LIFE INSURANCE CORPORATION OF INDIA vs ALKA SHUKLA

The petitioner Life Insurance Corporation of India (hereinafter referred to as the LIC) have challenged the order dated 19.06.2013, passed in appeal FA/13/400 by the Chattisgarh State Consumer Disputes Redressal Commission (hereinafter referred to as ''State Commission'') vide which, while dismissing the appeal, the order passed by the District Forum, Durg on 10.09.2012 in Consumer Complaint No. CC/12273 filed by the present respondent/complainant Smt. Alka Shukla, allowing the said complaint, was upheld.

The facts of the case as stated in the consumer complaint are that the husband of the respondent/complainant, Shri Anil Shukla, during his life time, purchased three insurance policies from the LIC at different times, which included the accidental benefit also. On 03.03.2012, Anil Shukla fell from his bike and died in late evening on the same day. The complainant filed claim under the Insurance Policies with the LIC which made payment of the sum assured under the said policies, but refused to pay the accidental benefit, saying that the death of the insured had not occurred due to accident. The version given by the LIC before the District Forum stated that the deceased suffered pain on the left side of chest and shoulder and fell from the bike following a heart attack. The LIC stated that there was no police report or investigation in the case, neither any post-mortem was conducted, but from the medical reports, it was clear that the deceased suffered a heart-attack. The accident benefit claim was, therefore, not payable as per the terms and conditions of the policy.

The District Forum, after examining the contentions of both the parties, allowed the complaint and stated that the LIC shall pay accident benefit under all the three policies alongwith 5000/- as compensation for mental agony alongwith interest @6% p.a. with effect from 10.09.2012 and 2000/- as cost of litigation. Being aggrieved against the order, the petitioner LIC filed an appeal before the State Commission, but the same was dismissed vide impugned order. Being aggrieved against the said order, the petitioner LIC is before me by way of the present revision petition.

At the time of hearing, learned counsel for the petitioner submitted that the LIC had already released the sum insured under the Policies alongwith bonus as per the rules. However, the claim for accident benefit was not payable, because the deceased did not die in an accident. There was no report lodged with the Police, neither there was any investigation. There was no post mortem conducted on the body of the deceased. The Learned Counsel referred to medical report given by Dr. S.S. Dhillon, Specialist, Internal Medicine and also by Dr. Ashutosh Singh, who is Zonal Medical Referee of the LIC. However, the learned counsel for the respondent stated that the concurrent findings given by the consumer fora below should be upheld in the exercise of the revisional jurisdiction. The death of the deceased was due to cardiac arrest, suffered after the accident. The Ld. Counsel for the petitioner has also drawn attention to the order passed by this Commission in RP No. 3869 of 2008 " LIC vs. N. Shanker Reddy, " decided on 10.10.2013 and the order passed in RP No. 2034 / 2012, " LIC of India vs. Ved Prakash Gupta & Ors. " decided on 26.02.2013, in support of his arguments.

I have examined the entire material on record and given a thoughtful consideration to the arguments advanced before me.

It shall be worthwhile to reproduce the relevant terms and conditions attached with the LIC New Bima Gold Policy for proper decision in this case. The condition 10 relating to accident benefit states as follows:-

"10. Accident benefit (Allowed under regular premium policy and during the accumulation period only) : if accident benefit is opted for, at any time when this policy is in force for the full Sum Assured, the life assured before the date of expiry of policy term or the before the poly anniversary on which the age nearer birthday of life assured is 70 years, whichever is earlier is involved in an accident resulting in either permanent disability as herein after defined or death and the same is proved to the satisfaction of the corporation, the corporation agrees in the case of :

(a) ..............

( b) Death of Life Assured : In addition to sum assured under Basic Plan, an additional sum equal to the Accident Benefit Sum Assured shall be payable under this policy, if the Life Assured shall sustain any bodily injury resulting solely and directly from the accident caused by outward, violent and visible means and such injury shall within 180 days of its occurrence solely, directly and independently of all other causes resulted in death of the Life Assured. However, such additional payable in respect of this policy shall not in any event exceed Rs.50 Lakhs taking all existing policies of the Life Assured and under individual as well as group schemes including policies with in built accident benefit taken with Life Insurance Corporation of India and other insurance companies."

A plain reading of the above provision says that additional sum equal to accident benefit sum assured shall be payable under the Policy, if the life assured sustains injuries in an accident. It is nowhere clear whether there was any accident by outward, violent and visible means. On the other hand, the report made by a medical specialist Dr. S.S. Dhillon mentions that the deceased complained of pain in the left side of chest and shoulder, after sudden fall from the bike. It shall not be proper to state, therefore, that the said pain in the chest and shoulder or sudden fall from the bike was the result of an accident from any outward, violent or visible means. Further, the report made by the Zonal Medical Referee says as follows:- "From the papers available, it is a case of Acute Coronary Syndrome (ACS), i.e., Acute Heart Attack in leads (V2 to V5). The BP & pulse ......... in the prescription of Dr. Dhillon is on the lower side, indicating the case to be of heart attack. This probably lead to a fall from bike. The patient was given necessary first aid & referred to a Hospital, where on arrival he was diagnosed as a case of Acute Heart attack (Ant. Wall m1), but could not be revived & was declared dead."

It is clear from the above that the deceased suffered heart attack while driving his bike and he fell down from the same. It has been held by this Commission in " LIC of India vs. N. Shanker Reddy " (supra) that where the complainant failed to prove that the death was caused due to accident, the claim was not payable.

While passing the impugned order, the State Commission has nowhere analysed the facts of the case to arrive it the conclusion that it was a death that took place due to accident. The District Forum also observed in their order that there was no evidence to explain the situation that cause of death was accident. The conclusion arrived at by the Consumer Fora below is, therefore,

not based on any material which may justify the version of the complainant that the death took place in an accident and that the complainant is entitled to the accident claim benefit. The orders passed by the Consumer Fora below are, therefore, set aside. The present revision petition is allowed and the consumer complaint stands dismissed with no order as to costs.