Life Insurance Corporation of India vs RAM AVTAR

-THIS appeal is directed against the order dated 16. 6. 2003 passed by the District Consumer Disputes Redressal Forum, Rewari whereby while accepting the complaint of the respondent-complainant direction has been given to the appellant-opposite party to pay Rs. 25,000 to the respondent-complainant along with interest @ 10% per annum from the date of filing the complaint till realization.

PUT shortly, the facts of the case are that the complainant had insured himself with the opposite party under policy No. 111249021 dated 28. 11. 1991. On 15. 10. 2001 in an accident the complainant lost his right hand resulting disability to the extent of 80%. Thereafter, he is unable to do any work and earn his livelihood on that account. He put up the claim with the opposite party for accident benefit under the terms of the policy. The opposite parties repudiated the claim denying the accident as well as the liability of the claim made in terms of the insurance policy. Aggrieved by the action of the opposite parties the present complaint was filed. The complaint was contested by the opposite parties on the ground that no accident had taken place, as alleged in the complaint and a concocted version had been put up by him in this regard. It was further maintained that the complainant had even not informed about the accident as well as the disability before filing the complaint. Accordingly, it was prayed that the complaint merited dismissal. On the basis of the pleadings of the parties and evidence adduced on record, the District Forum did not accept the version of the opposite parties and while accepting the complaint issued the directions in its order dated 16. 6. 2003. It is against the said order the present appeal has been filed. Learned Counsel representing the parties have been heard at length. Learned Counsel representing the appellant-opposite party while assailing the order dated 16. 6. 2003 of the District Forum vehemently urged that the District Forum had grossly erred in accepting the complaint as no acceptable evidence was led from the side of the complainant that he has lost his right hand and suffered disability to the extent of 80% in accident as no such intimation about the accident was given by him to the opposite parties. Additionally, it was submitted that the claim made by the complainant was not payable even as per the terms and conditions of the policy. Opposing the submission made, learned Counsel representing the respondent-complainant has justified the order of the District Forum for the reasons stated therein. The District Forum has accepted the complaint by taking into consideration the affidavit filed by the complainant Ex. C-1 in support of his version stated in the complaint. In addition, notice was taken of the certificate of disability for handicapped person issued by the Board of Directors, which reveals that he had suffered disability to the extent of 80% and on that basis concluded that right hand arm of the complainant was amputated, which evidence has not been rebutted by the opposite parties except the affidavit of Mr. B. S. Yadav, Branch Manager Ex. O. P. 1. The above finding of the District Forum, as such, cannot be sustained because the complainant was duty-bound to establish the manner in which he suffered injuries in the accident which resulted in amputation of his right hand. If the complainant had suffered injuries in the accident, he must have got himself treated from any doctor or in any hospital but no such document has been placed on record which could establish his version that he had suffered amputation of his right hand on 15. 10. 2001 during the currency of the policy. The opposite parties were fully justified in raising objections in this regard on two counts. Firstly, that the complainant had not intimated to the opposite party about the accident and even no evidence of accident has been on record. Under the circumstances of the case the affidavit of the complainant alone is not sufficient to accept the version of the complainant. Therefore, the complaint is liable to be dismissed on this ground alone.

Apart from that if the stand of the complainant is independently examined in order to cover the claim benefit under the insurance policy, he is required to fulfil the condition No. 10 of the benefit of the insurance 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 LIfe Assured is or 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 instalments spread over 10 years an additional sum equal to the sum assured under this Policy. If the Policy becomes a claim before the expiry of the said period of 10 years, the disability benefit instalments which have not fallen due will be paid along with the claim (ii) to waive the payment of future premium. The maximum aggergate limit of assurance under all policies on the same life to which benefits (i) and (ii) above apply shall not in any event exceed Rs. 5,00,000. If there be more policies than one and if the total assurance exceeds Rs. 5,00,000 the benefits shall apply to the first Rs. 5,00,000 assured in order of date of the policies issued. This waiver of premium shall extinguish all options under this policy and also the benefits covered by para (b) of this clause except as to such assurance. Many, as exceeds the maximum aggregate limit of Rs. 6,00,000 and which have been kept in force by continued payment of premiums. 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 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. Immediately after the happening of the disability, full particulars thereof must be given in writing in the office of the Corporation where this policy is received together with the then address and wherabouts of the Life Assured and within the ninety days after the happening of the 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 expenses 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 times before and/or after the disability is accepted by the Corporation as the Corporation may require. In the event of its being discovered of any time that a claim under the clause has been wrongly admitted, all premiums falling due after the date of the Corporation''s intimation to the effect shall be paid and no further instalments of the additional Sum Assured shall be paid as if no disability had occurred. "

THE reading of the above stated condition of the policy would leave no manner of doubt that accident benefits would accrue to the policy holder if it results in amputation of both hands at or above writs or in amputation of both feet and at or above ankles, or in the amputation of one hand at or above the wrist and one foot at or above the ankle. In this case according to the complainant he was disabled to the extent of 80% of his right hand which cannot be taken to be disability as total and permanent in terms of the above stated clause and no accidental benefit can be claimed by him. Similar question had also arisen in case of LIC of India v. Ramesh Chandra, II (1997) CPJ 45 (NC ). The facts were that the complainant had taken insurance policy under 15-year money back policy with accident benefit. The complainant met with an accident and his right hand was amputated. The opposite parties denied the claim. Consequently, he was denied the claim and his complaint was allowed by the District Forum and the order was affirmed by the State Commission. The revision was taken to the Hon''ble National Commission. Plea was raised that amputation of one hand at or above ankle constitute within the meaning of Clause 10 of the policy. It was held that such a disability would not be covered. The reliefs observed are as under: "held: The question is whether the amputation of right hand suffered by the complainant is a specified event and constitute disability entitled to an accident benefit under Clause 10 (a) of the policy bond. The accident benefit is available to the assured only if he is involved in an accident resulting in total and permanent disability as defined in Clause 10. The disability referred in the said clause must be disability which is the result of accident and must be total and permanent. The accidental injuries which independently of all other causes and within 120 days from 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 wrist or in the amputation of feet at or above ankles, or in the amputation of one hand at or above the wrist and one foot at or above the wrist only constitute such disability. The case of the complainant is not of the amputation of both hands at or above the wrists or in the amputation of feet at or above ankles. The case of the complainant is the amputation of one hand at or above the wrist but that is not independently deemed to be a disability as is covered since the coverage in the caluse is only in cases of amputation of one hand at or above the wrist and one foot at or above ankle. It bears repletion that the deeming clause constituting the disability will get attracted only if there was the amputation of one hand at or above the wrist and one foot at or above the ankle. If it is the amputation of one hand at or above wrist or the amputation of one foot at or above the ankle, then it does not by the fiction of the Clause 10 (a) constitute disability. The constitution of the policy bond which is the basis of the contract of insurance, is a question of law and its true and correct interpretation would give jurisdiction to the Fora to pronounce upon the deficiency in service, if any. The District Forum as well as the State Commission had no jurisdiction to go beyond the terms and conditions of the policy bond and could only order the payment of the disability benefit if it was specified event covered under Clause 10 of the conditions of policy. The amputation of only one hand does not fall within the deeming definition constituting disability in terms of Clause 10 (a) of the policy bond and thus the impugned orders suffer from serious illegalities. "

THE same view was taken in case Life Insurance Corporation of India v. Chandan Singh, III (2000) CPJ 101, as it was held that claim of the complainant was not covered under Clause 10 of the Policy as amputation of only one hand does not constitute disability. To same effect is the view taken by the State Commission, Punjab, Chandigarh in case First Appeal No. 158 of 2005 decided on 7. 2. 2006, Life Insurance Corporation of India and Another v. Lachman Ram, IV (2006) CPJ 292. In Revision Petition No. 2263 of 1999 decided on 16. 3. 2006, K. V. Raghavan v. LIC of India (NC), the driver-complainant had lost his right eye in an accident of falling acid on his right eye. He filed a claim against Life Insurance Corporation of India under the policy which was repudiated in terms of Clause 10 (4) of the conditions of the policy. The repudiation was upheld and the appeal filed by the complainant was dismissed while making the following observations: "the plain reading of the said clause would indicate that the case of the petitioner is not covered by the said clause for the losts of one eye would not make the complainant unable to do any other work or profession and he would not be able to earn or obtain any wages, compensation or profit. This clause covers 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 alone. This may cover a case where a person suffers such an injury to the spinal cord that he cannot move at all. Since the case of the complainant is not covered under the policy in view the definition of "disability" in Clause 10-4 of the terms and conditions, we feel that the complainant cannot claim any indemnification under Clause 10-4 of the terms and conditions. "

The ratio of the above mentioned cases would fully apply to the facts of the present case because even as per version of the complainant he has lost his right hand and has not been rendered totally handicapped of doing his work. All these aspects have not been taken into consideration by the District Forum while accepting the complaint and for that reasons the order of the District Forum under appeal cannot be sustained. For the aforesaid reasons while accepting the appeal the impugned order is set aside and the complaint is dismissed. Appeal allowed.