Case: ALKA SHUKLA Vs. LIFE INSURANCE CORPN. OF INDIA

(i) New Bima Gold Policy;(ii) LIC Jeevan Tarang Policy; and(iii) Twenty Years Money Back Policy with profits and accident benefitThe details of the policies are tabulated below: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 AssuredThe 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 solely and 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.HR, O/nil, BP-NR, Pupil B/L fixedAs 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 infarction3. 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 accident4. The appellant filed a consumer complaint under the Consumer Protection Act 1986 before the District Forum. On 2 May 2013, the District Forum allowed the complaint and directed the respondent to pay the accident benefit under the three policies together with interest at 6 percent per annum. The SCDRC by its judgment dated 14 March 2014 rejected the appeal of the insurer holding that:(i) It appeared that the death of the insured was due to a fall from the motorcycle; and(ii) The main cause for the heart attack was the fall from a motorcycle which was an accident under the terms of the policyIn a revision by the insurer, the NCDRC by its judgment dated 29 April 2016 reversed the judgment of the District Forum, which had been affirmed by the SCDRC. The NCDRC held that in the terms of the accident cover, the sum assured was payable in the event of an accident caused by outward, violent and visible means. Adverting to the medical evidence, the NCDRC held that the pain in the chest and shoulder and the sudden fall from the motorcycle were not the result of an accident caused by outward violent or visible means. The award of compensation in terms of the accident benefit was accordingly set aside. Assailing the decision of the NCDRC, the spouse of the insured has filed the present appeal.

Reasoning:
In order to sustain a claim under the accident benefit cover, it must be established that the assured has sustained a bodily injury which resulted solely and directly from the accident. There must, in other words exist a proximate causal relationship between the accident and the bodily injury. Moreover, the accident must be caused by outward violent and visible means. The expression outward violent and visible signifies that the cause of the accident must be external. Moreover, the injury must be the cause of the death within the period of 180 days. There has to be proximate relationship between the injury and the death to the exclusion of all other causes. The outcome of the present case involves interpretation of the accident benefit cover. Breaking down the clause into its components, what it postulates is that:(i) The assured must sustain a bodily injury;(ii) The injury must solely and directly result from an accident;(iii) The accident must be caused by outward, violent and visible means;(iv) The injury must solely, directly and independently of all other causes result in the death of the assured; and(v) Death must ensue within a period of 180 days from the injury caused in the accidentWhat needs to be determined is whether the insured suffered a heart attack as a result of the injuries sustained from the fall from the motorcycle or whether the fall was a result of the assured suffering a heart attack in the first place10. The plain reading of the policy is to be accepted as our guide. Under the policy, in order for the complainant to prove her claim, she must show direct and positive proof that the accident of the assured falling from his motorcycle caused bodily injury by external/outward, violent and visible means. The complainant will have to prove that the accident and the injuries sustained as a result were a direct or proximate cause of her husbands death11. In the present case, no post mortem of the deceased or police investigation was conducted. In the absence of a post mortem report indicating the nature of injuries sustained by the insured, we would have to rely upon the medical report that indicates the exact cause of death. The medical report of Dr Ajay Goverdhan who examined the assured on the date of the accident indicated that the insured suffered shoulder and chest pain and that the exact cause of death was an acute myocardial infraction. The insured was referred to a specialist, Dr SS Dhillon, who also recorded in his report that the diagnosis did not show the cause of death to be accidental. Dr S S Dhillon noted that the insured was experiencing pain in the left side of the chest and in the shoulder and there was a myocardial infarction. The insured was referred to Chandu Lal Memorial Hospital, a specialist medical center, where the OPD records noted that an ECG was taken at Dhillon Nursing Home and the insured was sweating and that he had chest pain, radiating to the left shoulder along with two episodes of vomiting. He died before he reached the hospital. There is no material on record to indicate that the assured sustained specific injuries as a result of a fall from the motorcycle or that the injuries were caused by outward, violent and visible means, which was the sole and proximate cause of his death. There is no direct nexus or causation between the assured suffering a heart attack and injuries sustained in an accident by outward, violent and visible means. Nothing has been brought on record to show that the injuries sustained by falling from the motorcycle aggravated the assureds condition that eventually led to his death. In the absence of any evidence to the contrary, the medical evidence on record is itself proof that the insured died due to a heart attack and not due to an accident of falling from the motorcycle. The heart attack had a distinct effect of the insured falling off from his motorcycle12. In the present case, there is no evidence to show that any bodily injuries were suffered due to the fall from the motorcycle or that they led to the assured suffering a heart attack. There is no evidence to show that the accident took place as a result of any outward, violent and visible means. The assured died as a result of a heart attack which was not attributable to the accident.