Life Insurance Corporation of India vs MUKHTIAR SINGH

BRIEF facts stated in the complaint are that Mukhtiar Singh, complainant was resident of village Rajo Wala, District Faridkot. He got himself insured with the opposite party - Life Insurance Corporation of India under Policy No. 23077849 dated 23.1.1985. Since then he had been paying the instalments regularly. The complainant met with an accident on 2.11.1994 and was permanently disabled while the policy was intact. Report No. 17 dated 2.11.1994 was lodged with the Police Station Kotwali, Faridkot, after the accident. It is then stated in the complaint that immediately after the accident, the complaiannt submitted the statement of claim to the office of the opposite party No. 2 i.e. Branch Manager, Life Insurance Corporation of India, Faridkot, who sent reply dated 20.2.1996 followed by letter dated 1.8.1996 asking for submission of certain documents. The complainant then submitted the requisite documents to opposite parties. Thereafter, despite repeated requests his claim was not accepted. Rather the opposite parties were maintaining a mysterious silence. Finding no way, the complainant lodged the present complaint alleging deficiency in service claiming an amount of Rs. 25,000/- by way of insurance money under the accident benefit policy besides a compensation amounting to Rs. 1,25,000/- for harassment and mental agony and expenses of the treatment suffered by him from the opposite parties.

THE opposite parties contested the complaint. Preliminary objection was raised by submitting that the complaint was not maintainable in the present form and since the claim of the complainant had been regretted after due inquiry, completion of formalities and after due application of mind on merits, the same could not be reopened. It was also submitted by the opposite parties that complicated questions of law and facts were involved in the complaint requiring detailed evidence and enquiry which could not be conducted in the summary proceedings before the District Forum. On merits, policy of insurance in favour of the complainant by the opposite party was admitted. THE payment of premium was also admitted. An objection was raised in the written reply that the complainant intimated to the opposite party No. 2 only on 20.4.1995 after a gap of 5 months of the accident and failed to submit the required documents for processing the claim. It was also stated in the reply that the complaiannt did not furnish the required medical documents. Even the photostat copy of FIR submitted by the complainant was not duly attested by the issuing authority. Ultimately, opposite party processed the claim in the light of the documents submitted by him and after due application of mind his claim was declined for the reason that the disability suffered by the complainant was not covered under the terms and conditions of the policy. It was also stated in the reply that the complaint was barred by time and the complainant had already availed a loan amounting to Rs. 15,000/- from the opposite party No. 1 on 20.6.1995 under the policy in question and the opposite parties reserved their right to recover the said amount. Deficiency on their part was declined. Lastly a prayer was made that the complaint be dismissed. The complainant had filed rejoinder to the counter of the opposite parties controverting the pleas taken therein and reiterated those made in the complaint. Preliminary objections raised were also refuted. However, the complainant admitted the taking of loan of Rs. 15,000/- from the opposite parties, but asserted that they were not liable to recover the same from him.

After hearing the learned Counsel for the parties and after perusal of the record carefully, District Forum, Faridkot allowed the complaint and directed the opposite parties to pay Rs. 25,000/- to the complainant by way of insurance money alongwith other benefits arising under the policy with interest @ 12% per annum with effect from the date of the accident, i.e. 2.11.1994 till realisation. It was ordered by the District Forum that the opposite parties shall be entitled to adjust the amount of loan due from the complainant to them out of the amount payable to the complainant. Costs of Rs. 500/- was also awarded to the complainant against the opposite parties.

THE claim of the complainant was declined for the only reason that disability suffered by the complainant was not covered under the terms and conditions of the policy. District Forum had allowed the claim of the complainant by discussing the factual position of the case and after taking into consideration the observations made in para 10 of the impugned order. Before discussing the matter, we would like to reproduce the relevant portion of the order of the District Forum on the basis of which the complaint was allowed. "We have ourselves also searched for the case law on the point of 100% disability and were able to lay our hands on two decisions having bearing on the point. Those are as under : (I) I (1998) CPJ 498, in case Karam Chand Sharma v. Branch Manager, LIC, decided by the Hon''ble State Commission, Himachal Pradesh, Simla, and (II) III (1995) CPJ 10, in case Bhartiya Jiwan Bima Nigam v. Partap Singh, delivered by the Hon''ble Madhya Pradesh State Commission, Bhopal. In these decisions, it has been held that Clause 10 of the Accident Benefit Policy, has two parts i.e. First and the Second and that to claim benefit of the accident under the said clause, the insured has to establish that the disability is the result of the accident and that disability is total and permanent and on account of such disability the insured cannot do any work or adopt any occupation or profession which he can sufficiently do or follow and cannot obtain any employment to earn his livelihood. It has been further held that the 2nd part of the Accident Benefit Clause deals with certain disabilities resulting in irrecoverable loss of the entire sight of both eyes or in the amputation of both hands at or above the wrist, or in the amputation of both feet at or above ankles, or in the amputation of one hand at or above the wrist and one foot at or above ankle, shall have also be deemed to constitute such disability. Thus, these injuries referred to in the 2nd part of Clause 10 have been constituted as disabilities under the deeming provisions. THEse injuries would be by themselves without anything more, be sufficient for holding that the resulting disability is such as would entitle the insured to the benefit of accident clause. Keeping in view the decisions and the principles laid down, in our opinion, the case in hand would also be covered under the First Part of Clause 10 of the Accident Benefit Policy. THE complainant was present before us on 4.8.1998 when the arguments were heard. We examined his both feet. THE left foot had been amputated whereas the right ankle had been removed and great toe of right foot also amputated. He could walk with difficulty with the help of crutches i.e. helping sticks and also needed some help from another person thereby indicating that he has been totally disabled and is unable to carry on any work or adopt any occupation or profession which he can sufficiently do or follow and cannot be gainfully employed to earn his livelihood. In view of the cases cited above, we can say that if the nature of disability suffered by the insured is of such a nature then it would be covered under the first part of the Caluse 10 relating to Accident Benefits. In view of the aforesaid authorities, we are inclined to take a view that the case of the complainant is also covered under these authorities and the disability suffered by the complainant shall be deemed to be total and 100%. In the instant case even in the certificate Annexure 3, the disability has been given to be 100% by the Civil Surgeon, Faridkot. THE non-examination of the doctor as a witness or in the absence of his affidavit, no adverse inference can be drawn against the doctor as the disability judged by him refers to the general disability and has no nexus with the work, occupation or profession of the insured. THE complainant, therefore, shall be entitled to the benefit of Accident Benefit Clause of the Insurance Policy. Consequently, the repudiation of the claim, made by the opposite parties vide Annexure A, was wrongful and not bona fide. That being so, this Forum has jurisdiction to adjudicate upon the validity or otherwise of the repudiation made by the opposite parties and as seen above, the repudiation of the claim of the complainant was wrong, illegal and improper and complainant can certainly be granted appropriate reliefs by this Forum."

The only point on which the whole case hinges is as to whether the complainant had suffered such a disability, which was covered under the terms and conditions of the policy. We will first note down the injuries on the body of the complainant. It is taken out from the certificate Annexure 3 found at page 87 of the paper book of the District Forum of Civil Surgeon, Faridkot. "BK amputation (L) leg with malunited # Tibia (R) with amputation of great toe, (R) foot with non-union (R) calvicle. Disability 100% (hundred)."

IT is undisputed that the complainant met with an accident on 2.11.1994 when the insurance policy in question was in force. In the above said accident he received injuries described above. Due to these injuries, complainant''s left foot below the knee had to be amputated and he had received crush injuries with multiple compound fractures. His right ankle was also dislocated with compound fractures. His right lower 1/3rd fibula was also fractured and the big toe of his right foot had also to be removed. The details of these injuries are also given in Annexure 2, the photostat of the discharge summary of the complainant was issued by Christian Medical College, Ludhiana. FIR, photocopy of which is Annexure-1, was lodged with the police, Police Station, City Faridkot. Now we would like to refer to relevant portion of Clause 10 of the policy, which relates to the disability permanent disability in such a matter, which reads as under : "10. 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 before 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 : xxx xxx xxx xxx xxx xxx 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 or 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 ninety days from the happening of such accident, result in the irrecoverable loss of the entire sight of both eyes or in the amputation of both hands at or above the wrists, or in the amputation of both feet at or above ankles or in the amputation of one hand at or above the wrist and one foot at or above the ankle, shall also be deemed to constitute such disability."

Reading of the relevant Clause 10 of the Insurance Policy leaves us without any doubt that the injuries suffered by the complainant in the accident are covered by the above said clause. The complainant''s left foot had been amputated; right ankle had been removed and great toe of right foot was also amputated. The complainant appeared before us also and it was rightly observed by the District Forum and we have also seen him. He could walk with difficulty with the help of crutches and needs help from the other person accompanying him for his bodily movement. All this clearly shows that he has been totally disabled and unable to carry on work or to adopt any profession or occupation as laid down in the Insurance Policy.

IN view of our discussion, made above and in view of the reasons given by the District Forum in detail, we find that the case of the complainant is squarely covered under Clause 10 of the Accident Benefit Policy. The direction given by the District Forum to the opposite parties to pay Rs. 25,000/- to the complainant under the insurance policy alongwith other benefits arising under the same with interest @ 12% is affirmed, except that the payment of interest shall be made from the period commencing immediately after four months of the submission of the claim by the complainant to the opposite party and not from the date of the accident.

CONSEQUENTLY, the appeal is dismissed except the modification made above. Appeal dismissed with modification.