The significance of medical evidence in determining the cause of death and the interpretation of insurance claim terms such as 'accident' and the requirement of lodging First Information Report and post-mortem examination.

Mr. Justice S.K. Dubey, President—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.

2. The facts and evidence in the two cases are common, hence are disposed of by this common order.

3. 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).

4. 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.

5. 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.

6. 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.

7. 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 ticke