While upholding an order passed by the Gujarat state consumer disputes redressal commission, the national consumer disputes redressal commission (NCDRC) directed SBI General Insurance Co Ltd to pay the Rs20 lakh death insurance claim with an interest of 9%pa (per annum) to the mother and nominee of the deceased life assured (DLA).
In an order earlier this week, the bench of Dr Inder Jit Singh (presiding member) said, "The state commission rightly noted in its order that the final determination of the cause of death cannot be made solely based on police statements, in accordance with settled legal provisions. Given the absence of corroborative evidence indicating a natural cause of death, the state commission rightly concluded that the death of the deceased was accidental rather than natural."
Navsari-based Dharmesh Jayanand Bhope held a savings account in State Bank of India (SBI). On 27 January 2015, he bought a personal accident policy of Rs20 lakh from SBI General Insurance Co by paying a premium of Rs1,000. As per the policy terms, in the event of his accidental death, his successors would receive the insurance amount.
On 17 June 2015, while driving his Maruti van from Bilimora to Surat with passengers, he was involved in an accident between Kamela Darwaja and Raghukul Market Garnada. As a result, he suffered internal injuries, including damage to the aorta and brain haemorrhage, leading to his immediate demise on the spot.
His mother, Kesarben Jayanand Bhope submitted the insurance claim to SBI General Insurance. However, SBI General Insurance denied the accidental compensation, contending that the cause of death was shock and haemorrhage due to the rupture of the ascending aorta which, they argued, did not qualify as an accident.
Alleging that the insurer's refusal to provide compensation for her deceased son's accident, despite the existence of the insurance policy, constitutes a deficiency in service, Ms Bhope filed a complaint before the Navsari district consumer disputes redressal forum.
However, on 1 December 2016, the district forum dismissed her complaint. Aggrieved by the district forum's order, Ms Bhope appealed in the state commission.
In an order on 23 October 2018, the state commission allowed the appeal and complaint while setting aside the order of the district forum. It directed SBI General Insurance to pay Rs20 lakh to Ms Bhope with 9% interest pa from 1 July 2016 to 31 December 2018.
SBI General Insurance challenged the order before NCDRC, alleging material irregularity by the state commission by misinterpreting the material evidence on record. "The state commission committed a serious error by disregarding the post-mortem report, which explicitly stated the absence of external injuries on the insured's body... the state commission's inference that the insured's death was accidental because the post-mortem report did not mention a 'heart attack' is baseless. The report aligns with other evidence suggesting that the insured was not involved in any accident and died of natural causes."
The counsel for Ms Bhope argued that the district forum's decision was patently illegal and contrary to the evidence on record. "(We) have provided ample evidence, including police investigation reports, post-mortem reports, witness statements, and the sub-divisional magistrate's report, all indicating that the deceased died as a result of an accident. The post-mortem report explicitly states the cause of death as 'shock due to haemorrhage as a result of rupture of ascending aorta', which is consistent with the accident scenario described by witnesses."
The counsel refuted SBI General Insurance's argument that the insurance policy only covers deaths resulting from external physical injury. He says, "The terms and conditions of the policy do not specify such a limitation and that deaths caused by internal injuries due to accidents are also covered. The happening of the accident is irrefutable, supported by various pieces of evidence such as police panchnama, inquest reports, inquiries, and eyewitness statements. The insurer has not presented any evidence to dispute the occurrence of the accident.”
After going through the orders of the state commission and district forum, other relevant records and rival contentions of the parties, NCDRC observed that the case at hand revolves around the circumstances surrounding the death of an individual, with the primary contention being whether the demise occurred naturally, possibly due to a heart attack, or was accidental in nature.
Dr Singh from NCDRC says, "SBI General Insurance, despite their position, failed to furnish any evidence to refute the narrative of an accidental death. The post-mortem report explicitly states the cause of death to 'shock due to haemorrhage as a result of rupture of ascending aorta', providing a clear indication that the death stemmed from an accident rather than natural causes."
"Furthermore, the absence of evidence indicating any pre-existing medical condition leading to brain haemorrhage supports this assertion. SBI General Insurance's sole contention, suggesting the death as resulting from natural causes, lacks both legal and evidentiary support. This argument is effectively refuted by the post-mortem report's findings, which do not suggest death due to a typical illness or heart attack," he says.
While dismissing the petition, NCDRC directed SBI General Insurance to pay Rs20 lakh with 9%pa interest to Ms Bhope, the mother of the DLA.
(Revision Petition No239 of 2019 Date: 2 April 2024)
