IMPORTANT POINT
Personal Accident Insurance Policy – Surveyor’s report is not the final word if it can be established that it was arbitrary or perverse.

ORDER

Subhash Chandra, Presiding Member.—The challenge in this appeal under Section 51 of the Consumer Protection Act, 2019 (in short, ‘the Act’) is to the order dated 10.06.2022 in Complaint No.5 of 2019 of the A.P. State Consumer Disputes Redressal Commission, Vijayawada (in short, ‘the State Commission’) allowing the complaint in part and directing OP Nos.1 to 3 (Appellants No.1 to 3 herein) to pay the sum assured under the Group Insurance Policy with interest @ 9% p.a. from the date of repudiation till realization along with costs to the Complainant/Respondent No.1 within two months from the date of the order while dismissing the complaint against Opposite Party/Respondent No.4.

2. This order will also dispose of FA nos. 756 to 762 of 2022 which are also related to the same issue, i.e., repudiation of claim under the Group Insurance Policy in question in respect of employees of respondent no.4 on whose behalf the insurance cover for life had been obtained by respondent No.4.

3. We have heard the learned counsel for both the parties and carefully considered the material on record.

4. For the reasons stated in the application for condonation of delay, the delay of 85 days in the filing of FA no.755 of 2022 was condoned in the interest of justice.

5. The relevant facts in FA no.755/2022 are that the Respondent No.4, which is a Public Sector Undertaking, had obtained a Group Insurance Policy covering personal accident insurance in respect of its employees called the Personal Accident Insurance Policy (Group) (in short, ‘the Policy’) and paid premium of Rs.7,60,77,419/- including GST vide proposal dated 01.04.2016. Based on the category of the employee, the Policy provided for different amounts of insurance to a life covered. Under this Policy, the insured employees in the Schedules attached to the Policy were covered for accident and injury which was to be verified and certified by a medical practitioner. Coverage included death of the insured person due to “accident” as defined in the Policy outside his/her residence and under a Special Free-Benefit, in addition to the amount payable under Sub Clause 1(a), a lump sum of 2% of capital sum insured or Rs.25,000/-, whichever is less, was payable for transportation of the insured person’s dead body to the place of residence. As per the Policy, an ‘accident’ was defined as a sudden, unforeseen and involuntary event caused by external, visible and violent means. As per the Policy, an ‘injury’ was defined as an accidental, physical bodily harm including illness or disease solely or directly caused by external, violent and visible and evident means which is verified and certified by a medical practitioner. Under the Policy, if such injury, within 12 calendar months of its occurrence, was the sole and direct cause of the death of the insured person, the capital sum insured under the policy was applicable to such person. Exceptions to this policy included the following:—

“Payment of compensation in respect of Death, injury of Disablement of the Insured person (a) from intentional self-injury, suicide or attempted suicide, (b) whilst under the influence of intoxicating liquor or drugs (c) whilst engaging in Aviation or Ballooning whilst mounting into, dismounting from or traveling in any balloon or aircraft other than as a passenger (fare paying or otherwise) in any duly licensed standard type of aircraft anywhere in the world, (d) directly or indirectly caused by venereal diseases, aids or insanity, (e) arising or resulting from the insured person committing any breach of law with criminal intent, (Standard type of Aircraft means any aircraft duly licensed to carry passengers (for hire or otherwise) by appropriate authority irrespective of whether such an aircraft is privately owned OR chartered OR operated by a regular airline OR whether such an aircraft has a single engine or multi engine.

(6) Payment of compensation in respect of Death, Injury or Disablement of the Insured person