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NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DELHI
Subhash Chandra, Presiding Member and AVM J. Rajendra, AVSM VSM (Retd.), Member
Sadhna Agrawal – Appellant
versus
United India Insurance
Company Limited – Respondent
First Appeal No.1740 of 2019
(Against the Order dated 03/06/2019 in Complaint No. 8/2019 of the State Commission Chhattisgarh)
Decided on 27.9.2023
Counsel for the Parties:
For the Appellant:Mr. Rajesh Kumar Bhawnani, Advocate
For the Respondent:Mr. Abhishek Gola, Advocate
IMPORTANT POINTS
(1) Interpretation of Insurance Policy - It is an established position that the terms of an insurance contract are to be understood and executed as stated thereat. There is limited scope for either party to introduce new conditions or interpret such conditions in their absence.
(2) Criminal Intent - It is an established principle of jurisprudence that for a criminal intent to be established there shall be a reasonable nexus between the actions of such person and the outcome of the same.
(3) Burden of Proof - In any case, the burden of proving that a claim falls under an exception clause in on the party claiming it.
(4) “Accident” - It is also clear that, by no stretch of imagination, a death resulting from an ‘accident’ can be said to have arisen/resulted from the insured committing a breach of law with criminal intent’.
Headnote:
Consumer Protection Act, 1986 – Section 19 [Consumer Protection Act, 2019 – Section 51] – Appeal - Services – Insurance – Repudiation of Claim – Denial of Claim – Deficiency of Service – Attributed - It is an established position that the terms of an insurance contract are to be understood and executed as stated thereat. There is limited scope for either party to introduce new conditions or interpret such conditions in their absence. In the event of absence of clarity, the decision needs to be in favour of the insured. Further, in any case, the burden of proving that a claim falls under an exception clause in on the party claiming it. While the Respondents have repeatedly argued that mere driving of a motor vehicle at public place without valid driving license in violation of the Motor Vehicle Act in itself constitutes the criminal intent, and thus the repudiation of the claim is within the scope of the terms of contract. However, it is an established principle of jurisprudence that for a criminal intent to be established there shall be a reasonable nexus between the actions of such person and the outcome of the same - Respondents are conscious of the facts of the case, the terms of contract, absence of any criminal intent and the limited scope for repudiation of the claim in the absence of such criminal intent. Even while being well aware of their liability, the Respondents still persisted with denial of the claim. This tantamounts to deficiency in service and unfair trade practice by the Respondent – Further, in the absence of a specific clause in the subject insurance policy laying down a condition that the deceased ought to be in possession of a valid driving licence for obtaining the benefit of the insurance claim, the same cannot be extraneously introduced - It is also clear that, by no stretch of imagination, a death resulting from an ‘accident’ can be said to have arisen/resulted from the insured committing a breach of law with criminal intent’ - The Respondent Insurance Company shall pay the sum assured i.e. Rs. 20 Lakh to the Appellant/Complainant, along with simple interest @ 9% per annum from 10.04.2017, the date on which her clam was repudiated till the date of payment – Appeal allowed. [Paras 5 to 38].
Result: Appeal allowed.
ORDER
AVM J. Rajendra, AVSM, VSM (Retd.), Member—The present First Appeal has been filed under Section 19 of the Consumer Protection Act, 1986 (hereinafter referred to as “the Act”) against the Order dated 03.06.2019 passed by the learned State Consumer Disputes Redressal Commission, Raipur, Chhattisgarh (hereinafter to be referred to as “the State Commission”), in Consumer Complaint No. 8 of 2019, wherein the Complaint filed by the Complainant (Appellant herein) was dismissed.
2. There was a delay of 14 days in filing the Appeal No. 1740 of 2019 by the Appellant. For the reasons stated in the Application of condonation of delay, the delay is condoned.
3. For the sake of Convenience, the parties in the present matter being referred to as mentioned in the Complaint before the State Commission. “Smt. Sadhna Agrawal” is identified as the Complainant who is wife of the insured policy holder Late Shri Pradeep Kumar Agrawal (since deceased). “United India Insurance Co. Ltd.” is referred to as the Opposite Party/Insurer (OP in short) in this matter.
4. Brief relevant facts of the case are that the Complainant’s late husband, Shri PK Agrawal, was issued a Group Personal Accident Policy No. 27030042100500000022 through the Departmental Officers’ Association upon his retirement from the post of AGM in Coke Zone Project at Bhilai Steel Plant. The policy, issued by the OP, covered all risks and illnesses and was effective from 01.06.2010 to 31.05.2022 for a sum assured of Rs.20,00,000/-. On 09.07.2016, during a marriage ceremony in the family at Raipur, the husband of the Complainant drove his vehicle Registration No. CG-07-ZD-4117 from Avanti Vihar to Hotel Sheetal and an Innova Car (Registration No. CG-04-DN-7520) driven allegedly negligently and recklessly by its driver collided with his vehicle. This collision resulted in severe injuries to the Complainant’s husband and substantial damage to the vehicle. Shri PK Agarwal was taken to Ramkrishna Care Hospital where he received treatment for over a month and, unfortunately, he died on 12.08.2016 due to the injuries sustained in the said accident. An FIR was filed against the driver of the Innova (Crime No. 193/16), and no charges were averred against the Complainant’s husband.
5. The total hospital expenditures were Rs.8,44,904/-. Thereafter, the Complainant filed the insurance claim with the OP. It was initially assured by the OP for prompt settlement. However, it was alleged that on 10.04.2017, the OP informed the Officers’ Association Bhilai that the insured, with Membership No. 507, did not possess a valid driving license at the time of the accident on 09.07.2016. Thus, citing breach of policy condition 5(e) as the reason, the claim was repudiated.
6. Being aggrieved by the repudiation of claim and deficiency in service on the part of the OP/Insurer, the Complainant filed Consumer Complaint (No. 8 of 2019) before the learned State Commission and sought Rs.21,00,000/- along with the interest towards entire claim; Rs.1,00,000/- towards the relief of mental, physical and financial pain. It was specifically stated that the Complainant’s husband had a valid driving license till 02.02.2015, and there was no violation of terms and conditions of the policy.
7. The OP/Insurer denied the claim, stating that the complaint is not maintainable due to non-joinder of parties. Further, the Driving License of Shri PK Agrawal was valid up to 02.02.2015. The Driving License was not renewed as per Section 3 of the Motor Vehicle Act after attaining the age of 66 years. Thus, as on the date of accident on 09.07.2016 he had no valid Driving License. Hence, his act of driving without license is as an offence punishable under section 181 of the Motor Vehicle Act and the claim of the Complainant was repudiated as per the terms and conditions of the policy. Therefore, the complaint of the Complainant deserves to be dismissed.
8. The State Commission upon due consideration of the matter and the facts and the ci
