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NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION
B.N.P. Singh, Presiding Member and S.K. Naik, Member
SBI LIFE INSURANCE COMPANY LTD. - Appellant
Versus
Y. DAYAMANI - Respondent
Revision Petition No. 3375 of 2009 from Order dated 14.7.2009 in Appeal No. 1586 of 2008 of State Commission, A.P.
Decided on : 25-05-2010
Mr. Rakesh Malhotra, Advocate, for the Appellant; Mrs. K. Radha, Advocate, for the Respondent
The central legal point established in the judgment is the interpretation of the Group Insurance Policy's Clause 6 of Schedule II and the determination of what constitutes an accidental death under the policy.
Headnote:
Insurance - Group Insurance Policy - Clause 6 of Schedule II - Acute Myocardial Infarction - [Clause 6 of Schedule II] - The court discussed the interpretation of Clause 6 of Schedule II of the policy, which stated that the insurer is not liable to pay the assured sum within the first 45 days of the commencement of the policy, except in the case of an accidental death. The court analyzed whether the death due to Acute Myocardial Infarction fell within the category of accidental death or not, considering the medical history of the deceased and the circumstances of the heart attack. The court concluded that a death due to heart attack in the normal course would not fall in the category of an accidental death, and therefore, the State Commission's view declaring it as a case of an accidental death was erroneous. The court set aside the State Commission's order.
Fact of the Case:
The respondent widow filed a complaint against the petitioner SBI Life Insurance Company Ltd., alleging unjustifiable repudiation of her claim after the death of the life assured. The District Forum rejected the petitioner's objections, but the State Commission allowed the appeal, directing the petitioner to pay the claim amount. The petitioner filed a revision petition against this order.
Finding of the Court:
The court held that the death due to Acute Myocardial Infarction did not fall within the category of accidental death, as determined by the State Commission. It set aside the State Commission's order and accepted the revision petition.
Issues: The main issue was whether the death due to Acute Myocardial Infarction fell within the category of accidental death as per the Group Insurance Policy.
Ratio Decidendi: The court's decision was based on the interpretation of Clause 6 of Schedule II of the policy and the determination that a death due to heart attack in the normal course would not be considered an accidental death.
Final Decision: The court set aside the State Commission's order and accepted the revision petition filed by the petitioner.
ORDER
S.K. Naik, Member - Petitioner SBI Life Insurance Company Ltd. was the opposite party before the District Consumer Disputes Redressal Forum-II, Krishna at Vijayawada where the respondent widow, being the legal heir of the life assured had filed a complaint on the ground that the petitioner SBI LIC had unjustifiably repudiated her claim.
2. Before the District Forum, the petitioner/opposite party had advanced three grounds:
According to them, this being a Group Insurance Policy, there was no privity of contract between them and the life assured. This objection had been over-ruled by the District Forum holding that since the complainant was a beneficiary under the policy for which premium was paid by the life assured, though as a member of a Group Insurance Scheme, the petitioner Insurance Company was bound to render the service under the policy and, therefore, it cannot be said that there was no privity of contract between them.
The second contention raised by the petitioner/opposite party was that there was suppression of material fact inasmuch as the life assured has failed to disclose that he was suffering from Diabetes Mellitus for over a period of five years prior to the taking of the policy. The District Forum rejected this contention too holding that Diabetes Mellitus was not included in the list of critical illness in the declaration.
However, taking cognizance of Clause 6 of the Schedule II of the policy which contained an exclusion period of 45 days, subject however, to any death due to accident and holding that the life assured having died due to Acute Myocardial Infarction (heart attack) which did not amount to an accident, the District Forum had dismissed the complaint.
3. Aggrieved thereupon, an appeal was preferred by the respondent/complainant before A.P. State Consumer Disputes Redressal Commission. The State Commission, however, over-ruled the view taken by the District Forum that death due to Acute Myocardial Infarction (heart attack) was an accidental death and, therefore, the claim of the respondent/complainant very much fell within the ambit of the policy. The appeal, accordingly was allowed by setting aside the order of the District Forum directing the petitioner Insurance Company to pay a sum of Rs. 5.5 lakh along with 9% interest p.a. from 1.12.2006 till payment and further the petitioner-Insurance Company was directed to adjust the payment towards the loan account of the deceased-life assured.
4. Dissatisfied with this order dated 14.7.2009 of the State Commission that the opposite party Insurance Company has filed this revision petition.
5. We have heard the learned Counsel for the parties and have perused the records of the case.
6. Facts with regard to the life assured having been admitted as a member of the 'super Suraksha Group Insurance Scheme w.e.f. 9.11.2006 is not in dispute. Nor is there any dispute with regard to the life assured having borrowed a home loan of Rs. 5.5 lakh linked to the insurance. There is also no dispute with regard to the death of the life assured on 1.12.2006 due to Acute Myocardial Infarction (heart attack) which is within 22 days of the date of commencement of risk. Having said so, we may take note of Clause 6 of schedule II of the policy which reads as under:
Benefits:
"In the event of the death of the member at any time, after 45 days (except for Accidental Death), from the date of commencement of risk, subject to the policy being in full force, but not later than the member completing the age of 70 years, to pay the Grantees or any person so authorized by the Grantees the sum assured."
7. It is clear from this clause that in the event of the death of a member, the insurer (petitioner in this case) is not liable to pay the assured sum within the first 45 days of the commencement of the policy ; subject to the exception of an accidental death. In other words, the insurer would be liable even within the first 45 days in case of only an accidental death. In this case, life ass
