. Hence the opposite party is having deficiency of service for non -payment of insurance amount to the complainant. In view of the above facts and circumstances of this case, the complaint of the complainant is accepted. Therefore, the opposite party no.1 is hereby directed to pay the full amount of policy alongwith all other benefits accrued on account of the said insurance policy within a period of 30 days positively. Further, the premium paid by the complainant after November 2003 shall also be returned to the complainant alongwith the amount of insurance claim. If the amount is n ot paid within stipulated period, the interest @ 9% p.a. will be paid by the opposite party w.e.f. the date of filing the complaint till realization of the amount benefits. The parties will bear their own costs. ''''

BEING aggrieved of the order of the District Forum, the petitioners opposite parties preferred an appeal before the State Commission Haryana Panchkula and the State Commission dismissed the appeal. This has resulted in filing of the revision petition. Mr. Ashok Kashyap, learned counsel for the petitioners has contended that the impugned orders are not sustainable, being based on incorrect appreciation of law and facts. Expanding on the argument, learned counsel for the petitioners has taken us through the complaint as also the terms and conditions of the insurance policy particularly clause 10 -2 of the policy which deals with the accident benefit. Learned counsel for the petitioners argued that perusal of the aforesaid provision would show that accident benefit in respect of permanent disability has resulted because of involvement of the life assured in the accident. However, in the instant case, as per the allegations in the complaint, the petitioner has suffered permanent disability because of certain medical reasons. As such, the petitioners company was justified in repudiating the claim. It is further argued that State Commission has also ignored the fact that the cause of action for filing the claim under the insurance policy arose in the year 2004 when the respondent complainant suffered permanent disability. Therefore, in view of section 24A of the Consumer Protection Act, 1986, the complainant was required to file the complaint within two years of the date of cause of action but the complainant has filed the complaint after the expiry of period of limitation with the delay of almost five years, in the year 2011. As such, the complaint ought to have been dismissed as barred by limitation.

MR . Harikesh Singh, Advocate, learned counsel for the respondent complainant on the contrary has argued in support of the impugned order and prays for dismissal of the revision petition.

WE have considered the rival contentions and perused the record. It is undisputed that the respondent complainant suffered onset of severe headache followed by loss of consciousness resulting in permanent disability. It is also not in dispute that the respondent complainant filed insurance claim with the petitioner company under the accident benefit clause of the insurance policy. Stand of the petitioner is that permanent disability suffered by the respondent complainant is due to a medical reason and not due to some accident as envisaged by the insurance policy. As such, the petitioner is justified in repudiating the claim. Both the foras below while allowing the complaint of the respondent have taken the view that the disease which ultimately resulted in permanent disability suffered by the complainant was sudden and unexpected. Therefore, it is covered under the definition of the accident as envisaged in the insurance policy. From this it is evident that real controversy between the parties is about definition and scope of term accident as envisaged by the insurance policy. In order to find answer to this controversy, it would be useful to have a look on relevant terms and conditions of the insurance policy. Clauses 10 -2, 10 -4 and 10 -5 of the insurance policy deals with the claims of the insured relating to the permanent disability suffered on account of the accident. The said clauses are reproduced thus: 10 -2 ''''Accident Benefit ''''; If at any time when this policy is in force for the full sum assured, the life assured before the expiry of the period for which the premium is payable or bvefore the policy anniversary on which the age nearer birthday of the life assured is 70, whichever is earlier, is involved in an accident resulting in either permanent disability as hereinafter defined or death and the same is proved to the satisfaction of the Corporation. The Corporation agrees in the case of; (a) Disability to the life assured; (i) to pay in monthly instalment spread over 10 years and additional sum equal to the sum assured under the policy, if the policy becomes a claim before the expiry of the said period of ten years, the disability benefit instalments which have not fallen due wil be paid alongwith the claim (ii) to waive the payment of future premiums. 10 -4 The disability above referred to must be disability which is the result of an accident and must be total and permanent and such that there is neither then nor at any time thereafter any work, occupation or profession that the Life Assured can ever sufficiently do or follow to earn or obtain any wages, compensation or profit. Accidental injuries which independently of all other causes and within 120 days from the happening of such accident, result in the irrevocable loss of entire site of both eyes or amputation of both hands at or above the writs or in the amputation of both the feet at or above the ankles or above the wrist and ankle should also be deemed to constitute such disability. 10 -5 Immediately after the happening of the disability full particulars thereof must be given in writing to the Branch Office of the Corporation where this policy serviced together with the then address and whereabouts of the life assured and within 120 days after the happening of disability there must be given to the servicing office of the Corporation in the manner required by it, proof of disability satisfactory to the Corporation and without any expense to the Corporation, and thereafter similar proof must be given as and when required by the Corporation, of the continuance of such disability. Any medical examiner nominated by the Corporation shall be allowed to examine the person of the Life Assured in respect of any disability claimed in such manner and at such time before and/or after the disability is accepted by the Corporation as the Corporation may require ''''.

BEFORE venturing into finding the answer to the above question, it would be useful to have a look on the law relating to interpretation of the insurance contract. The question relating to interpretation of an insurance contract came up before the Supreme Court in the case of Oriental Insurance Co. Ltd. V. Sony Cheriyan (1996) 6 SCC 451 wherein Hon ''ble Supreme Court observed thus: ''''The insurance policy between the insurer and the insured represents a contract between the parties. Since the insurer undertakes to compensate the loss suffered by the insured on account of risks covered by the insurance policy, the terms of the agreement have to be strictly construed to determine the extent of liability of the insurer. The insured cannot claim anything more than what is covered by the insurance policy ''''.

Similarly in the case of General Assurance Society Ltd. V. Chandumull Jain (1996) 3 SCR 500 the Constitution Bench of the Hon ''ble Supreme Court observed thus: ''''In interpreting documents relating to a contract of insurance, the duty of the court is to interpret the words in which the contract is expressed by the parties, because it is not for the Court to make a new contract, however reasonable, if the parties have not made it themselves. Looking at the proposal, the letter of acceptance and the cover notes, it is clear that a contract of insurance under the standard policy for fire and extended to cover floor, cyclone, etc. had come into being ''''.

Similar view was taken by the Hon ''ble Supreme Court in the matter of United India Insurance Co. Ltd. V. Harchand Rai Chandan Lal (2004) 8 SCC 644, wherein it was observed thus: ''''Therefore, it is settled law that the terms of the contract have to be strictly read and natural meaning must be given to it. No outside aid should be sought unless the meaning is ambiguous ''''.

ON perusal of record, we find that the District Forum as also the State Commission while allowing the complaint and insurance claim of the respondent have observed that physical ailment which resulted in permanent disability suffered by the complainant was sudden and unexpected. Therefore, it is covered under the definition of accident and as such, the repudiation of the claim by the insurance policy was unjustified. The view taken by the foras below is not sustainable because it is based upon the incorrect interpretation of the word ''accident '' used in the insurance policy. In our view, the word ''accident '' in the context of the insurance policy means an event which is unintended and unforeseen and which is something that does not occur in the usual course of events. No doubt the headache followed by permanent disability to the complainant occurred unexpectedly but this does not mean that aforesaid medical ailment is covered by the word ''accident '' as envisaged in the insurance policy. The foras below while taking the above noted view have lost sight of the terms and conditions of the insurance contract as stipulated in clause 10 (2), 10 (4) and 10 (5) reproduced above. On reading of clause 10 (2), it is evident that accident benefit is promised by the insurer only if the assured is involved in an accident resulting in permanent disability or death. Clause 10 (4) of the insurance contract clarifies the disability under claim must be a permanent disability which is result of an accident. The clause further provides certain injuries which are deemed to constitute disability under accident benefit clause and it also provides that such disabilities should be the result of injuries independent of all other causes as a result of an accident. From the aforesaid stipulation, it is clear that the word ''accident '' used in the policy particularly under the accident benefit clause, means the accident as understood in common parlance and it does not include the disability caused by medical reasons. Thus in our view, the foras below have committed a grave error in allowing the complaint by giving an expansive definition to the word '' accident '', which is not envisaged by the insurance contract. Therefore, the impugned orders being contrary to the law laid down by the Supreme Court cannot be sustained.

AS a result of above discussion, we allow the revision petition, set aside the orders of the fora below and dismiss the complaint. No order as to costs.