Dr Dhananjaya Y Chandrachud, J
1 The present appeal arises from a judgement of the National Consumer
Disputes Redressal Commission1 which reversed the judgment of the Chhattisgarh
State Consumer Disputes Redressal Commission2. The SCDRC had affirmed the
view of the District Consumer Disputes Redressal Forum, Durg3 allowing an
accident insurance claim.
2 The spouse of the appellant obtained three insurance policies from the Life
Insurance Corporation of India4 :
1 “NCDRC”
2 “SCDRC”
3 “the District Forum”
4 “LIC of India” (ii) LIC Jeevan Tarang Policy; and
(iii) Twenty Years Money Back Policy with profits and accident benefit.
The details of the policies are tabulated below:
Policy No Policy Date of Total Term Sum Premium
Number Commenceme Assured (in Rs)
nt (Rs)
1 Bima Gold 27.06.1992 75-20 50,000 3188/-
Policy yearly
370473369
2 LIC New 10.08.2006 178-10 2,00,000 21134/-
Bima Gold yearly
Policy
384067139
3 Twenty 11.01.2008 179-12 2,00,000 7641/-
Years half-yearly
Money Back
Policy (with
accident
benefit)
385316764
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 “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 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.
4 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 policy.
In 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.
5 The issue before this Court is: (i) whether the assured’s death was due to a
bodily injury resulting from an accident caused by outward, violent and visible means;
and (ii) whether the injury was proximately caused by the accident. It is only when
both the questions are answered in the affirmative that the complainant would be
entitled to claim under the policy.
6 During the course of the hearing, learned counsel appearing for the appellant
argued that the assured suffered a heart attack as a result of the injuries sustained
due to a fall from the motorcycle, which was within the purview of the policy. On the
other hand, learned counsel for the respondent argued that the medical reports are
indicative of the fact that the death of the assured was due to a heart attack and not
an accident and therefore, no claim arises under the policy. It was also argued that
while determining the insurance cover for accidental death, a distinction has to be
made between ‘accidental means’ and ‘accidental result’. The distinction sought to be
introduced is with a view to make the application of the insurance cover more
restrictive.
The rival submissions fall for our consideration.
7 The policy of insurance indicates that a claim on account of the accident benefit
is payable only if the following conditions are satisfied: (i) the assured sustained bodily
injuries resulting solely and directly from an accident; (ii) the accident was caused by
“outward, violent and visible means”; and (iii) that such injury “solely and directly and
independently of other causes” results in the death of the assured. These conditions
are cumulative. The terms “bodily injury” and “outward, violent and visible means”
have not been defined in the policy. In Union of India v Sunil Kumar Ghosh5, this
Court dealt with the expression ‘accident’ and held thus:
“13…An accident is an occurrence or an event which is
unforeseen and startles one when it takes place but does not
startle one when it does not take place. It is the happening of
the unexpected, not the happening of the expected, which is
called an accident. In other words an event or occurrence the
happening of which is ordinarily expected in the normal
course by almost everyone undertaking a rail journey cannot
be called an “accident”. But the happening of something
which is not inherent in the normal course of events, and
5 (1984) 4 SCC 246
which is not ordinarily expected to happen or occur, is called
a mishap or an accident.”
P Ramanatha Aiyar’s Law Lexicon6, defines the expression ‘accident’ as:
“an event that takes place without one’s foresight or
expectation; and event that proceeds from an unknown
cause, or is an unusual effect of a known cause, and
therefore not expected, chance, causality, contingency.”
The expression ‘accident’ in the context of an accident insurance policy has been
explained in MacGillivray on Insurance Law7:
“In the context of an accidental insurance policy the word is
usually contained in phrases such as “injury by accident”,
“accidental injury”, “injury caused by or resulting from an
accident” or “injury caused by accidental means” and in each
of these phrases it has the connotation of an unexpected
occurrence outside the normal course of events.”
Colinvaux’s Law of Insurance8 explains the expression ‘bodily injury’ thus:
“It is usual for the policy to require an accident to manifest
itself as “bodily injury” to the assured. The most obvious form
of bodily injury is external trauma causing physical injury, but
the phrase is not limited to injury to the exterior of the body:
the term “bodily injury”, when used in a personal accident
policy, is not limited to lesions, abrasions or broken bones.
Nor is it essential that there should be an external mark of
injury on the assured’s body…”
The word ‘violent’ according to Black Law’s Dictionary9 means:
“1. Of, relating to, or characterised by strong physical force
<violent blows to legs>. 2. Resulting from extreme or intense
force <violent death>. 3. Vehemently or passionately
threatening <violent words>.”
6 3rd Edition 8 11th Edition – See pg. 1133 for case laws relied upon. The word ‘visible’ according to Black Law’s Dictionary10 means something which is:
“1. Perceptible to the eye; discernible by sight. 2. Clear,
distinct, and conspicuous.”
A passage from Colinvaux’s Law of Insurance11 discusses the effect and the impact
of the expressions “violent, external and visible”:
““Violent”. The notion of violence... is not limited to the
situation where another person does violence to the assured,
and it has been said that the word is used simply as the
antithesis of “without any violence at all”. “Violent means”
include any external, impersonal cause, such as drowning, or
the inhalation of gas. Thus, ‘violent’ does not necessarily
imply actual violence, as where the assured is bitten by a
dog… The element of violence will obviously be present
where the injury is inflicted by a third party or by some natural
phenomenon, since there could otherwise be no effect upon
the body of the assured.”
““External”. It is the means of causing the injury which must
be external, rather than the injury itself. Thus, a rupture or
other internal injury is quite capable of falling within the ambit
of a personal accident policy. Given this distinction, it appears
that the word “external” in these policies merely serves to
reiterate the general principle that the injury must not be
attributable to natural causes. It will therefore be obvious that
a given type of injury may fall within or without the policy
according to the event which caused it, and it is this cause
which must always be examined.”
““Visible”. It is probable that this word adds nothing to the
policy coverage, since every external cause must also be
visible. It appears to be included merely for purposes of
emphasis.”
An accident postulates a mishap or an untoward happening, something which is
unexpected and unforeseen. A bodily injury caused by an accident is not limited to
any visible physical marks in the form of lesions, abrasions or broken bones on the
body. A bodily injury can be caused by violent means that are external and relate to
11 11th Edition – See pg. 1126 for case laws relied upon. the use of strong physical force or even threatening someone by the use of violent
words or actions.
8 There is a divergence of opinion between courts across international
jurisdictions - including the UK, US, Canada and Singapore on whether a distinction
should be maintained between ‘accidental means’ and ‘accidental result’ while
deciding accidental insurance claims. The distinction was laid out in Clidero v
Scottish Accident Insurance Co12, where the Scottish Court of Session (First
Division) unanimously held that the injury suffered by the insured to his colon on
slipping while putting on his stocking, which then led to his death was not caused by
“violent, accidental, external and visible means” because the insured’s conduct in
putting on his stockings was intentional and voluntary and there was no other external
factor that affected the insured’s movement which resulted in the injury. It was held
thus:
“…The death being accidental in the sense in which I have
mentioned, and the means which lead to the death as
accidental, are to my mind two quite different things. A person
may do certain acts, the result of which acts may produce
unforeseen consequences, and may produce what is
commonly called accidental death, but the means are exactly
what the man intended to use, and did use, and was prepared
to use. The means were not accidental, but the result might
be accidental…”
The above distinction was applied by the US Supreme Court in Landress v Phoenix
Mutual Life Insurance13, where the insured while playing golf suffered a sunstroke
and died. The complainant sought recovery of the amounts stipulated in one policy, to
be paid if death resulted “directly and independently of all other causes from bodily
injuries effected through external, violent and accidental means, and not directly or
indirectly, wholly or partly from disease or physical or mental infirmity,” and, in the
12 (1892) 19 R. 355 13 291 US 491, 496 (1934) other policy, if death resulted “from bodily injuries effected directly and independently
of all other causes through external, violent and accidental means.” The majority,
while denying the insurance claim, laid down a strict test which differentiated between
‘accidental means’ and an ‘accidental result’. This distinction emerges from the
following extract:
“Petitioner argues that the death, resulting from voluntary
exposure to the sun's rays under normal conditions, was
accidental in the common or popular sense of the term, and
should therefore be held to be within the liability clauses of
the policies. But it is not enough, to establish liability under
these clauses, that the death or injury was accidental in the
understanding of the average man—that the result of the
exposure 'was something unforeseen, unexpected,
extraordinary, an unlooked-for mishap, and so an accident,'
see Lewis v. Ocean Accident & Guarantee Corp., 224 N.Y.
18, 21, 120 N.E. 56, 57, 7 A.L.R. 1129; see, also, AEtna Life
Insurance Co. v. Portland Gas & Coke Co. (C.C.A.) 229 F.
552, L.R.A. 1916D, 1027, for here the carefully chosen
words defining liability distinguish between the result
and the external means which produces it. The insurance
is not against an accidental result. The stipulated
payments are to be made only if the bodily injury, though
unforeseen, is effected by means which are external and
accidental. The external means is stated to be the rays of the
sun, to which the insured voluntarily exposed himself.
Petitioner's pleadings do not suggest that there was anything
in the sun's rays, the weather, or other circumstances
external to the insured's own body and operating to produce
the unanticipated injury, which was unknown or unforeseen
by the insured.” (Emphasis supplied)
However, Justice Cardozo in his dissenting opinion warned about the inherent
problem in creating a distinction between ‘accidental means’ and ‘accidental result’:
“The attempted distinction between accidental results and
accidental means will plunge this branch of the law into a
Serbonian Bog. …
When a man has died in such a way that his death is spoken
of as an accident, he has died because of an accident, and
hence by accidental means …
The insured did not do anything which in its ordinary
consequences was fraught with danger. The allegations of
the complaint show that he was playing golf in the same
conditions in which he had often played before. The heat was
not extraordinary; the exertion not unusual. By misadventure
or accident, an external force, which had hitherto been
beneficent, was transformed into a force of violence, as much
so as a stroke of lightning. The opinion of the court concedes
that death 'from sunstroke, when resulting from voluntary
exposure to the sun's rays,' is 'an accident.' Why? To be sure,
the death is not intentional, but that does not make it an
'accident,' as the word is commonly understood, any more
than death from indigestion or pneumonia. If there was no
accident in the means, there was none in the result, for
the two were inseparable. No cause that reasonably can
be styled an accident intervened between them. The
process of causation was unbroken from exposure up to
death. There was an accident throughout, or there was
no accident at all.” (Emphasis supplied)
In a decision of the Court of Appeal in UK in Dhak v Insurance Company of North
America (UK) Ltd14, the insured to relieve herself of backpain started consuming
alcohol and died due to acute alcoholism. The accidental insurance policy provided for
benefits payable for “bodily injury resulting in death or injury within 12 months of the
accident occurring during the period of insurance and caused directly or indirectly by
the accident.” The term “bodily injury” was defined as one “caused by accidental
means.” The court held that the words “caused by accidental means” were a clear
indication that the terms of the policy required the court to concentrate on the cause of
the injury and to inquire whether it was by accidental means. It held thus:
“I have come to the conclusion, however, that it has not been
established that the bodily injury to the deceased was
“caused by accidental means” within the meaning of the
policy. In reaching this conclusion I have been persuaded that
the words “caused by accidental means” are a clear indication
that it is the cause of the injury to which the court must direct
its attention.
14 [1996] 1 WLR 936
In my judgment, however, whatever the position may be in
some other jurisdictions, the terms of this policy require a
court in this country to concentrate on the cause of the injury
and to inquire whether the injury was caused by accidental
means…
…the deceased must have been well aware of the
consequences and dangers of drinking alcohol to excess and
that she must be taken to have foreseen what might happen
in the event of someone drinking to excess… I am satisfied
that there must have been a point at which she would have
realised that any further drinking would be dangerous and
that vital bodily functions might be impaired or interrupted.”
The Canadian Supreme Court, in American International Assurance Life Company
Ltd and American Life Insurance Company v Dorothy Martin15, has taken a
contrary view and moved away from the distinction laid out in Landress (supra). This
case dealt with the interpretation of an accidental death benefit provision, which
stipulated that “the Company will pay the amount of the Accidental Death Benefit …
upon receipt of due proof that the Life Insured's death resulted
directly, and independently of all other causes, from bodily injury effected solely
through external, violent and accidental means”. The insured in the course of treating
a peptic ulcer, developed an addiction to opiate medications and died due to high
levels of Demerol in his body. The insurers challenged the claim on the ground that
the death was not through “accidental means” and that self-injection of Demerol was a
deliberate act making the death a foreseeable consequence. Chief Justice McLachlin,
speaking for the Bench held thus:
“The first question to be considered is whether deaths caused
by accidental means form a subclass of accidental deaths. To
put the question another way, is the category of deaths
caused by accidental means narrower than that of accidental
deaths?
15 [2003] 1 SCR 158 The insurers argue that… a death is only caused by accidental means when both the death and the actions that are among its immediate causes are accidental.
This view seems to me, however, to be problematic. Almost all accidents have some deliberate actions among their immediate causes. To insist that these actions, too, must be accidental would result in the insured rarely, if ever, obtaining coverage. Consequently, this cannot be the meaning of the phrase “accidental means” in the policy. Insurance policies must be interpreted in a way that gives effect to the reasonable expectations of the parties: Reid Crowther & Partners Ltd.v. Simcoe & Erie General Insurance Co., [1993] 1 S.C.R 252, at p. 269. A policy that seldom applied to what reasonable people would consider an accidental death would violate this principle.
In my view, the phrase “accidental means” conveys the idea that the consequences of the actions and events that produced death were unexpected.
It follows that to ascertain whether a given means of death is “accidental”, we must consider whether the consequences were expected. We cannot usefully separate off the “means” from the rest of the causal chain and ask whether they were deliberate. Cardozo J. emphasized in his dissenting judgment in Landress v. Phoenix Mutual Life Insurance Co., 291 U.S 491 (1934), at p. 501, that “[i]f there was no accident in the means, there was none in the result”. The converse is equally true: if there was no accident in the result, there can be none in the means. As Cardozo J. went on to say, either “[t]here was an accident throughout, or there was no accident at all”. Hence, to determine whether death occurred by accidental means, we must look to the chain of events as a whole, and we must consider whether the insured expected death to be a consequence of his actions and circumstances.
...Usually we intend the consequences of our actions. However, sometimes our actions have unintended or unexpected results. When death is the unexpected result of an action, we say that the death was “accidental”, or that it was brought about by “accidental means” as opposed to “intentional means”. In ordinary language, then, “death by accidental means” and “accidental death” have the same meaning. …
I conclude that the phrase “accidental means” in this
insurance policy does not refer to a narrow subclass of the
broader category of “accidental deaths”.
“Accidental death” and “ death by accidental means”
connote a death that was in some sense unexpected. The
two phrases have essentially the same meaning.”
(Emphasis supplied)
The Court of Appeal of Singapore in Quek Kwee Kee Victoria v American
International Assurance Co. Ltd16, agreed with the Canadian Supreme Court in
Dorothy Martin (supra) and noted that the courts in many jurisdictions have moved
away from the distinction laid out in Landress (supra):
“… we prefer the view that the use of phrases such as
“accidental means” would not restrict the situations covered
by a personal accident insurance policy to those where the
proximate cause of the insured’s injury or death was not a
deliberate or voluntary action on the part of the insured. For
example, if a person injures himself by driving off a cliff in the
mistaken belief that the road continued, that person would
have met with an “accident” just as much as one who slips
and fractures his leg while walking on a slippery surface. It
would, in our view, accord with ordinary experience to hold
that the injury suffered by an insured in such cases would be
a result of “accidental means”. In this regard, we find
ourselves in agreement with the observations of McLachlin
CJ in Martin…
…courts in the Commonwealth have moved away from this
distinction between intended means and unintended results.
Although this still appears to be good law in England (see, for
example, Dhak v Insurance Co of North America [1996] 1
WLR 936 (“Dhak”) at 949), the distinction has been rejected
in New Zealand (see Groves at 127–128), the United States
(see Wickman v Northwestern National Insurance Co 908 F
2d 1077 (1st Cir 1990) (“Wickman”)), Scotland (see MacLeod
v New Hampshire Insurance Co Ltd 1998 SLT 1191),
Australia (see the judgment of Wilson, Deane and Dawson JJ
in Australian Casualty Co Ltd v Federico [1986] HCA 32 at
[18]–[20]) and Canada (see Martin v American International
Assurance Life Co [2003] SCC 16 (“Martin”) at [10]–[13])…”
16 [2017] 1 SLR 461 9 The respondent has placed reliance upon a decision of a Single Judge of the
Patna High Court in Kamlawati Devi v State of Bihar17, where the deceased who
was on election duty was threatened by armed miscreants while relieving himself
which triggered a heart attack. Justice Aftab Alam (as his Lordship then was) while
discussing precedent from other jurisdictions and authorities on Insurance Law noted
that there exists a divergence of opinion about whether a distinction exists between an
‘accidental result’ and ‘accidental means’ while assessing a claim under an accident
insurance policy. The court while holding that the act of threatening by armed
miscreants was covered by the expression “external violent and any other visible
means”, held thus:
“A plain reading of the cover clause in the M.O.U. would
make it clear that it is intended to impose a twofold limitation.
A death in order to qualify for the insurance cover must not
only be accidental but the accident causing death must itself
result from some external, violent and other visible means.
This two fold limitation is based on what is called, in the Law
of Insurance, the distinction between ‘accidental result’ and
‘accidental means’. An unexpected and unforeseen
consequence or result from a normal or routine activity may
constitute an accident but it would not qualify as ‘accidental
means’. Thus, if a person suffers a fatal heart attack while
dancing (considered to be a normal activity) the death may be
called ‘accidental’ but it would fail to attract the insurance
cover because it was not due to ‘accidental means’. On the
other hand, if a person dies due to heart attack suffered as a
result of over-exertion on being chased by a ferocious dog
(an unintended occurrence, and not a normal activity) the
death might attract the insurance cover as it was caused by
‘accidental means’.
On examining this branch of the law of insurance one finds a
series of decisions which tend to do away with the distinction
between ‘accidental result/death’ and ‘accidental means’. One
also finds another set of decisions which though maintaining
the formal distinction between ‘accidental result’ and
‘accidental means’ have so interpreted the key words in the
restrictive clause (e.g. accident, external, violence and any
17 (2002) 3 PLJR 450
other means etc.) as to greatly relax the rigours of the
ordinary meanings of those words.”
On the facts of the case, the High Court held:
“In the light of the above there can be no denying that the
death of Parshuram Singh was an accidental death caused
by accidental means. If the view expressed in the book, the
Law of Insurance that the words “by violent, external and
visible means” add little if anything to an accident policy is to
be accepted, then his death would attract the insurance cover
without anything else. But even if the applicability clause in
the M.O.U. is to be given a literal interpretation and the
distinction between accidental result and accidental means is
to be maintained, I come to the unescapable conclusion that
the act of threatening by the armed miscreants was plainly
covered by the expression “external, violent and any other
visible means” and the deceased encountering those threats
while he had gone to relieve himself was clearly an accident
that triggered off the heart attack and, thus, resulting solely
and directly into his death. It appears to me, therefore, that
the death of the petitioner's husband was fully covered by the
cover clause in the M.O.U.”
In a Letters Patent Appeal, the Division Bench of the Patna High Court in Branch
Manager, United India Insurance Co v State of Bihar18 affirmed the aforesaid
judgment and held thus:
“... In the present matters, it appears that the Insurance
Companies are belabouring under misapprehension that
unless the person suffers an external visible injury by external
visible means the Insurance Company would not be
answerable to it. In our opinion, the phraseology used in the
cover does not have the scope to read external visible injury.
The phrase simply says—“in the event of death only resulting
solely and directly from accident caused by external violent
and any other visible means.””
There exists a divergence of opinion on whether ‘accidental means’ and ‘accidental
death’ are to be read as similar or whether in order for an accidental insurance claim
to succeed, the means causing the injury or death also have to be accidental in
18 (2003) 51 (2) BLJR 117 nature. For the purposes of this case, it is not necessary to conclusively decide this
question. 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
accident.
What 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 place.
10 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 husband’s death.
11 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
assured’s 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 motorcycle.
In a case decided by the NCDRC - LIC of India v Smt Mamta Rani19 - clause 10.2 of
the insurance policy provided an accident benefit cover if the assured sustained any
bodily injury resulting solely and directly from the accident caused by outward, violent
and visible means. The assured died of a heart attack. The district and state forums
allowed the claim of the complainant for accidental benefit. However, the NCDRC
rejected the claim and held thus:
“… it is clear that in case of death of life assured, the
additional accident benefit equal to the sum assured is
payable only if the life assured dies because of any bodily
injury resulting solely and directly from an accident by
outward, violent and visible means. In the instant case, as per
the record, the life assured died on 01.07.2002 due to heart
attack. There is no evidence on record to indicate that the life
assured died because of some injury suffered in an accident.
Thus, the fora below have committed a material illegality in
awarding the accident benefit to the respondents against the
terms and conditions of the insurance contract.”
Similarly, in Swaranjit Kaur v ICICI Lombard General Insurance Co Ltd20, the
assured while travelling on his scooter, suffered a heart attack and fell from his
scooter. The claim for accidental benefit cover was repudiated on the ground that the
insured had died a natural death because of heart attack. The state commission set
aside the order of the district forum allowing the claim. The NCDRC while upholding
the state commission’s judgment, noted that the onus to prove that the insured had
died as a result of an accident and not a heart attack was on the claimant. It held thus:
“…On perusal of the copy of repudiation letter, it is clear that
the respondents repudiated the insurance claim on the
19 II (2014) CPJ 624 (NC) : RP No. 4468 of 2012 20 2015 SCC OnLine NCDRC 4168
ground that cause of death of insured was heart attack. On
perusal of the report of the investigator, we find that the stand
of the petitioners in the statement made before the
investigator on 17.8.2006 was that while driving the scooter
insured suffered a heart attack, consequently, he fell down
from the scooter and died. From this, it is clear that the
accident took place after the insured had suffered heart
attack. Otherwise also, in order to succeed in the insurance
claim, the onus of proving that the insured had died as a
result of accident was on the petitioners. Undisputedly,
incident was not reported to the police nor post mortem to
establish cause of death was done. No evidence has been
produced by the petitioners to prove the cause of death of the
insured. There is nothing in the statement of the petitioners as
recorded by the investigator that the insured had suffered any
bodily injuries due to fall from the scooter. Thus, under the
circumstances, the conclusion of the State Commission that
cause of death of the insured was heart attack and not an
accident cannot be faulted…”
The High Court of Madras held in Life Insurance Corporation v Minor Rohini21 that
in the absence of any evidence that the assured had sustained any bodily injury
resulting solely and directly from the accident caused by outward, violent or 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.
In Krishna Wati v LIC of India22, the NCDRC had to deal with whether the accidental
injuries which resulted in the death of the assured due to a heart attack after three
days of the accident could be termed as an accidental death or a natural death. The
assured while riding his bicycle was attacked by a cow and upon arriving at the
hospital complained of pain in the legs and in the chest, because of a fall from his
bicycle. The NCDRC relied on the investigation report and the allowed the claim for
accident insurance. It held thus:
“… In our view, from the record as it is, it is apparent that first
the accident took place, resulted in injuries and chest pain
which ultimately resulted in 'death'. May be, the death in the
21 2012 (1) MWN (Civil) 740. Also see New India Assurance Company Limited v K. Thilagam 2009 (2) TN MAC 197 22 1 (2006) CPJ 21 (NC)
medical terms be described as 'due to heart-attack, but the
main cause for leading to heart-attack was injury caused due
to accident. Accident is the basis for causing chest pain and
thereafter heart-attack…”
12 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.
13 For the above reasons, we are of the view that the judgment of the NCDRC
dated 29 April 2016 does not suffer from any error. The appeal shall accordingly stand
dismissed. There shall be no order as to costs.
[Dr Dhananjaya Y Chandrachud]
[Hemant Gupta]
New Delhi; April 24, 2019.