LIFE INSURANCE CORPORATION OF INDIA vs Vaijayanti Bai

THE Life Insurance Corporation of India (for short the ''LIC'') against the order dated 1.10.2000 passed in Case Nos. 616/1999 and 617/1999 by the District Consumer Disputes Redressal Forum, Gwalior (for short, the ''District Forum'') has filed two separate appeals.

THE facts and evidence in the two cases are common, hence are disposed of by this common order. Admittedly, life assured Late Nawab Singh obtained two policies, one Twenty Years Money Back Policy with Profits (With Accident Benefit) No. 201054131 of the table and term 75 -20, date of commencement 28.9.1992 of which half yearly premium was Rs. 3,420/ - and the other Endowment Assurance Policy with Profit (With Accident Benefit) No. 200822182 of the table and term 14 -20, date of commencement 28.3.1996 of which half yearly premium was of Rs. 2,984/ -. On 21.12.1998 the life assured when he was in his Foreign Liquor Shop at Malanpur slipped and fell down from staircase where he received the head injury. He became unconscious and was taken by Mahendra Pratap Khurana immediately to Dr. J.S. Namdhari who found him unconscious and vomiting and a mark of injury on his temporal region which is evident from the certificate dated 15.3.1999 issued by Dr. J.S. Namdhari, MD (Medicine).

THE respondent submitted two separate claim forms wherein the circumstances of the accident and details were given. The LIC appointed Investigator who recorded the statements of witnesses and gave a report wherein, the Investigator found inconsistency in the statements of the witnesses. In the absence of the First Information Report and post -mortem report and the report of the Investigator, the LIC made the payment of the sum assured of Rs. 1,00,000/ -, but did not make the payment of the accident benefit. The respondent filed two separate complaints, which were resisted. The District Forum dismissed the complaints holding that the complaint involves complex issues. The appeal Nos. 899/2000 and 900/2000 preferred decided on 3.6.2002 were allowed and the cases were remitted for their decision afresh in accordance with law after affording opportunity to the parties to adduce evidence.

AFTER remand, the respondent filed affidavit of Dr. J.S. Namdhari to prove the certificate. However, the LIC did not file any additional evidence, nor the affidavit of the Investigator to prove the report and the statements recorded during the investigation. The District Forum after appreciation of evidence held that primary cause of the death was head injury due to fall from the staircase resulting in respiratory cardiac failure. Hence, in terms of the policies ordered to pay the amount of accident benefit of each policy of Rs. 1,00,000/ - with interest thereon at the rate of 9 per cent per annum from 30.8.1999 besides Rs. 2,000/ - as costs in each case. After hearing learned Counsel for the parties and on perusal of the record, we are of the opinion that in the circumstances and facts, which have come on record the life assured received injuries due to slip and falling down from the staircase from his foreign liquor shop, in the circumstances it was not necessary to lodge a First Information Report as the fall was not due to any violent act of any outside agency. As the First Information Report was not lodged, the question of performance of autopsy also does not arise as it was not a medico legal case.

THIS Commission in a case of accidental fall where First Information Report and post -mortem was not produced has considered the question in New India Assurance Co. Ltd. v. Ramkushal Kushwaha [Appeal No. 1297 of 2001, dated 18.12.2002] and observed in Paras 5 to 7 thus: ''5. After hearing learned Counsel for the parties and on reappraisal of evidence on record, we are of the opinion that the finding recorded by the District Forum that death was due to accidental fall, does not call for any interference in view of the fact that the Gram Panchayat gave the certificate and in OPD ticket the cause of injuries is written by the doctor, when she was taken to the Hospital. Therefore, in the absence of any evidence in rebuttal, it cannot be held that the insured person has not met with an accident and did not receive head injuries by slip and fall from the stairs. Non -production of First Information Report, post -mortem report and final report would not mean that death was not due to injuries received in accident. 6. True, condition No. 2 of the policy lays down that in the event of death, to make a post -mortem examination of the body of the insured and such evidence as the company may from time -to -time require. However, in a case where the injuries are received in an accident at home, the question of lodging First Information Report, post -mortem or final report does not arise. In such circumstances, though the Insurance Company repudiated the claim in the absence of papers but, that does not mean that the claim was not payable as death was caused due to accident, which is covered under the policy. 7. In case of Branch Manager, Life Insurance Company of India v. Raj Kumar Mishra, I (2000) CPJ 113 of the Uttar Pradesh State Consumer Disputes Redressal Commission, Lucknow, a case where the deceased died due to Saree being caught in wheel of motor -cycle whereby she received head injuries considered the question of FIR, post -mortem report and Final report and observed in Paras 7 and 8 thus : 7. Thus from the perusal for the dictionary meaning of accident and accidental it will be clear that any event which happens without any cause or is not expected to be caused in normal circumstances is covered under it. It is also an unfortunate event causing physical harm or damage caused by some unintentional act. 8. Thus the event which happened in the present case was merely an accident. It is not a routine or a normal course that the Saree will be caught between the spokes of a moving vehicle and will cause fall of a person sitting on the motor -cycle or any other two -wheeler. It does not occur in normal course of life. Thus the event which occurred in the present case is merely by chance and is covered by the word accident. A word is to be given its normal meaning by which it is understood by a common man. Even a common man will say that if such an event happens, it is by chance accident and not a natural phenomenon occurring so often. Thus, the repudiation of the claim of the claimant on this ground is totally baseless and devoid of any reasoning which has been adopted by the Insurance Company merely to cause harassment to the complainant.''

IN the case in hand from the certificate of Dr. J.S. Namdhari, which has been proved by his affidavit clearly shows that when the life assured brought to his Nursing Home, he was found unconscious and vomiting with injury marks on the right temporal region, who succumbed to injuries. The LIC has not cross -examined Dr. J.S. Namdhari nor adduced any evidence except of producing the statements recorded during investigation. Even the report of the Investigator supported by affidavit has not been filed. The LIC contends on the basis of the report of the Investigator wherein inconsistency is found in the statements recorded by the Investigator about the fall from staircase or roof of the foreign liquor wine shop and that the investigator reported death due to heart attack, which does not clearly establish that the death was not because of the head injuries coupled with cardiac respiratory failure. Cardiac respiratory failure is also the collapse of system because of damage caused in brain and it is one of the most probable causes which is because of the head injury resulting solely and directly from the accident caused due to slip and fall from the staircase. In the book ''The Essentials of Forensic Medicine and Toxicology'' by Dr. K.S. Narayan Reddy, Twenty -first Edition 2002 at page 211 in the caption of ''Concussion of the Brain'', it is stated that the ''Concussion is a state of temporary unconsciousness, due to partial or complete paralysis of cerebral function, due to head injury, comes to immediately after injury, is always followed by amnesia and tends to spontaneous recovery.

AT page 214 of the book in caption of ''Cause of Death in Head Injuries'', it is stated that most deaths are due to damage to vital cerebral areas, located around the posterior hypothalamus, midbrain and medulla. Usually respiratory failure or paralysis is followed by permanent cardiac arrest.

IN ''Bailey and Loves, short Practice of Surgery, 23rd Edition at Page 550, while dealing ''Primary brain injury'', and ''Cerebral Concussion'' it is stated that this is a clinical diagnosis and is manifested by temporary dysfunction that is most severe immediately after injury and resolves after a variable period. It may be accompanied by autonomic abnormalities including brady -cardia, hypotension and sweating. Loss of consciousness often, but not invariably accompanies concussion. Amnesia for the event is common and varying degrees of temporary lethargy, irritability and memory dysfunction are hallmarks. For the assessment of a head injury points to determine from the history are given at page 552 of the book which are, period of loss of consciousness, period of post -traumatic amnesia, cause and circumstances of the injury and presence of headache and vomiting.

FROM the medical references and medical certificate proved by the affidavit of Dr. J.S. Namdhari, it is evident, that the life assured had all the symptoms of head injury, which resulted in cardiac respiratory failure. The LIC, in support of the defence, has not proved the report by filing the affidavit of the investigator nor filed affidavits of the witnesses where statements were recorded by the Investigator. It is well settled that the evidence collected during the investigation is no evidence unless it is turned into legal evidence. The decision of the Supreme Court in Virendra v. State of Delhi, JT (1993) 3 SC 31, and Kaptan Singh v. State of M.P.AIR 1997 SC 2485, followed by this Commission in Smt. Usha Pavaiya v. United India Insurance Co. Ltd.

MOREOVER , even assuming for arguments sake that in the statements of the witnesses, there is inconsistency about the place of fall, that will not make much difference as the fact remains that the life assured received injuries in his right temporal region by fall, which falls within the ambit of the ''accident''. In such circumstances, in the absence or any evidence in rebuttal that the claim is false, in our opinion, in not making the payment of accident benefit merely on the basis of the report of the investigator that the life assured died as a result of heart attack, which has not been substantiated by leading cogent and reliable evidence by the LIC was not justified.

HOWEVER , the award of interest at the rate of 9 per cent per annum is excessive in view of the changes in economy and the policy of the Reserve Bank of India whereby the interest rate has been lowered down, the ends of justice would meet if the interest is awarded at the rate of 6 per cent per annum.

ACCORDINGLY , the LIC is ordered to pay the amount as ordered by the District Forum with interest thereon at the rate of 6 per cent per annum, from 30.8.1999 till payment within a period of two months from the date of receipt of certified copy of this order. In the result, the appeals are partly allowed. The order of the District Forum shall stand modified as indicated hereinabove. A copy of this order be conveyed to the parties and a copy be sent to the District Forum along with the record of the case. Appeals partly allowed. -