1. Insurance claim for accident benefit — Death following heart attack and fall from motorcycle — Repudiation of claim by insurer. (Para 1 , 2 , 3 , 4 )
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2019 Supreme(SC) 486
SUPREME COURT OF INDIA
Dr Dhananjaya Y. Chandrachud, Hemant Gupta, JJ.
Smt. Alka Shukla – Appellant
Versus
Life Insurance Corporation Of India – Respondent
Civil Appeal No. 3413 of 2019 (Arising out of SLP (C) No. 32335 of 2016)
Decided on : 24-04-2019
Important Points
IMPORTANT POINTS
(1) Accident postulates a mishap or an untoward happening, something which is unexpected and unforeseen.
(2) In order to sustain claim under accident benefit cover, it must be established that assured has sustained a bodily injury which resulted solely and directly from accident.
(1) Accident postulates a mishap or an untoward happening, something which is unexpected and unforeseen.
(2) In order to sustain claim under accident benefit cover, it must be established that assured has sustained a bodily injury which resulted solely and directly from accident.
Subject
INSURANCE - ACCIDENTAL INSURANCE
Act Referred
Headnote
(A) Consumer Protection Act, 1986 – Section 23 – Insurance – Life Policies – Death due to acute myocardial infarction (Heart Attack) – Repudiation of death claim by NCRDC reversing orders passed by Fora below awarding compensation – In order to sustain claim under accident benefit cover, it must be established that assured has sustained a bodily injury which resulted solely and directly from accident – There must exist a proximate causal relationship between accident and bodily injury – Accident must be caused by outward violent and visible means – Expression “outward violent and visible” signifies that cause of accident must be external – Injury must be the cause of death within period of 180 days – There has to be proximate relationship between injury and death to exclusion of all other causes – There is no material on record to indicate that assured sustained specific injuries as a result of a fall from motorcycle or that injuries were caused by outward, violent and visible means which was sole and proximate cause of his death – There is no direct nexus or causation between assured suffering a heart attack and injuries sustained in an accident by outward, violent and visible means – Heart attack had distinct effect of insured falling off from his motorcycle – There is no evidence to show that accident took place as a result of any outward, violent and visible means – Assured died as a result of a heart attack which was not attributable to accident – Judgment of NCDRC upheld. (Paras 9, 11, 12 and 13)
(B) Words and Phrases – Accident – Import – Accident postulates a mishap or an untoward happening, something which is unexpected and unforeseen – A bodily injury caused by an accident is not limited to any visible physical marks in form of lesions, abrasions or broken bones on body – A bodily injury can be caused by violent means that are external and relate to use of strong physical force or even threatening someone by use of violent words or actions – There exists divergence of opinion on whether ‘accidental means’ and ‘accidental death’ are to be read as similar or whether in order for an accidental insurance claim to succeed, means causing the injury or death also have to be accidental in nature. (Para 7)
Facts of Case:
Insurance matter. Issue before this Court is: (i) whether the assured’s death was due to a bodily injury resulting from an accident caused by outward, violent and visible means; and (ii) whether injury was proximately caused by accident. It is only when both the questions are answered in the affirmative that the complainant would be entitled to claim under the policy. Assailing decision of NCDRC setting aside award of compensation, spouse of insured has filed present appeal.
Findings of Court:
No post mortem of the deceased or police investigation was conducted. In absence of a post mortem report indicating nature of injuries sustained by insured, Court would have to rely upon medical report that indicates the exact cause of death. There is no material on record to indicate that the assured sustained specific injuries as a result of a fall from the motorcycle or that the injuries were caused by outward, violent and visible means, which was the sole and proximate cause of his death. There is no direct nexus or causation between the assured suffering a heart attack and injuries sustained in an accident by outward, violent and visible means. Nothing has been brought on record to show that injuries sustained by falling from motorcycle aggravated the assured’s condition that eventually led to his death.
Result : Appeal dismissed.
Legal Category Hierarchy
Advocates Appeared:
For the Appellant :Ms. Divya Roy, Advocate,
Ms. Indra Sawhney, Advocate.
For the Appellant :Ms. Divya Roy, Advocate,
Ms. Indra Sawhney, Advocate.
Table of Contents
2. Whether death resulted from injuries sustained in a fall or whether a heart attack caused the fall — Distinction between accidental means and accidental result. (Para 6 )
3. Absence of evidence showing bodily injury from the fall caused the heart attack — Medical reports indicate heart attack as the primary cause of death. (Para 10 , 11 , 12 )
4. Accident benefit requires proof of bodily injury resulting solely and directly from an accident caused by outward, violent, and visible means as the proximate cause of death. (Para 9 )
5. Appeal dismissed — Judgment of the National Consumer Disputes Redressal Commission upheld. (Para 13 )
6. What constitutes an accident in the context of insurance policies?
An accident is an unforeseen and unexpected occurrence or event that is not inherent in the normal course of events, proceeding from an unknown cause or an unusual effect of a known cause. (Para 7 )
7. Does bodily injury in accident policies require visible external marks?
No, bodily injury is not limited to external trauma, lesions, or broken bones; it can include internal injuries, provided the cause is external and not attributable to natural causes. (Para 7 )
8. What is the distinction between accidental means and accidental result?
Some jurisdictions distinguish between the means used (which may be intentional) and the result (which is accidental), while others view them as inseparable, focusing on whether the consequence was unexpected. (Para 8 , 9 )
9. What are the cumulative conditions for claiming accident benefit under the analyzed policy?
The assured must sustain a bodily injury resulting solely and directly from an accident caused by outward, violent, and visible means, which then solely and directly results in death within 180 days. (Para 9 )
JUDGMENT
Dr Dhananiava Y Chandrachud, J.
The present appeal arises from a judgement of the National Consumer Disputes Redressal Commission [NCDRC] which reversed the judgment of the Chhattisgarh State Consumer Disputes Redressal Commission [SCDRC]. The SCDRC had affirmed the view of the District Consumer Disputes Redressal Forum, Durg [the District Forum] allowing an accident insurance claim.
2. The spouse of the appellant obtained three insurance policies from the Life Insurance Corporation of India [LIC of India]:
(i) New Bima Gold Policy;
(ii) LIC Jeevan Tarang Policy; and
(iii) Twenty Years Money Back Policy with profits and accident benefit.
The details of the policies are tabulated below:
Policy No
Policy Number
Date of Commencement
Total Term
Sum Assured (Rs)
Premium (in Rs)
1
Bima Gold Policy370473369
27.06.1992
75-20
50,000
3188/- yearly
2
LIC New Bima Gold Policy384067139
10.08.2006
178-10
2,00,000
21134/- yearly
3
Twenty Years Money Back Policy (with accident benefit) 385316764
11.01.2008
179-12
2,00,000
7641/- half-yearly
Condition 10 (2) of the first policy, condition 10 (b) of the second policy and condition 11 (b) of the third policy contain a stipulation for accident benefit, on which the controversy in the present case rests. The stipulation in the New Bima Gold Policy in relation to accident benefit is extracted below, in so far as is material:
"(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 meansand such injury shall within 180 days of its occurrence solely, directly and independently of all other causes result in death of the Life Assured."
(Emphasis supplied)
The stipulations in the other two policies are similar, where the accident benefit was payable if the assured sustained any bodily injury resulting solely and directly from the accident caused by "outward, violent and visible means", and that such injury "solelyand directly and independently of other causes" results in death. On 3 March 2012, the spouse of the appellant, while riding his motorcycle, experienced pain in the chest and shoulder, suffered a heart attack and fell from the motorcycle. He was attended to at 10:10 pm on 3 March 2012 by Dr Ajay Goverdhan, a general physician. He was referred to Dr SS Dhillon who diagnosed the mishap as having been caused by "a sudden fall from the bike". Dr Dhillon noted that the patient was experiencing pain in the left side of the chest and in the shoulder and there was a myocardial infarction. He referred the patient to a specialist medical center. He was taken to the Chandulal Chandrakar Memorial Hospital at Bhilai. The OPD card notes the following position at admission:
"Sweating, radiating to left shoulder and 2 episodes of vomiting Following this patient was taken to Dhillon Nursing Home where ECG taken showed Ant. Wall M1. He was given loading dose of Ant. Platelet and Referred. On his way to the hospital, Pt. collapsed. On reaching here, on examination Pt. had so sign of life AHR, O/nil, BP-NR, Pupil B/L fixed."
As the above diagnosis indicates, the patient had died by the time that he had been admitted to the above hospital. The report of the physician indicates that death had occurred due to an acute myocardial infarction.
3. Dr Ajay Goverdhan furnished his report in Claim Form B indicating that: (i) the cause of death was an acute myocardial infarction; and (ii) the symptoms of illness were pain in the chest and shoulder. The insurance claim was settled in respect of the basic cover of insurance. However, the insurer repudiated the claim under the accident benefit component of the insurance policy on the ground that the death of the insured had occurred due to a heart attack and not due to an
