Insurance Regime: Criteria for accidental death benefit
Accidental Death Under Insurance Law – In Alka Shukla V Life Insurance Corporation of India[1], the Hon’ble Supreme Court comprising of Justice D.Y. Chandrachud and Justice Hemant Gupta found that there was no evidence to show that any injury suffered because of a fall from the motorcycle led to the insured having a heart attack. The insured died because of a heart attack which was not related to the accident. Hence, the insurer was correct to repudiate the claim of the insured under the accidental benefit component of the insurance policy.
BACKGROUND – Accidental Death Under Insurance Law
The insured obtained three insurance
policies from the Life Insurance Corporation of India. The policies were
payable only if the insured sustained any bodily injury resulting solely and
directly from the accident caused by “outward, violent and visible means” leading
to his death. The insured experienced pain in the shoulder & chest, while
riding a bike, and suddenly had a heart attack. By the time, the insured had was
admitted to the hospital, he was already dead. The report given by Dr. Dhillon
showed that insured died due to an Acute Myocardial Infraction. Insurance
company repudiated the claim on the ground that insured died because of heart
attack and not an accident. The appellant filed a consumer complaint before the
district forum and district forum directed the insurance company to pay the
insurance amount under the three policies along with interest. The State
Commission confirmed the order given by district forum. The insurer filed the
revision petition before the National Commission and the commission reversed
the order of district forum and set aside the award of compensation. Award
passed by the National Commission is challenged before the Hon’ble Supreme
Court of India.
ISSUES
- Whether the insured person died due to
bodily injury resulting from an accident triggered by an outward, violent and
visible means? - Whether injury suffered by the insured
was closely or directly caused by the accident?
ARGUMENTS
Appellant: Learned counsel appearing on behalf
of the Appellant contended that insured suffered a heart attack from the
injuries sustained due to fall from the bike.
Respondent: Learned counsel for the Respondent
contended that medical reports clearly show that the death of the insured was
due to a heart attack and not an accident.
FINDINGS OF THE COURT – Accidental Death Under Insurance Law
Hon’ble Supreme Court observed that,
claim, in case of an accident, is payable only if the following conditions are
satisfied:
- The
insured sustained injuries directly and solely from the accident; - The
accident was caused by violent, outward and visible means; and - That
injury solely and directly of other causes results in the death of the insured
person.
In LIC of India V. Smt Mamta
Rani,[2]
NCDRC rejected the claim of the complainant and held that in case of
death due to an accident, the sum assured is payable only if the insured person
dies because of any bodily injury directly and solely from an accident by
violent, outward and visible means.
In Life Insurance Corporation v.
Minor Rohini,[3]
Madras High Court observed that it cannot be said that a death because of heart
attack would amount to an accident for the purpose of accidental insurance
claim in the absence of any evidence that insured had suffered any bodily
injury resulting directly & solely from the accident.
In the present case, Hon’ble Supreme
Court cited the above two cases and observed that in order to prove the claim,
the Appellant must show direct and positive proof that accident of the insured
cause bodily injury by violent, external and visible means. No post mortem of
the deceased was performed and in the absence of post mortem report, the
Hon’ble Court has to rely on the medical report of Dr. Ajay Goverdhan. Examination
report produced by the doctor on the date of accident indicates that he suffered
shoulder and chest pain and that the exact cause of the death was an Acute
Myocardial Infraction. Later, the insured was referred to a specialist, Dr. SS
Dhillon whose report says that death was not due to the accident.
Hon’ble Supreme Court also observed
that there are no material records to show that insured sustained specific
injuries as a result of a fall from the bike or the injuries were caused by
violent, outward and visible means, which was the sole and proximate cause of
the death. Nothing has been brought on record to show the nexus between the
injuries sustained by falling off the bike and death of the insured from a heart
attack. The court said that in the absence of any evidence to the contrary, the
medical evidence on record that the insured died due to a heart attack will be
taken as a proof to decide on the claim of insurance.
DECISION – Accidental Death Under Insurance Law
Hon’ble Supreme Court in the present
case held that there is no evidence to show that any bodily injury was suffered
due to fall from the bike or that led to the insured suffering a heart attack.
There is no evidence to show that the accident took place as a result of any
violent, outward and visible means. For the reasons stated above, Hon’ble
Supreme Court is of the view that judgment of the NCDRC does not suffer from
any error and the appeal shall stand dismissed.
CONCLUSION
In my view, the Appellant failed to
prove the fact that the death of the insured was because of an accident or due
to any injuries sustained solely and directly from the accident. As per the
medical reports, the exact cause of the death was an Acute Myocardial
Infraction which is a medical name of a Heart Attack. NCDRC and Supreme Court
were right in giving the judgement in the favour of insurance Company.
Contributed By – Anshu Singh and Simran Tandon
Designation – Associate
King Stubb & Kasiva,
Advocates & Attorneys
New Delhi | Mumbai | Bangalore | Chennai | Hyderabad | Kochi
Tel: +91 11 41032969 | Email: info@ksandk.com
By entering the email address you agree to our Privacy Policy.