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Case Synopsis

Alka Shukla (Appellant)

Vs

Life Insurance Corporation of India (Respondent)

Case Facts

Spouse of Appellant had taken 3 insurance policies from respondent covering accidental benefit as well.

On 3rd march 2012, spouse of appellant while riding his bike experienced pain in chest & shoulder, suffered
a heart attack, fell from his bike. At 10:10 pm was attended by Dr Ajay Goverdhan thereafter referred to
Dr SS Dhillon who noted that patient was experiencing pain in left side of chest, shoulder & there was
Myocardial Infarction. Patient was taken to Chandulal Chandrakar Memorial Hospital but died on the way.
Dr Ajay Goverdhan furnished report in claim form, cause of death was Myocardial Infraction and
symptoms of illness were pain in chest & shoulder.

Respondent repudiated claim stating that death of the assured/insured/spouse of appellant was caused
by heart attack and not due to accident.

Wife of deceased filed a complaint with district forums, 0n 02.05.2013 claim was allowed, respondent was
directed to pay claim amount arising from all 3 insurances with interest @6% p.a. Respondent filed an
appeal with SCDRC which was dismissed on 14.03.2014 stating that death was caused due to fall from
bike and main cause of heart attack was fall from bike which was an accident.

In revision filed by respondent to NCDRC, on 29.4.2016 NCDRC reversed the orders passed by district
forums and affirmed by SCDRC by stating that “Sum assured was payable where accident was caused by
outward, violent, visible means. Pain in chest and shoulder and sudden fall from bike were not result of
accident caused by outward, violent, visible means.”

Appeal to Supreme Court- by Spouse of Deceased/Assured/Insured.

Issues Framed in Appeal:

1. Assured’s death was due to bodily injury resulting from accident caused by outward, violent,
visible means or not and
2. Injury was proximately caused by accident or not.

Arguments

Arguments by Appellant Counsel: Assured suffered heart attack as a result of injuries sustained due to
fall form bike which was within the purview of policy.

Arguments by Respondent’s Counsel: That medial reports indicates the fact that death of deceased was
due to heart attack and not accident thus no claim arises from the policy.

It was also argued that for deciding insurance cover for accidental death, a distinction was to be made
between ‘accidental means’ and ‘accidental result’.

It was affirmed from the respondent’s insurance policy that a claim on account of accidental benefit, was
payable only if the following 3 conditions were satisfied:

1. Assured sustained bodily injuries resulting solely and directly from the accident.
2. Accident was caused by outward, violent and visible means.
3. Injury ‘solely and directly and independently of other causes’ results in death.

The burden of proof was on the appellant to prove that the accident and the injuries sustained as a result
were direct or proximate cause or her husband’s death.
Final Order by Supreme Court: Relying on the medical report and because of no evidence to show that
bodily injury were suffered by deceased due to fall from the bike or they led to the assured suffering from
heart attack or to show that accident was result of any outward, violent, visible means, Supreme Court
held that the judgement passed by NCDRC on 29.04.2016 did not suffer from any error and dismissed the
appeal.

Judgements in support of order:

In LIC of India vs SMt. Mamta Rani, NCDRC held that is was clear from the death of life assured, additional
accident benefit was payable only if the assured died because of any bodily injury resulting solely and
directly from an accident by outward, violent and visible means.

In Swaranjit Kaur vs ICICI Lombard General Insurance Co. Ltd, NCDRC held that in order to succeed in the
insurance claim, the onus of proving that insured had died as a result of accident was on petitioners and
since no evidence was produced by petitioner to prove the cause of death of the insured, the conclusion
of the State Commission that cause of death of the insured was heart attack and not an accident couldn’t
be faulted.

In Life Insurance Corporation vs Minor Rohini, High Court of Madras held that in absence of any evidence
that the assured has sustained any bodily injury resulting solely and directly from the accident caused by
outward, violent, visible means, it cannot be said that the death due to a heart attack would amount to
an accident for the purposes of accidental insurance claim under the policy.

Our Observation:

As per our assessment, the appellant didn’t proved the fact that the death of the insured was because of
an accident or because of any injuries sustained by the insured solely and directly from the accident.
Moreover as per the medical reports, the insured suffered chest and shoulder pain and thereafter a
heart attack. NCDRC and Supreme Court were right with their decision.

In Swaranjit Kaur V. ICICI Lombard General Insurance Co. Ltd. (2015 SCC OnLine NCDRC
4168) the insured while travelling on his scooter suffered a heart attack and fell from his scooter.
The claim was repudiated on the ground that insured died from heart attack and not because of
accident. NCDRC observed that there is nothing in the statement which shows that insured has
suffered any bodily injury due to fall from scooter.

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