1.       The present Revision Petition (RP) has been filed by the Petitioner against Respondent as detailed above, under section 21(b)of Consumer Protection Act 1986, against the order dated 31.05.2017 of the State Consumer Disputes Redressal Commission, Punjab, Chandigarh (hereinafter referred to as the ‘State Commission’), in First Appeal (FA) No. 393/2016 in which order dated 26.04.2016 of Hoshiarpur District Consumer Disputes Redressal Forum (hereinafter referred to as District Forum) in Consumer Complaint (CC) No. 229/2015 was challenged, inter alia praying for:-

(i)      setting aside the impugned order dated 31.05.2017 passed by the Punjab State Commission in FA/393/2016.

(ii)     dismissing the complaint filed by the complainant/respondent herein bearing CC No. 229/2015 with the District Forum, Hoshiarpur.

2.       While the Revision Petitioner (hereinafter also referred to as OP/Insurance Company) was Respondent and the Respondent (hereinafter also referred to as Complainant) was Appellant  in the said FA/393/2016 before the State Commission, the Revision Petitioner was OP and Respondent was Complainant before the District Forum in CC/229/2015.  Notice was issued to the Respondent on 17.05.2018.  Delay of 5 days in filing the Revision Petition is condoned after considering the reasons stated in the condonation of delay application. Parties filed Written Arguments/Synopsis on 14.09.2023 (Petitioner) and 27.03.2023 (Respondent) respectively.

3.       Brief facts of the case, as emerged from the RP, Order of the State Commission, Order of the District Forum and other case records are that: -

The son of the complainant namely Sh. Dharm Dev (deceased), during his lifetime, got himself insured with the opposite parties under the policy "Pravasi Bhartiya Bima Yojna", having insurance cover of Rs.10,00,000/-in case of disability or death of insured, valid from 05.06.2014 to 04.06.2016. The deceased Sh. Dharm Dev was working as an employee of 'Green Line Health and Electrical Installations LLC’  at Abu Dhabi, U.A.E. On 27.07.2014 he died on the way to hospital, after accidental fall from the height while working at site under the employment of said company. Deceased Dharm Dev, who was unmarried, died leaving behind his mother as his sole legal heir. The complainant (mother of the deceased) lodged the claim with the opposite parties on account of the accidental death of her son, which was repudiated by the OPs. Even the issuance of legal notice dated 14.10.2015, did not yield any fruit. Hence, the complainant approached the District Forum. 

4.       Vide Order dated, in the CC No. 229/2015, the District Forum dismissed the complaint. Aggrieved by the said Order dated 26.04.2016 of District Forum, the Complainant/Respondent herein appealed in State Commission and the State Commission vide order dated 31.05.2017 in FA No. 393/2016 allowed the Appeal and passed the following order:-

“17. Sequel to the appeal discussion, the appeal is allowed and the impugned order passed by the District Forum is set aside. Consequently, the complaint filed by the complainant is accepted and the following directions are issued to the opposite parties:

i)  to pay 10,00,000/-, being the sum assured under the policy, in question, to the complainant, along with interest at the rate of 9% per annum from the date of lodging the claim till realization;

ii) to pay Rs.1,00,000/-, as compensation for the mental agony and harassment suffered by the complainant; and

iii)            to pay Rs.11,000/-, as litigation expenses.

18. The opposite parties shall comply with this order within 30 days of the receipt of certified copy of the same, failing which the compensation amount shall also carry interest at the rate of 9% per annum from the date of this order till realization.”

5.       Petitioner has challenged the said Order dated 31.05.2017 of the State

Commission mainly on following grounds:-

(i)      The order of the State Commission dated 31.05.2017 is bad both in law as well as on facts and ought to be set aside and/or quashed. The State Commission has passed the order without due application of mind and the same is erroneous and as the same is based on conjunctures and surmises. The State Commission erred by not considering the fact that the respondent had created the false story of deceased/insured falling from height resulting in Cardiac Arrest to illegitimately get claim from the petitioner insurance company. The said story was nothing but an afterthought. This fact is apparent from bare perusal of the Claim Form filled by the respondent which is absolutely silent about any kind of fall, accidental injury etc. In fact the "Death Notification" prepared by the concerned Doctor is absolutely clear wherein the concerned Doctor had not chosen the cause of death as "Injury (external cause)" and specifically chosen "Myocardial infarction" as cause of the death. Had it been a case that the deceased would have died due to any kind of fall or accident, the concerned doctor must have mentioned the same in it's report. Hence, the complaint of the respondent had been rightly dismissed by the District Forum and the impugned order is not tenable in the eyes of law.

(ii)     The State Commission erred in ignoring the fact that the respondent had not led any rebuttal evidence to disprove or dispute the findings given by the concerned doctor. The "Dead Body Clearance Certificate" also substantiate the finding given in the "Death Notification" as the cause of death in the said Certificate is specifically mentioned as "Cardiac Arrest".

(iii)    The  State Commissioner erred in ignoring the settled law that the onus was on the respondent to prove that the death of the insured was accidental, which the respondent failed to prove the same. The affidavit filed by the alleged eye witness is also not reliable as the same is afterthought to illegitimately get claim from the petitioner. No evidence had been filed by the respondent to show that the alleged fall from the height had caused Cardiac Arrest to the deceased and his death was accidental in nature. On the contrary, the documents/evidence produced by the petitioner clearly established that there was no accidental injury caused to the deceased insured and hence, the claim of the respondent does not fall under the ambit of the policy.

(iv)    The State Commission erred in ignoring plethora of judgments by this Commission wherein it had been held that "Heart Attack/Cardiac Arrest" is not an accident. The State Commission erred in observing in para 10 of the impugned order that the fall of deceased from height is evident from the Death Certificate. The said finding of the State Commission is absolutely perverse.

(v)     The  State Commission erred in observing in para 12 of the impugned order that the petitioner had not denied in its reply that the deceased died on the way to Hospital after he accidentally fell from height. It is pertinent to mention that the petitioner had vehemently denied the allegation of fall from height and accidental injury/death. The impugned order is totally based on the presumptions, which is not allowed under law. The impugned order is liable to be set aside on this sole ground itself. Because the State Commission further erred in observing in the impugned order that the petitioner had not led any evidence to prove that the deceased had a past history of heart ailment. This finding had no impact on the claim of the respondent as the claim was not lodged under Medi-claim Policy or petitioner had not denied the claim stating Heart Disease as pre-existing disease. Personal Accident Claim was payable only in case of accidental injury/death. The State Commission erred in not relying upon the Death Notification.

(vi)    The State Commission erred in relying upon the judgements of this Commission which are not applicable in the present facts and circumstances of the case. The State Commission failed to appreciate the terms and conditions of the policy. The claim is payable under the policy only in the case of accidental death and that too by the accident caused by violent, external and visible means. There is no iota of evidence on record which suggest that the death of the deceased was accidental. Hence, the claim of the respondent had been rightly repudiated. The State Commission failed to appreciate that the insurance is a contract like any other commercial contract and the terms of the contract are binding on both the parties. Insured cannot claim anything which is not covered under the policy. The same view been upheld by the Hon'ble Supreme Court of India through plethora of judgments some of which are cited herein below:- i. Export Credit Guarantee Corp. of India v. Garg Sons International (2013(1)SCALE 410) ii. United India Insurance Company Harchand Rai Chandan Lal (2005) ACJ 570, iii. National Insurance Company Vs. Anjana Shyam (2007) ACJ 2129.

6.       Heard counsels of both sides.  Contentions/pleas of the parties, on various issues raised in the RP, Written Arguments, and Oral Arguments advanced during the hearing, are summed up below.

6.1     Petitioner in addition to repeating what has been stated in para 5 under the grounds, has contended in its written arguments that the Petitioner issued a Pravasi Bharatiye Bima Yojana policy in favor of deceased Mr. Dharm Dev, who was working as an employee of ‘Green Line Health and Electrical Installation LLC’ at Abu Dhabi, U.A.E. The policy was valid from 05.06.2014 to 04.06.2016 and the liability of the petitioner is strictly as per the terms and conditions of the policy.  On 27.07.2014 the insured died due to heart attack.  The respondent submitted the claim form to the petitioner wherein nothing had been mentioned about any kind of injury or accident despite having specific question regarding the same.  While processing of the claim the petitioner perused the ‘Death Notification’ prepared by the concerned doctor and also ‘Dead Body Clearance Certificate’.  In both the documents the cause of death was precisely mentioned as Cardiac Arrest/Myocardial Infarction.  Nothing is mentioned about any fall or accident or accidental injury in the said documents.  The ‘Death Notification’ had specific questions for the doctor concerned about the injury if resulted in death.  The concerned doctor had not chosen the option of Injury (External Cause) rather chosen the option ‘Cardiovascular Disease’. After considering the facts of the claim and treatment papers, it had transpired to the petitioner that no accident had taken place of any kind and the deceased died due to Cardiac Arrest and which had not caused due to any accident or injury.  Hence, the claim had been repudiated by the petitioner vide its self-explanatory Repudiation Letter dated 29.07.2015. The Respondent dragged the Petitioner to litigation by filing the consumer complaint, wherein the Respondent made an afterthought story that the deceased had fallen down from height, which caused Cardiac Arrest. None of the document at the time of claim processing revealed/disclosed any kind of accidental injury/fall from height etc.  Even claim form is silent about the same. The District Forum after appreciating the terms and condition, facts of the case, evidence on record and the settled law rightly dismissed the complaint of the Respondent.  The State Commission, without appreciating the facts and circumstances of the case, evidence on record and the judgments of the Hon’ble Supreme Court and this Commission had erroneously allowed the appeal of the Respondent. 

6.2     On the other hand Respondent/complainant contended that on 27.07.2014, Dharm Dev had an accidental fall from height while working at site and died on the way to hospital.  The policy was valid at the time of death of insured Dharm Dev.  The Respondent lodged claim with the Petitioner.  The claim was wrongly repudiated by the Petitioner vide letter dated 29.07.2015. Aggrieved from the deficiency in service of the petitioner, a legal notice dated 14.10.2015 was served upon the petitioner, but of no use.  Hence, filed complaint before the District Forum, which was dismissed vide order dated 26.04.2016 and an Appeal against the said order of the District Forum was filed as FA/393/2016 before the State Commission.  The State Commission has allowed the Appeal vide order dated 31.05.2017.  The Petitioner has filed the Revision Petition against the order of the State Commission.  The Revision Petition has been filed after expiry of limitation period, but the entire story of the petitioner does not disclose ‘sufficient cause’.  The respondent/ complainant led ample evidence in super of her complaint, which are affidavit of the complainant.   The respondent got examined witness Dharmveer who was working with the deceased son of respondent and his deposition remains unrebutted. The State Commission has rightly held in para No. 11 of its order that it is a matter of common knowledge that after the fall from height and suffering of injury the consequences of shock and cardiac arrest are possible.  The State Commission has given its reasoned findings in para No. 11 of its order dated 31.05.2017.  The State Commission in para No. 14 of its order has rightly referred the judgment passed by the National Commission in Eeta Devi Vs. United India Insurance Co. Ltd. 2015 (2) CLT 504 (NC), the National Commission held that the onus to prove the death of the insured is a natural one and not an accidental death shifts on the Insurance Company.  The repudiation of the claim was held totally unjustifiable.  In the present case, the OPs failed to discharge their onus by proving that the death of the insured was a natural one. 

7.       The case of Petitioner Insurance Company is that it was not a case of accidental death, hence not covered under the policy, while the case of Respondent/complainant is that deceased had fallen down from height, which caused cardiac arrest.  State Commission has considered at length the rival contentions of the parties, various case laws on the subject and affidavit evidence of an eye-witness.  Extract of relevant para of State commission’s order is reproduced below:

“11. The complainant has produced affidavit Ex.C-2 of the eye-witness Sh.Dharamveer S/o Sh. Santokh Singh, R/o  Village Gumtala, P.S. Bilga, District Jalandhar, who specifically deposed that on 27.07.2014, he  and Dharm Dev were working as  employees of Green Line Health and Electrical Installations LLC Abu Dhabi, U.A.E. at the site of work. The DLA was working at height and all of a sudden, he fell from the height on the ground, due to which he was under severe shock and pain. After arranging the conveyance, Dharm Dev was taken to hospital, where the doctors declared him 'brought dead'. He specifically deposed that the death of Dharm Dev was sudden and voluntary, due to severe shock due to accidental/sudden fall from the height. He further deposed that he brought the dead body of the deceased from U.A.E. to India for his last rites. He further deposed that the deceased was a healthy person and was not suffering from any disease. The complainant also proved the air ticket and work permit of said Dharamveer as Ex.C-7 and Ex.C-8 respectively, in order to authenticate his deposition made in the affidavit.

“12. It is a matter of common knowledge that after fall from height and suffering of injury, the consequences sequences of shock and heart attack are possible.  Once a person comes to know that injury is of such a severe nature, shock affects such a person; which may result into heart attack…….”

“15. Applying the ratio of the law laid down in the above authorities, it can be held that after the fall from the height, the insured must have suffered shock due to which he further suffered heart attack and died due to accidental injuries……”

8.       We have carefully gone through the order of the State Commission, District Forum, other relevant records and rival contentions of the parties.  Keeping in view the entirety of facts and circumstances of the case and evidence of eye-witness before the State Commission, we tend to agree with the findings of the State Commission with respect to cause of death being accidental, hence covered under the policy.

9.       As was held by the Hon’ble Supreme Court in Rubi Chandra Dutta Vs. United India Insurance Co. Ltd. [(2011) 11 SCC 269], the scope in a Revision Petition is limited. Such powers can be exercised only if there is some prima facie jurisdictional error appearing in the impugned order. In Sunil Kumar Maity Vs. State Bank of India & Ors. [AIR (2022) SC 577]  held that “the revisional jurisdiction of the National Commission under Section 21(b) of the said Act is extremely limited. It should be exercised only in case as contemplated within the parameters specified in the said provision, namely when it appears to the National Commission that the State Commission had exercised a jurisdiction not vested in it by law, or had failed to exercise jurisdiction so vested, or had acted in the exercise of its jurisdiction illegally or with material irregularity.” 

10.     The State Commission has given a well-reasoned order and we do not see any reason to interfere with the same.  There is no illegality or material irregularity or jurisdictional error in the order of the State Commission, hence the same is upheld.  Accordingly, the Revision Petition is dismissed.  All payments as per order of the State Commission to be made within 30 days from the date of this order, failing which, it will carry interest @12% p.a..  

11.     The pending IAs in the case, if any, also stand disposed off.