Life Insurance Corporation of India vs SURENDRA KUMAR TRIPATHI

THIS is one of the matters in which after hearing parties judgment was reserved. But before the judgments were prepared and delivered one of the Members ceazed work. In the interest of justice this case alongwith remaining 42 cases of such nature were listed for further hearing. THIS is how this matter has come up for hearing again today.

THESE four appeals have, therefore, been listed for further hearing in pursuance of notice to the learned Counsel for the parties. Two appeals are by the Life Insurance Corporation of India (in short ''LIC'') against the judgment of the District Forum, Mirzapur decreeing the claim of the complainant holding that amputation of one leg at the knee level constituted a permanent and total disability and, therefore, he was entitled to the accidental benefit clause envisaged in those two policies. Mr. Rajesh Chadha has argued two other appeals also which have been filed by the complainant with the allegation that compensation awarded by the District Forum was inadequate.

The only issue coming up for discussion in the instant appeals is whether the amputation of only one leg at or from the knee level would constitute permanent and total disability within the meaning of the law entitling the complainant to get the benefit which he had claimed through the complaint before the District Forum because the LIC repudiated the said claim and was/and is of the view that the type of injuries sustained does not come within the purview of permanent and total disability as defined in the policy bond.

BEFORE proceeding further, it may be pointed out that Mr. B.L. Jaiswal appearing for the LIC has said that in view of the decision of the National Commission reported in II (1997) CPJ 45 (NC), LIC of India v. Ramesh Chandra, no scope is left for interpreting the said clause 10 of the policy bond describing therein the accident benefit and its payability. Mr. Jaiswal argued that this Commission has followed the aforesaid decision of the National Commission in principle in Appeal No. 78/1999, Branch Manager, Life Insurance Corporation of India & Anr. v. Subodh Kumar, where both the legs of the complainant stopped working as a result of injuries. The complainant therein had sustained injuries after felling down from a buggi and got hurt in the spinal cord. Mr. B.L. Jaiswal has relied upon the following observations in Ramesh Chandra''s case (supra) : "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 wrists 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 ankle 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 the 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 clause is only in cases of amputation of one hand at or above the wrist and one foot at or above ankle. It bears repetition 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."

In fact Mr. Jaiswal emphasises the caution which has been expressed by the National Commission in the aforesaid paragraph that the amputation of one hand does not fall within the deeming definition constituting disability in terms of Clause 10(A) of the policy bond. Before the said expression, the National Commission has observed that the District Forum as well as 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 by Clause 10.

MR. Jaiswal also placed implicit reliance on the decision of this Commission in Appeal No. 78/1999 Branch Manager, Life Insurance Corporation of India & Anr. v. Subodh Kumar. "Thus we find that the complaint could not have been decreed by the District Forum as the disability which has occurred to the complainant is not covered by condition 10(4) of the policy. However, it would be desirable to mention that in such case where the complainant is not able to do any work as in the present case where both the legs are useless the disability should be taken by the Insurance Company as total and Clause 10(4) should be suitably amended by the Insurance Company and a liberal view should be taken by the Insurance Company in such cases where injury is sufficient to disable a person completely."

Mr. R. Chadha, learned Counsel for the complainant vehemently argued that the National Commission in the aforesaid decision of Ramesh Chandra''s (supra), did not examine the issue involved in the relevant larger perspective but confined its observation to the fact involved in that case alone and, therefore, this Commission should endure to find a way out so that real justice is done and a policy holder who has lost his one leg permanently, who always has to walk with two stretchers, who is unable to dispense with normal routine work of a human being because of the said accidental injury and loss of leg, one who by very appearance demonstrates his permanent disability, one who is always dependent on the mercy and care of a third person must be included within the meaning of permanent disability. In this connection, reliance was placed by Mr. Chadha on an averments made in paragraph 13 of the written statement of the LIC before the District Forum which contain an opinion of the Medical Officer of the LIC who was apparently consulted while deciding the claim of the complainant, the relevant portion of which is quoted below : " xxx xxx xxx xxx" Mr. Chadha also placed reliance on the disability report relating to the complainant and the Chief Medical Officer''s report indicating that the complainant has suffered an injury which can be termed as total and permanent disability.

THE other argument of Mr. Chadha was that such policy holder as the complainant, filling the proposal form on whatever is explained to them by the Agent and have no nexus to the policy bond which comes quite after sometime i.e. after the proposal is received with the first premium receipt and the acceptance letter follows and thereafter in due course the policy bond reaches to the policy holder. In this view of the matter, it was strongly contended that at the time of offering the proposal form, a contract with the LIC for the Life Insurance with accidental benefit, the policy holder-complainant had no other term except what is contained in paragraph 10 of the policy bond. THErefore, the Commission should refrain from referring to the said definition of permanent disability.

THE third argument of Mr. Chadha was that even if it is assumed for a moment that the policy bond may be referable in determining the claim of the complainant, since expression ''total'' and ''permanent'' are not defined and explained either in the policy bond or in the LIC Act, 1956, or under Insurance Act, 1938, preference must be given to the definition of these two expressions as found in the dictionaries particularly law dictionary. THEse expressions are legal terminology generally used for determining claims of the persons suffering from accidental injuries and claiming compensation or policy amount as the case may be. In this connection, therefore, he has placed reliance on the definition of the aforesaid two terms as appearing at page 462 in Black''s Law Dictionary, the relevant portion of which is quoted below : Permanent disability : Incapacity forever from returning to work formerly performed before accident, though this incapacity may be either total or partial. See also permanent disability. Total disability : Total disability to follow insured''s usual occupation arises where person is incapacitated from performing any substantial part of his ordinary duties, though still able to perform a few minor duties and be present at his place of business. "Total disability" within an accident policy does not mean absolute physical disability to transact any business pertaining to insured''s occupation, but disability from performing substantial and material duties connected with it. THE term may also apply to any impairment of mind or body rendering it impossible for insured to follow continuously a substantially gainful occupation without seriously impairing his health, the disability being permanent when of such nature as to render it reasonably certain to continue throughout the life-time of insured. See also permanent disability; wholly disabled. Mr. Jaiswal in his own persuasive style refuted the arguments of Mr. Chadha by saying that proposer makes specific reference to the table under which he proposes to have the policy and, therefore, as soon as that proposal is accepted he is supposed to know what the policy bond is going to talk about. He further said that Doctor''s opinion referred to in paragraph 13 is relevant because it shows that complainant is able to do all normal work like a normal human being in a sitting position, therefore, it is immaterial whether all routine work could be done by him or not. He further said that the expression ''total'' and ''permanent'' as used in Clause 10 of the policy bond fully explains the LIC''s understanding of those two terms and, therefore, there is no need at all to go to the Law Dictionary. Lastly he has again said that only distinction on the case of Ramesh Chandra (supra), was that the complainant therein had lost one hand permanently as a result of the accident whereas in the instant case the complainant had lost one leg permanently. He, therefore, says that even on facts no distinction can be made and the Commission should be bound by said decision.

In view of the aforesaid discussion the complainant''s complaint must not have been decreed.

MUCH though the Commission feels as expressed by this Commission earlier in the case of Subodh Kumar, it is high time that the LIC or the Legislature prefer to consider the need to bring about such amendments in the regulations under which Clause 10 of the policy bond has been drafted which undoubtedly require scrutiny. In view of aforesaid discussion the Appeal No. 1848/SC/2001 and Appeal No. 1849/SC/2001 filed by the Life Insurance Corporation of India are allowed and Appeal Nos. 2816/SC/2001 and 2817/SC/2001 filed by the complainant are dismissed. The parties shall bear their own costs.

LET copy of this order be made available to the parties as per rules. Let the original judgment be kept in Appeal File No. 1848/SC/2001 and the certified copy of this order be placed in Appeal File Nos. 1849/SC/2001, 2816/SC/2001 and 2817/SC/2001 which shall also be governed by this judgment. Ordered accordingly.