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NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DELHI
Ajit Bharihoke, Presiding Member and Suresh Chandra, Member
LIC of India Through Assistant Secretary
& Ors. —Petitioners
versus
Kamlesh Through Shri Jai
Bhagwan —Respondent
Revision Petition No. 4476 of 2012
(Against the order dated 30.07.2012 in First Appeal No. 1398/2011 of the State Commission Haryana, Panchkula)
Decided on 9.1.2014
Counsel for the Parties:
For the Petitioners:Mr. Ashok Kashyap, Advocate.
For the Respondent:Mr. Harikesh Singh, Advocate.
IMPORTANT POINT
Word ‘accident’ used in insurance policy means accident as understood in common parlance and it does not include disability caused by medical reasons.
Headnote:Consumer Protection Act, 1986—Sections 15, 17, 19 and 21—Insurance—100% physical disability—Insurance claim repudiated on ground that disability suffered by complainant was not a consequence of accident—Complaint allowed by Fora below—District Forum as also State Commission while allowing complaint and insurance claim of respondent have observed that physical ailment which resulted in permanent disability suffered by complainant was sudden and unexpected and it is covered under definition of accident and as such, repudiation of claim under insurance policy was unjustified—Word ‘accident’ in context of insurance policy means an event which is unintended and unforeseen and which is something that does not occur in usual course of events—Headache followed by permanent disability to complainant occurred unexpectedly but this does not mean that medical ailment is covered by word ‘accident’ as envisaged in insurance policy—Fora below have committed grave error in allowing complaint by giving expansive definition to word ‘ accident’ which is not envisaged by insurance contract—Impugned orders being contrary to law laid down by Supreme Court cannot be sustained—Orders passed by State Commission and District Forum set aside and consumer complaint dismissed.
(Paras 8, 11, 12 and 13)
Ajit Bharihoke, Presiding Member—This revision is directed against the order of the State Commission dated 30.07.2012 whereby State Commission Haryana Panchkula dismissed the appeal preferred by the petitioners opposite parties against the order of the District Forum Jind dated 09.08.2011.
2. Briefly put, the facts relevant for the disposal of this revision petition are that complainant respondent purchased an insurance policy worth Rs.25000/- from the petitioner on 10.05.2001 with half year premium of Rs.904/-. The complainant respondent dutifully paid the insurance premium. The complainant unfortunately developed complaint of severe headache in the month of November 2003. On 25.12.2003, the complainant became unconscious and she was taken to All India Institute of Medical Sciences, New Delhi. There she remained under treatment w.e.f. 02.01.2004 to 27.01.2004 as an impatient. Her treatment is still going on and she has become 100% disabled. The complainant filed the claim under the insurance policy alongwith 100% permanent disability certificate issued by the Board of Doctors of General Hospital Jind on 02.06.2008. The opposite party, however, repudiated the claim. This led to the filing of the consumer complaint by the complainant Ms. Kamlesh through her husband and nominee Jai Bhagwan.
3. The petitioners opposite parties contested the complaint by filing written statement wherein opposite parties took the plea that the complaint was barred by limitation. On merits, it was alleged that disability suffered by the complainant was not a consequence of an accident. As such, the petitioners opposite parties was not bound to pay the claim as per terms and conditions of the insurance policy.
4. The District Forum on perusal of the pleadings and evidence accepted the complaint with following observations:
“The medical certificate of All India Institute of Medical Sciences, New Delhi has issued a certificate in respect of the complainant, Kamlesh, which clearly mention that “sudden onset severe headache and loss of consciousness on 25.12.2003, dysphagia from 30.12.2003, weakness of right side of body-1.1.2004. K/C/O of Dm/Hypertension on irregular treatment.
The disease was sudden unexpected and unfortunate which may be covered under definition of accident. Hence the opposite party is having deficiency of service for non-payment of insurance amount to the complainant.
In view of the above facts and circumstances of this case, the complaint of the complainant is accepted. Therefore, the opposite party no.1 is hereby directed to pay the full amount of policy alongwith all other benefits accrued on account of the said insurance policy within a period of 30 days positively. Further, the premium paid by the complainant after November 2003 shall also be returned to the complainant alongwith the amount of insurance claim. If the amount is n ot paid within stipulated period, the interest @ 9% p.a. will be paid by the opposite party w.e.f. the date of filing the complaint till realization of the amount benefits. The parties will bear their own costs.”
5. Being aggrieved of the order of the District Forum, the petitioners opposite parties preferred an appeal before the State Commission Haryana Panchkula and the State Commission dismissed the appeal. This has resulted in filing of the revision petition.
6. Mr. Ashok Kashyap, learned counsel for the petitioners has contended that the impugned orders are not sustainable, being based on incorrect appreciation of law and facts. Expanding on the argument, learned counsel for the petitioners has taken us through the complaint as also the terms and conditions of the insurance policy particularly clause 10-2 of the policy which deals with the accident benefit. Learned counsel for the petitioners argued that perusal of the aforesaid provision would show that accident benefit in respect of permanent disability has resulted because of involvement of the life assured in the accident. However, in th
