SMT. ALKA SHUKLA versus LIFE INSURANCE CORPORATION OF INDIA on 24 April 2019

1. The present appeal arises from a judgement of the NationalConsumer Disputes Redressal Commission[1] which reversed the judgmentof the Chhattisgarh State Consumer Disputes Redressal Commission[2].The SCDRC had affirmed the view of the District Consumer DisputesRedressal Forum, Durg[3] allowing an accident insurance claim.

E

2. The spouse of the appellant obtained three insurance policiesfrom the Life Insurance Corporation of India[4] :

F

(i) New Bima Gold Policy;

(ii) LIC Jeevan Tarang Policy; and

(iii) Twenty Years Money Back Policy with profits and accidentbenefit.

G

The details of the policies are tabulated below:

1 “NCDRC”

2 “SCDRC”

3 “the District Forum”

4 “LIC of India”

H

APolicy No Policy Date of Total Term Sum Premium Number CommencemeAssured (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 BPolicy 384067139 3 Twenty 11.01.2008 179-12 2,00,000 7641/- Years half-yearly Money Back Policy (with accident benefit) C385316764

Condition 10 (2) of the first policy, condition 10 (b) of the secondpolicy and condition 11(b) of the third policy contain a stipulation foraccident benefit, on which the controversy in the present case rests.The stipulation in the New Bima Gold Policy in relation to accident benefitDis extracted below, in so far as is material:

“(b) Death of Life Assured : In addition to sum assured underBasic Plan, an additional sum equal to the Accident Benefit SumAssured shall be payable under this policy, if the Life Assuredshall sustain any bodily injury resulting solely and directlyEfrom the accident caused by outward, violent and visiblemeans and such injury shall within 180 days of its occurrencesolely, directly and independently of all other causes result in deathof the Life Assured.”

FThe stipulations in the other two policies are similar, where theaccident benefit was payable if the assured sustained any bodily injuryresulting solely and directly from the accident caused by “outward, violentand visible means”, and that such injury “solely and directly andindependently of other causes” results in death. On 3 March 2012, theGspouse of the appellant, while riding his motorcycle, experienced pain inthe chest and shoulder, suffered a heart attack and fell from themotorcycle. He was attended to at 10:10 pm on 3 March 2012 by DrAjay Goverdhan, a general physician. He was referred to Dr SS Dhillonwho diagnosed the mishap as having been caused by “a sudden fall fromthe bike”. Dr Dhillon noted that the patient was experiencing pain in theHleft side of the chest and in the shoulder and there was a myocardial infarction. He referred the patient to a specialist medical center. Hewas 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 vomitingFollowing this patient was taken to Dhillon Nursing Home whereECG taken showed Ant. Wall M1. He was given loading dose ofAnt. Platelet and Referred. On his way to the hospital, Pt.collapsed. On reaching here, on examination Pt. had so sign oflife.\HR, O/nil, BP-NR, Pupil B/L fixed.”

As the above diagnosis indicates, the patient had died by the timethat he had been admitted to the above hospital. The report of thephysician indicates that death had occurred due to an acute myocardialinfarction.

3. Dr Ajay Goverdhan furnished his report in Claim Form Bindicating that: (i) the cause of death was an acute myocardial infarction;and (ii) the symptoms of illness were pain in the chest and shoulder. Theinsurance claim was settled in respect of the basic cover of insurance.However, the insurer repudiated the claim under the accident benefitcomponent of the insurance policy on the ground that the death of theinsured had occurred due to a heart attack and not due to an accident.

4. The appellant filed a consumer complaint under the ConsumerProtection Act 1986 before the District Forum. On 2 May 2013, theDistrict Forum allowed the complaint and directed the respondent to paythe accident benefit under the three policies together with interest at 6percent per annum. The SCDRC by its judgment dated 14 March 2014rejected the appeal of the insurer holding that:

(i) It appeared that the death of the insured was due to a fallfrom the motorcycle; and

(ii) The main cause for the heart attack was the fall from amotorcycle which was an accident under the terms of thepolicy.

In a revision by the insurer, the NCDRC by its judgment dated 29April 2016 reversed the judgment of the District Forum, which had beenaffirmed by the SCDRC. The NCDRC held that in the terms of theaccident cover, the sum assured was payable in the event of an accidentcaused by “outward, violent and visible means”. Adverting to the medical A

B

C

D

E

F

G

H

Aevidence, the NCDRC held that the pain in the chest and shoulder andthe sudden fall from the motorcycle were not the result of an accidentcaused by outward violent or visible means. The award of compensationin terms of the accident benefit was accordingly set aside. Assailing thedecision of the NCDRC, the spouse of the insured has filed the presentappeal.B

5. The issue before this Court is: (i) whether the assured’s deathwas due to a bodily injury resulting from an accident caused by outward,violent and visible means; and (ii) whether the injury was proximatelycaused by the accident. It is only when both the questions are answeredin the affirmative that the complainant would be entitled to claim underCthe policy.

6. During the course of the hearing, learned counsel appearingfor the appellant argued that the assured suffered a heart attack as aresult of the injuries sustained due to a fall from the motorcycle, whichwas within the purview of the policy. On the other hand, learned counselDfor the respondent argued that the medical reports are indicative of thefact that the death of the assured was due to a heart attack and not anaccident and therefore, no claim arises under the policy. It was alsoargued that while determining the insurance cover for accidental death,a distinction has to be made between ‘accidental means’ and ‘accidentalEresult’. The distinction sought to be introduced is with a view to makethe 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 theaccident benefit is payable only if the following conditions are satisfied:F(i) the assured sustained bodily injuries resulting solely and directly froman accident; (ii) the accident was caused by “outward, violent and visiblemeans”; and (iii) that such injury “solely and directly and independentlyof other causes” results in the death of the assured. These conditionsare cumulative. The terms “bodily injury” and “outward, violent and visibleGmeans” have not been defined in the policy. In Union of India v SunilKumar Ghosh[5], this Court dealt with the expression ‘accident’ andheld thus:

“13…An accident is an occurrence or an event which is unforeseenand startles one when it takes place but does not startle one when H5 (1984) 4 SCC 246

it does not take place. It is the happening of the unexpected, notthe happening of the expected, which is called an accident. Inother words an event or occurrence the happening of which isordinarily expected in the normal course by almost everyoneundertaking a rail journey cannot be called an “accident”. But thehappening of something which is not inherent in the normal courseof events, and which is not ordinarily expected to happen or occur,is called a mishap or an accident.”

P Ramanatha Aiyar’s Law Lexicon[6], 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 unusualeffect of a known cause, and therefore not expected, chance,causality, contingency.”

The expression ‘accident’ in the context of an accident insurancepolicy has been explained in MacGillivray on Insurance Law[7]:

“In the context of an accidental insurance policy the word is usuallycontained in phrases such as “injury by accident”, “accidentalinjury”, “injury caused by or resulting from an accident” or “injurycaused by accidental means” and in each of these phrases it hasthe connotation of an unexpected occurrence outside the normalcourse of events.”

Colinvaux’s Law of Insurance[8]explains the expression ‘bodilyinjury’ thus:

“It is usual for the policy to require an accident to manifest itselfas “bodily injury” to the assured. The most obvious form of bodilyinjury is external trauma causing physical injury, but the phrase isnot limited to injury to the exterior of the body: the term “bodilyinjury”, when used in a personal accident policy, is not limited tolesions, abrasions or broken bones. Nor is it essential that thereshould be an external mark of injury on the assured’s body…”

The word ‘violent’ according to Black Law’s Dictionary[9] means:

6 3rd Edition

7 12th Edition

8 11th Edition - See pg. 1133 for case laws relied upon.

9 10th Edition

A

B

C

D

E

F

G

H

A“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 <violentwords>.”

The word ‘visible’ according to Black Law’s Dictionary[10] meansBsomething which is:

“1. Perceptible to the eye; discernible by sight. 2. Clear, distinct,and conspicuous.”

A passage from Colinvaux’s Law of Insurance[11] discusses theeffect and the impact of the expressions “violent, external and visible”:

C

“”Violent”. The notion of violence... is not limited to the situationwhere another person does violence to the assured, and it hasbeen said that the word is used simply as the antithesis of “withoutany violence at all”. “Violent means” include any external,impersonal cause, such as drowning, or the inhalation of gas. Thus,D‘violent’ does not necessarily imply actual violence, as where theassured is bitten by a dog… The element of violence will obviouslybe present where the injury is inflicted by a third party or by somenatural phenomenon, since there could otherwise be no effectupon the body of the assured.”

E

E“”External”. It is the means of causing the injury which must beexternal, rather than the injury itself. Thus, a rupture or otherinternal injury is quite capable of falling within the ambit of apersonal accident policy. Given this distinction, it appears that theword “external” in these policies merely serves to reiterate thegeneral principle that the injury must not be attributable to naturalFcauses. It will therefore be obvious that a given type of injurymay fall within or without the policy according to the event whichcaused it, and it is this cause which must always be examined.”

“”Visible”. It is probable that this word adds nothing to the policycoverage, since every external cause must also be visible. ItGappears 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 10 10th EditionH11 11th Edition - See pg. 1126 for case laws relied upon.

by an accident is not limited to any visible physical marks in the form oflesions, abrasions or broken bones on the body. A bodily injury can becaused by violent means that are external and relate to the use of strongphysical force or even threatening someone by the use of violent wordsor actions.

8. There is a divergence of opinion between courts acrossinternational jurisdictions - including the UK, US, Canada and Singaporeon whether a distinction should be maintained between ‘accidental means’and ‘accidental result’ while deciding accidental insurance claims. Thedistinction was laid out in Clidero v Scottish Accident InsuranceCo[12], where the Scottish Court of Session (First Division) unanimouslyheld that the injury suffered by the insured to his colon on slipping whileputting on his stocking, which then led to his death was not caused by“violent, accidental, external and visible means” because the insured’sconduct in putting on his stockings was intentional and voluntary andthere was no other external factor that affected the insured’s movementwhich resulted in the injury. It was held thus:

“…The death being accidental in the sense in which I havementioned, and the means which lead to the death as accidental,are to my mind two quite different things. A person may do certainacts, the result of which acts may produce unforeseenconsequences, and may produce what is commonly calledaccidental death, but the means are exactly what the man intendedto use, and did use, and was prepared to use. The means werenot accidental, but the result might be accidental…”

The above distinction was applied by the US Supreme Court inLandress v Phoenix Mutual Life Insurance[13], where the insuredwhile playing golf suffered a sunstroke and died. The complainant soughtrecovery of the amounts stipulated in one policy, to be paid if deathresulted “directly and independently of all other causes from bodily injurieseffected through external, violent and accidental means, and not directlyor indirectly, wholly or partly from disease or physical or mental infirmity,”and, in the other policy, if death resulted “from bodily injuries effecteddirectly and independently of all other causes through external, violentand accidental means.” The majority, while denying the insurance claim,laid down a strict test which differentiated between ‘accidental means’

12 (1982) 19 R. 355

13 291 US 491, 496 (1934)

A

B

C

D

E

F

G

H

Aand an ‘accidental result’. This distinction emerges from the followingextract:

“Petitioner argues that the death, resulting from voluntary exposureto the sun’s rays under normal conditions, was accidental in thecommon or popular sense of the term, and should therefore beBheld to be within the liability clauses of the policies. But it is notenough, to establish liability under these clauses, that the death orinjury 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 anaccident,’ see Lewis v. Ocean Accident & Guarantee Corp., 224CN.Y. 18, 21, 120 N.E. 56, 57, 7 A.L.R. 1129; see, also, AEtna LifeInsurance Co. v. Portland Gas & Coke Co. (C.C.A.) 229 F. 552,L.R.A. 1916D, 1027, for here the carefully chosen wordsdefining liability distinguish between the result and theexternal means which produces it. The insurance is notDagainst an accidental result. The stipulated payments areto be made only if the bodily injury, though unforeseen, iseffected by means which are external and accidental. Theexternal means is stated to be the rays of the sun, to which theinsured voluntarily exposed himself. Petitioner’s pleadings do notsuggest that there was anything in the sun’s rays, the weather, orEother circumstances external to the insured’s own body andoperating to produce the unanticipated injury, which was unknownor unforeseen by the insured.”

FHowever, Justice Cardozo in his dissenting opinion warned aboutthe inherent problem in creating a distinction between ‘accidental means’and ‘accidental result’:

“The attempted distinction between accidental results andaccidental means will plunge this branch of the law into a SerbonianGBog. …

…

When a man has died in such a way that his death is spoken of asan accident, he has died because of an accident, and hence byaccidental means …

H…

The insured did not do anything which in its ordinary consequenceswas fraught with danger. The allegations of the complaint showthat he was playing golf in the same conditions in which he hadoften played before. The heat was not extraordinary; the exertionnot unusual. By misadventure or accident, an external force, whichhad hitherto been beneficent, was transformed into a force ofviolence, as much so as a stroke of lightning. The opinion of thecourt concedes that death ‘from sunstroke, when resulting fromvoluntary exposure to the sun’s rays,’ is ‘an accident.’ Why? Tobe sure, the death is not intentional, but that does not make it an‘accident,’ as the word is commonly understood, any more thandeath from indigestion or pneumonia. If there was no accidentin the means, there was none in the result, for the two wereinseparable. No cause that reasonably can be styled anaccident intervened between them. The process ofcausation was unbroken from exposure up to death. Therewas an accident throughout, or there was no accident atall.”

In a decision of the Court of Appeal in UK in Dhak v InsuranceCompany of North America (UK) Ltd[14], the insured to relieve herselfof backpain started consuming alcohol and died due to acute alcoholism.The accidental insurance policy provided for benefits payable for “bodilyinjury resulting in death or injury within 12 months of the accident occurringduring the period of insurance and caused directly or indirectly by theaccident.” The term “bodily injury” was defined as one “caused byaccidental means.” The court held that the words “caused by accidentalmeans” were a clear indication that the terms of the policy required thecourt to concentrate on the cause of the injury and to inquire whether itwas by accidental means. It held thus:

“I have come to the conclusion, however, that it has not beenestablished that the bodily injury to the deceased was “caused byaccidental means” within the meaning of the policy. In reachingthis conclusion I have been persuaded that the words “caused byaccidental means” are a clear indication that it is the cause of theinjury to which the court must direct its attention.

A

B

C

D

E

F

G

A…

In my judgment, however, whatever the position may be in someother jurisdictions, the terms of this policy require a court in thiscountry to concentrate on the cause of the injury and to inquirewhether the injury was caused by accidental means…

B

…

…the deceased must have been well aware of the consequencesand dangers of drinking alcohol to excess and that she must betaken to have foreseen what might happen in the event of someonedrinking to excess… I am satisfied that there must have been apoint at which she would have realised that any further drinkingwould be dangerous and that vital bodily functions might be impairedor interrupted.”

C

The Canadian Supreme Court, in American InternationalAssurance Life Company Ltd and American Life InsuranceDCompany v Dorothy Martin[15], has taken a contrary view and movedaway from the distinction laid out in Landress (supra). This case dealtwith the interpretation of an accidental death benefit provision, whichstipulated that “the Company will pay the amount ofthe Accidental Death Benefit … upon receipt of due proof that the LifeEInsured’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 apeptic ulcer, developed an addiction to opiate medications and died dueto high levels of Demerol in his body. The insurers challenged the claimon the ground that the death was not through “accidental means” andFthat self-injection of Demerol was a deliberate act making the death aforeseeable consequence. Chief Justice McLachlin, speaking for theBench held thus:

“The first question to be considered is whether deaths causedby accidental means form a subclass of accidental deaths. To putGthe question another way, is the category of deaths causedby accidental means narrower than that of accidental deaths?

The insurers argue that… a death is only causedby accidental means when both the death and the actionsthat are among its immediate causes are accidental.

H15 [2003] 1 SCR 158

…

This view seems to me, however, to be problematic. Almostall accidents have some deliberate actions among theirimmediate causes. To insist that these actions, too, mustbe accidental would result in the insured rarely, if ever,obtaining coverage. Consequently, this cannot be themeaning of the phrase “accidental means” in the policy.Insurance policies must be interpreted in a way that giveseffect to the reasonable expectations of the parties: ReidCrowther & Partners Ltd.v. Simcoe & Erie General InsuranceCo., [1993] 1 S.C.R 252, at p. 269. A policy that seldom applied towhat reasonable people would consider an accidental death wouldviolate this principle.

In my view, the phrase “accidental means” conveys the idea thatthe consequences of the actions and events that produced deathwere unexpected.

It follows that to ascertain whether a given means of deathis “accidental”, we must consider whether theconsequences were expected. We cannot usefully separateoff the “means” from the rest of the causal chain and askwhether they were deliberate. Cardozo J. emphasized in hisdissenting judgment in Landress v. Phoenix Mutual Life InsuranceCo., 291 U.S 491 (1934), at p. 501, that “[i]f there was no accidentin the means, there was none in the result”. The converse isequally true: if there was no accident in the result, therecan be none in the means. As Cardozo J. went on to say, either“[t]here was an accident throughout, or there was no accident atall”. Hence, to determine whether death occurred by accidentalmeans, we must look to the chain of events as a whole, and wemust consider whether the insured expected death to be aconsequence of his actions and circumstances.

...Usually we intend the consequences of our actions. However,sometimes our actions have unintended or unexpectedresults. When death is the unexpected result of an action,we say that the death was “accidental”, or that it wasbrought about by “accidental means” as opposed to“intentional means”. In ordinary language, then, “death A

B

C

D

E

F

G

H

A

by accidental means” and ”accidental death” have the samemeaning.

…

I conclude that the phrase “accidental means” in this insurancepolicy does not refer to a narrow subclass of the broader categoryof “accidental deaths”. “Accidental death” and ” deathby accidental means” connote a death that was in somesense unexpected. The two phrases have essentially thesame meaning.”

B

(Emphasis supplied)C

The Court of Appeal of Singapore in Quek Kwee Kee Victoriav American International Assurance Co. Ltd[16], agreed with theCanadian Supreme Court in Dorothy Martin (supra) and noted thatthe courts in many jurisdictions have moved away from the distinctionlaid out in Landress (supra):

D

“… we prefer the view that the use of phrases such as “accidentalmeans” would not restrict the situations covered by a personalaccident insurance policy to those where the proximate cause ofthe insured’s injury or death was not a deliberate or voluntaryaction on the part of the insured. For example, if a person injuresEhimself by driving off a cliff in the mistaken belief that the roadcontinued, that person would have met with an “accident” just asmuch as one who slips and fractures his leg while walking on aslippery surface. It would, in our view, accord with ordinaryexperience to hold that the injury suffered by an insured in suchcases would be a result of “accidental means”. In this regard, weFfind ourselves in agreement with the observations of McLachlinCJ in Martin…

E

…

…courts in the Commonwealth have moved away from thisdistinction between intended means and unintended results.Although this still appears to be good law in England (see, forexample, Dhak v Insurance Co of North America [1996] 1 WLR936 (“Dhak”) at 949), the distinction has been rejected in NewZealand (see Groves at 127–128), the United States (see Wickman G

16 [2017] 1 SLR 461

v Northwestern National Insurance Co 908 F 2d 1077 (1st Cir1990) (“Wickman”)), Scotland (see MacLeod v New HampshireInsurance Co Ltd 1998 SLT 1191), Australia (see the judgment ofWilson, Deane and Dawson JJ in Australian Casualty Co Ltd vFederico [1986] HCA 32 at [18]–[20]) and Canada (see Martin vAmerican International Assurance Life Co [2003] SCC 16(“Martin”) at [10]–[13])…”

9. The respondent has placed reliance upon a decision of a SingleJudge of the Patna High Court in Kamlawati Devi v State of Bihar[17],where the deceased who was on election duty was threatened by armedmiscreants while relieving himself which triggered a heart attack. JusticeAftab Alam (as his Lordship then was) while discussing precedent fromother jurisdictions and authorities on Insurance Law noted that thereexists a divergence of opinion about whether a distinction exists betweenan ‘accidental result’ and ‘accidental means’ while assessing a claimunder an accident insurance policy. The court while holding that the actof 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 itclear that it is intended to impose a twofold limitation. A death inorder to qualify for the insurance cover must not only be accidentalbut the accident causing death must itself result from someexternal, violent and other visible means. This two fold limitationis based on what is called, in the Law of Insurance, the distinctionbetween ‘accidental result’ and ‘accidental means’. Anunexpected and unforeseen consequence or result from a normalor routine activity may constitute an accident but it would notqualify as ‘accidental means’. Thus, if a person suffers a fatalheart attack while dancing (considered to be a normal activity)the death may be called ‘accidental’ but it would fail to attract theinsurance cover because it was not due to ‘accidental means’.On the other hand, if a person dies due to heart attack suffered asa result of over-exertion on being chased by a ferocious dog (anunintended occurrence, and not a normal activity) the death mightattract the insurance cover as it was caused by ‘accidentalmeans’.

…

17 (2002) 3 PLJR 450

AB

C

D

E

F

G

AOn examining this branch of the law of insurance one finds aseries of decisions which tend to do away with the distinctionbetween ‘accidental result/death’ and ‘accidental means’. Onealso finds another set of decisions which though maintaining theformal distinction between ‘accidental result’ and ‘accidentalmeans’ have so interpreted the key words in the restrictive clauseB(e.g. accident, external, violence and any other means etc.) as togreatly 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 deathCof Parshuram Singh was an accidental death caused by accidentalmeans. If the view expressed in the book, the Law of Insurancethat the words “by violent, external and visible means” add little ifanything to an accident policy is to be accepted, then his deathwould attract the insurance cover without anything else. But evenif the applicability clause in the M.O.U. is to be given a literalDinterpretation and the distinction between accidental result andaccidental means is to be maintained, I come to the unescapableconclusion that the act of threatening by the armed miscreantswas plainly covered by the expression “external, violent and anyother visible means” and the deceased encountering those threatsEwhile he had gone to relieve himself was clearly an accident thattriggered off the heart attack and, thus, resulting solely and directlyinto his death. It appears to me, therefore, that the death of thepetitioner’s husband was fully covered by the cover clause in theM.O.U.”

FIn a Letters Patent Appeal, the Division Bench of the Patna HighCourt in Branch Manager, United India Insurance Co v State ofBihar[18] affirmed the aforesaid judgment and held thus:

“... In the present matters, it appears that the Insurance Companiesare belabouring under misapprehension that unless the personGsuffers an external visible injury by external visible means theInsurance Company would not be answerable to it. In our opinion,the phraseology used in the cover does not have the scope to readexternal visible injury. The phrase simply says—”in the event ofdeath only resulting solely and directly from accident caused byexternal violent and any other visible means.””

H18 (2003) 51 (2) BLJR 117

There exists a divergence of opinion on whether ‘accidentalmeans’ and ‘accidental death’ are to be read as similar or whether inorder for an accidental insurance claim to succeed, the means causingthe injury or death also have to be accidental in nature. For the purposesof this case, it is not necessary to conclusively decide this question. Inorder to sustain a claim under the accident benefit cover, it must beestablished that the assured has sustained a bodily injury which resultedsolely and directly from the accident. There must, in other words exist aproximate causal relationship between the accident and the bodily injury.Moreover, the accident must be caused by outward violent and visiblemeans. The expression “outward violent and visible” signifies that thecause of the accident must be external. Moreover, the injury must be thecause of the death within the period of 180 days. There has to beproximate relationship between the injury and the death to the exclusionof all other causes. The outcome of the present case involvesinterpretation of the accident benefit cover. Breaking down the clauseinto 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 visiblemeans;

(iv) The injury must solely, directly and independently of all othercauses result in the death of the assured; and

(v) Death must ensue within a period of 180 days from the injurycaused in the accident.

What needs to be determined is whether the insured suffered aheart attack as a result of the injuries sustained from the fall from themotorcycle or whether the fall was a result of the assured suffering aheart 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, shemust show direct and positive proof that the accident of the assuredfalling from his motorcycle caused bodily injury by external/outward,violent and visible means. The complainant will have to prove that theaccident and the injuries sustained as a result were a direct or proximatecause of her husband’s death.

A

B

C

D

E

F

G

H

A11. In the present case, no post mortem of the deceased or policeinvestigation was conducted. In the absence of a post mortem reportindicating the nature of injuries sustained by the insured, we would haveto rely upon the medical report that indicates the exact cause of death.The medical report of Dr Ajay Goverdhan who examined the assuredon the date of the accident indicated that the insured suffered shoulderBand chest pain and that the exact cause of death was an acute myocardialinfraction. The insured was referred to a specialist, Dr SS Dhillon, whoalso recorded in his report that the diagnosis did not show the cause ofdeath to be accidental. Dr S S Dhillon noted that the insured wasexperiencing pain in the left side of the chest and in the shoulder andCthere was a myocardial infarction. The insured was referred to ChanduLal Memorial Hospital, a specialist medical center, where the OPDrecords noted that an ECG was taken at Dhillon Nursing Home and theinsured was sweating and that he had chest pain, radiating to the leftshoulder along with two episodes of vomiting. He died before he reached

the hospital. There is no material on record to indicate that the assuredDsustained specific injuries as a result of a fall from the motorcycle orthat the injuries were caused by outward, violent and visible means,which was the sole and proximate cause of his death. There is no directnexus or causation between the assured suffering a heart attack andinjuries sustained in an accident by outward, violent and visible means.ENothing has been brought on record to show that the injuries sustainedby falling from the motorcycle aggravated the assured’s condition thateventually 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 toa 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 hisFmotorcycle.

In a case decided by the NCDRC - LIC of India v Smt MamtaRani[19]- clause 10.2 of the insurance policy provided an accident benefitcover if the assured sustained any bodily injury resulting solely and directlyfrom the accident caused by outward, violent and visible means. TheGassured died of a heart attack. The district and state forums allowed theclaim of the complainant for accidental benefit. However, the NCDRCrejected the claim and held thus:

“… it is clear that in case of death of life assured, the additionalaccident benefit equal to the sum assured is payable only if thelife assured dies because of any bodily injury resulting solely anddirectly from an accident by outward, violent and visible means.In the instant case, as per the record, the life assured died on01.07.2002 due to heart attack. There is no evidence on record toindicate that the life assured died because of some injury sufferedin an accident. Thus, the fora below have committed a materialillegality in awarding the accident benefit to the respondents againstthe terms and conditions of the insurance contract.”

Similarly, in Swaranjit Kaur v ICICI Lombard GeneralInsurance Co Ltd[20], the assured while travelling on his scooter, suffereda heart attack and fell from his scooter. The claim for accidental benefitcover was repudiated on the ground that the insured had died a naturaldeath because of heart attack. The state commission set aside the orderof the district forum allowing the claim. The NCDRC while upholdingthe state commission’s judgment, noted that the onus to prove that theinsured had died as a result of an accident and not a heart attack was onthe claimant. It held thus:

“…On perusal of the copy of repudiation letter, it is clear that therespondents repudiated the insurance claim on the ground thatcause of death of insured was heart attack. On perusal of thereport of the investigator, we find that the stand of the petitionersin the statement made before the investigator on 17.8.2006 wasthat while driving the scooter insured suffered a heart attack,consequently, he fell down from the scooter and died. From this, itis clear that the accident took place after the insured had sufferedheart attack. Otherwise also, in order to succeed in the insuranceclaim, the onus of proving that the insured had died as a result ofaccident was on the petitioners. Undisputedly, incident was notreported to the police nor post mortem to establish cause of deathwas done. No evidence has been produced by the petitioners toprove the cause of death of the insured. There is nothing in thestatement of the petitioners as recorded by the investigator thatthe insured had suffered any bodily injuries due to fall from thescooter. Thus, under the circumstances, the conclusion of the State A

B

C

D

E

F

G

ACommission that cause of death of the insured was heart attackand not an accident cannot be faulted…”

The High Court of Madras held in Life Insurance Corporationv Minor Rohini[21] that in the absence of any evidence that the assuredhad sustained any bodily injury resulting solely and directly from theBaccident caused by outward, violent or visible means, it cannot be saidthat the death due to a heart attack would amount to an accident for thepurposes of accidental insurance claim under the policy.

In Krishna Wati v LIC of India[22], the NCDRC had to deal withwhether the accidental injuries which resulted in the death of the assuredCdue to a heart attack after three days of the accident could be termed asan accidental death or a natural death. The assured while riding hisbicycle was attacked by a cow and upon arriving at the hospital complainedof 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 claimfor accident insurance. It held thus:D

“… In our view, from the record as it is, it is apparent that first theaccident took place, resulted in injuries and chest pain whichultimately resulted in ‘death’. May be, the death in the medicalterms be described as ‘due to heart-attack, but the main causefor leading to heart-attack was injury caused due to accident.EAccident is the basis for causing chest pain and thereafter heart-attack…”

12. In the present case, there is no evidence to show that anybodily injuries were suffered due to the fall from the motorcycle or thatthey led to the assured suffering a heart attack. There is no evidence toFshow that the accident took place as a result of any outward, violent andvisible means. The assured died as a result of a heart attack which wasnot attributable to the accident.

13. For the above reasons, we are of the view that the judgmentof the NCDRC dated 29 April 2016 does not suffer from any error. TheGappeal shall accordingly stand dismissed. There shall be no order as tocosts.

Kalpana K. Tripathy

Appeal dismissed.

21 2012 (1) MWN (Civil) 740. Also see New India Assurance Company Limited v. K. Thilagam 2009 (2) TN MAC 197H22 1 (2006) CPJ 21 (NC)