DHANANIAVA Y. CHANDRACHUD - (1.) The present appeal arises from a judgement of the National Consumer Disputes Redressal Commission (NCDRC) which reversed the judgment of the Chhattisgarh State Consumer Disputes Redressal Commission (SCDRC). The SCDRC had affirmed the view of the District Consumer Disputes Redressal Forum, Durg (the District Forum) allowing an accident insurance claim.
(2.) The spouse of the appellant obtained three insurance policies from the Life Insurance Corporation of India (LIC of India) : JUDGEMENT_104_LAWS(SC)4_2019.htm Condition 10 (2) of the first policy, condition 10 (b) of the second policy and condition 11 (b) of the third policy contain a stipulation for accident benefit, on which the controversy in the present case rests. The stipulation in the New Bima Gold Policy in relation to accident benefit is extracted below, in so far as is material: "(b) Death of Life Assured : In addition to sum assured under Basic Plan, an additional sum equal to the Accident Benefit Sum Assured shall be payable under this policy, if the Life Assured shall sustain any bodily injury resulting solely and directly from the accident caused by outward, violent and visible means and such injury shall within 180 days of its occurrence solely, directly and independently of all other causes result in death of the Life Assured." (Emphasis supplied) The stipulations in the other two policies are similar, where the accident benefit was payable if the assured sustained any bodily injury resulting solely and directly from the accident caused by "outward, violent and visible means", and that such injury "solelyand directly and independently of other causes" results in death. On 3 March 2012, the spouse of the appellant, while riding his motorcycle, experienced pain in the chest and shoulder, suffered a heart attack and fell from the motorcycle. He was attended to at 10:10 pm on 3 March 2012 by Dr Ajay Goverdhan, a general physician. He was referred to Dr SS Dhillon who diagnosed the mishap as having been caused by "a sudden fall from the bike". Dr Dhillon noted that the patient was experiencing pain in the left side of the chest and in the shoulder and there was a myocardial infarction. He referred the patient to a specialist medical center. He was taken to the Chandulal Chandrakar Memorial Hospital at Bhilai. The OPD card notes the following position at admission: "Sweating, radiating to left shoulder and 2 episodes of vomiting Following this patient was taken to Dhillon Nursing Home where ECG taken showed Ant. Wall M1. He was given loading dose of Ant. Platelet and Referred. On his way to the hospital, Pt. collapsed. On reaching here, on examination Pt. had so sign of life AHR, O/nil, BP-NR, Pupil B/L fixed." As the above diagnosis indicates, the patient had died by the time that he had been admitted to the above hospital. The report of the physician indicates that death had occurred due to an acute myocardial infarction.
(3.) Dr Ajay Goverdhan furnished his report in Claim Form B indicating that: (i) the cause of death was an acute myocardial infarction; and (ii) the symptoms of illness were pain in the chest and shoulder. The insurance claim was settled in respect of the basic cover of insurance. However, the insurer repudiated the claim under the accident benefit component of the insurance policy on the ground that the death of the insured had occurred due to a heart attack and not due to an accident.;