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 23.10.2018 of the State Consumer Disputes Redressal Commission, Gujarat, Ahmedabad, (hereinafter referred to as the ‘State Commission’), in First Appeal (FA) No. 734 of 2016 in which order dated 01.12.2016, District Consumer Disputes Redressal Forum, Navsari (hereinafter referred to as District Forum) in Consumer Complaint (CC) no. 88 of 2016 was challenged, inter alia praying to set aside the order passed by the State Commission.    

2.       While the Revision Petitioner (hereinafter also referred to as OP) was Respondent and the Respondent (hereinafter also referred to as Complainant) was Appellant in the said FA/734/2016 before the State Commission, the Revision Petitioner was OP and Respondent was Complainant before the District Forum in the CC no. 88/2016.

3.       Notice was issued to the Respondent.  Parties filed Written Arguments/Synopsis on 21.05.2021 (Petitioner/OP) and 20.08.2019 (Respondent/Complainant) respectively.

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

The complainant's son held a savings account with the State Bank of India (OP), which issued personal insurance policies for its consumers. The complainant's son acquired a personal accident policy and paid an insurance premium of Rs. 1000/- to the OP on 27.01.2015, securing an insurance coverage of Rs. 20,00,000/- (twenty lacs only). It was assured that in the event of the complainant's son's accidental death, his successors would receive the aforementioned amount. Tragically, on 17.06.2015, while driving his Maruti Van from Bilimora to Surat with passengers, the complainant's son 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 hemorrhage, leading to his immediate demise on the spot. Following the funeral of the deceased son, the complainant, through his other son Manish J. Bhope, submitted a claim to the OPs for the insurance obtained by the deceased son. However, the OPs denied the accidental compensation, contending that the cause of death was shock and hemorrhage due to the rupture of the ascending aorta, which they argued did not qualify as an accident. The OPs' refusal to provide compensation for the deceased son's accident, despite the existence of the insurance policy, constitutes a deficiency in service. Consequently, a complaint was filed before the consumer forum.

5.       Vide Order dated 01.12.2016, in the CC no. 88/2016 the District Forum has dismissed the complaint.

6.       Aggrieved by the said Order dated 01.12.2016 of District Forum, Respondent/Complainant appealed in State Commission and the State Commission vide order dated 23.10.2018 in FA No. 734/2016 has allowed the appeal and complaint; has set aside the order of District Forum and directed OP to pay an amount of Rs. 20,00,000/- to the complainant with 9% interest p.a. from 01.07.2016 to 31.12.2018.

7.       Petitioner has challenged the said Order dated 23.10.2018 of the State Commission mainly on following grounds:

1. The State Commission's decision reflects a material irregularity by misinterpreting the material evidence on record. Contrary to the findings of the District Forum, the State Commission concluded that the insured's death was accidental rather than natural. This contradicts the relevant findings of the Post-mortem and Police reports, which clearly indicate the absence of external injuries. The State Commission's order overturns the District Forum's findings, which were based on a thorough examination of evidence including the post-mortem report, scene Panchnama, police report, witness testimony, and vehicle photographs. The District Forum's decision was grounded in a thorough analysis of the evidence, unmistakably indicating that the insured's death was due to natural causes.

2. 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. Conducted by the Surat Municipal Institute of Medical Education and Research, the post-mortem attributed the cause of death to haemorrhage resulting from the rupture of the ascending aorta. Therefore, 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.

3. The State Commission erred by reaching its own conclusion regarding the insured's death without adequate support from the material evidence. Its assertion that the insured's death resulted from an accident lacks basis in the post-mortem report, police report, and witness statements. The State Commission failed to provide reasoning for its determination that the death was accidental, and no details of the alleged accident were provided in the impugned Order or any other relevant document. The State Commission's observation regarding the lack of corroboration between the Post Mortem report and witness statements is erroneous. A straightforward examination of the post-mortem report clearly indicates that the insured sustained no injuries and died due to haemorrhage resulting from the rupture of the ascending aorta.

4. The State Commission's acceptance of the complainant's Complaint without due consideration of material witness statements is a significant error. Witnesses testified that the insured experienced dizziness and was transported to the hospital unconscious after the van was parked near a compound. The State Commission failed to properly exercise its appellate jurisdiction in evaluating the evidence presented before the District Forum. The impugned Order issued by the State Commission not only contradicts the evidence on record but also lacks any supporting evidence to justify or explain the claim for compensation in the event of accidental death.

5. The policy terms of the Personal accident policy define an accident as a sudden, voluntary, and unforeseen event caused by external, visible, and violent means. Additionally, any resulting injury must be certified by a medical practitioner under the policy. The State Commission failed to interpret the terms and conditions outlined in the insurance policy. Its conclusion that the insured's death was accidental lacks substantiation demonstrating the insured's involvement in an accident as described and covered by the insurance policy.

8.       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.

1. The counsel for petitioner/OP argued that the terms and conditions of the Master Policy explicitly state that coverage is limited to death resulting from accidents only. The death of the Insured in this case, caused by shock and hemorrhage due to natural causes, does not fall within the purview of "accidental death." The Supreme Court in Suraj Mal Ram Niwas Oil Mills (P) Ltd. v. United India Insurance Co. Ltd., (2010) 10 SCC 567 emphasized the paramount importance of the words used in insurance contracts. It reaffirmed that insurance contracts must be strictly construed based on their terms.

2. The post-mortem report indicates that the cause of death was shock due to hemorrhage as a result of the rupture of the ascending aorta, which is a natural death. Additionally, the Inquest Panchanama Report suggests the cause of death as an accident while driving, but this is contradicted by the post-mortem report. In cases of inconsistency between the post-mortem report and the Inquest Panchanama Report, the former should prevail as it reflects the medical doctor's professional assessment. This principle was upheld by the Supreme Court in Javed Abdul Rajjaq Shaikh v. State of Maharashtra, (2019) 10 SCC 778. The counsel further asserted that the witness statements indicate that the Insured felt dizzy before stopping the vehicle and eventually becoming unconscious. While there were discrepancies regarding the collision of the vehicle, the statements collectively suggest that the Insured experienced internal distress before stopping the vehicle. The State Commission's order incorrectly inferred that the insured's death was accidental based on witness statements, despite the absence of clear medical evidence supporting this assertion.

3. The counsel argues that the State Commission overlooked the significance of the post-mortem report, which indicated a natural cause of death. The absence of injuries on the body and the specific cause of death mentioned in the report should have been given paramount importance. The Petitioner cites a Supreme Court judgment Narbada Devi & Ors. v. H.P. State Forest Corporation & Anr. to support their argument. In this case, the court emphasized the importance of adhering to the explicit terms of the insurance policy, which only indemnify accidental deaths. The judgment underscores the necessity of conclusive medical evidence in determining the cause of death. Given the discrepancy between the witness statements and the post-mortem report, the counsel contends that the State Commission's decision to award the insurance claim is flawed. The lack of clear evidence supporting an accidental death should invalidate the claim.

4. The counsel for Petitioner/OP relied on following cases:-

1. In Suraj Mal Ram Niwas Oil Mills (P) Ltd. v. United India Insurance Co. Ltd., (2010) 10 SCC 567 the Hon’ble Supreme Court observed:-

“23. Before embarking on an examination of the correctness of the grounds of repudiation of the policy, it would be apposite to examine the nature of a contract of insurance. It is trite that in a contract of insurance, the rights and obligations are governed by the terms of the said contract. Therefore, the terms of a contract of insurance have to be strictly construed, and no exception can be made on the ground of equity.”

2. In Javed Abdul Rajjaq Shaikh v. State of Maharashtra, (2019) 10 SCC 778 the Hon’ble Supreme Court observed:-

“49. As far as the injuries in the inquest report not being noticed in the post-mortem report is concerned, there can be no doubt that the medical doctor knows exactly what medical injuries are and ordinarily in case of inconsistency, the medical report of the doctor should prevail…..”

3.  In Narbada Devi v. H.P. State Forest Corpn., (2021) 18 SCC 699 the Hon’ble Supreme Court:-

“14. From a bare perusal of the insurance policy, as quoted supra, it is clear that only if the insured sustains any bodily injury resulting solely and directly from accident caused by outward, violent and visible means, the Insurance Company would be liable to indemnify the insured. Therefore, as per the insurance policy, only accidental death of the insured shall be indemnified. As noted above, the post-mortem report clearly indicates that there were no injuries found on the body of the deceased. The probable cause of death as per the final opinion in the post-mortem report is asphyxiation caused by alcohol consumption and regurgitation of food into larynx. As such, we find it difficult to conclude that the deceased's death was accidental. Further, the expert opinions of Dr D.S. Puri and Dr D.J. Das Gupta (supra) also show that the cause of death was due to consumption of alcohol. In light of the explicit terms of the insurance policy, we find that the National Commission and the State Commission have rightly held that the deceased's death was not accidental, and that the Insurance Company would not be liable to settle the appellants' claim.”

5. The counsel for Respondent/complainant argued that the State Commission's decision, which overturned the District Forum's rejection of the complaint, is just and reasonable. The District Forum's decision was patently illegal and contrary to the evidence on record. The counsel submits that they 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 hemorrhage as a result of rupture of ascending aorta," which is consistent with the accident scenario described by witnesses.

6. The counsel contends that they have met their burden of proof by demonstrating that the death occurred due to an accident; the onus of proof then shifts to the Petitioner/OP, who has failed to provide any evidence to refute the accident narrative. The counsel refutes the Petitioner's argument that the insurance policy only covers deaths resulting from external physical injury. 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 OP has not presented any evidence to dispute the occurrence of the accident.

7. The post-mortem report clearly states the cause of death as "Shock due to hemorrhage as a result of rupture of ascending aorta," indicating that the death resulted from the accident and not from natural causes. The absence of evidence showing the deceased had a pre-existing medical condition leading to brain hemorrhage further supports this assertion. The OP’s sole contention, that the death occurred due to natural causes, lacks legal and evidentiary support. The post-mortem report disproves this claim, as it indicates that the death was not normal and did not occur due to a typical illness or heart attack. The OP's rejection of the genuine insurance claim on flimsy grounds amounts to a deficiency of service under the Consumer Protection Act.

9.       We have carefully gone through the orders of the State Commission, District Forum, other relevant records and rival contentions of the parties. State Commission, in its order has observed as follows:-

“10. The learned forum has arrived at the decision that, it is a natural death but if the statements of the passengers seated in the vehicle are considered, they have accepted that they were seated as passengers in the vehicle and the vehicle met with an accident. They have provided their opinion as for the death of Late Dharmesh Bhope and it is opined that the death may be heart attack but while considering the manner in which the incident has occurred, we are of the decision that, one cannot arrive at conclusion of heart attack solely on the basis of opinion of these three passengers. The fact is that as for arriving at a cause of death, specific medical evidence is required and other corroborative evidence is required. On that basis only one can derive the decision that the cause of death is heart attack but no such evidence is put forth in this case. Even the post mortem report does not suggest that the Late Dharmesh Bhope has suffered heart attack. While considering the settled provisions of law, the final decision as to the cause of death cannot be taken solely on the basis of statements recorded by the police and therefore, having no corroborative evidence to suggest that the death of deceased is a natural one, we arrive at the decision that, the death of deceased is not natural but accidental. As for this we rely on the below mentioned principles established by law.

1) 2010(4) CPR P.548

Overturning is part of accident and insurance company is liable to pay compensation.

(ii) Insurance Law - Object of Insurance - Insurance is meant to protect men against uncertain events which may otherwise be some disadvantage to them not only persons to who positive loss may arise by such events occasioning deprivation of that which they may possess but also those who is consequence of such events may have interpreted them advantage of profits which but for such event they will acquire according to ordinary and probable course of things.

(iii) Words and Phrase - Accident - Word "accident' generally denotes an event that takes place without one's foresight or expectation; an event which proceeds from an unknown cause-Accident is an unintended occurrence which had an adverse physical result-Accident is not same as an occurrence but something that happens out of normal or ordinary course of things.

2) Himachal Pradesh State Consumer Dispute Redressal Commissioner matter being First Appeal no. being National Insurance company limited v/s Hardayal and the honourable state commission has made the below mentioned observations.

10. Submission of learned Advocate appearing on behalf of appellant that at the time of accident five persons were travelling in the vehicle as per FIR Annexure-P3 placed on record and on this ground appeal be allowed is decided accordingly. It is well settled law that FIR is not substantive piece of evidence. It is also well settled law that proceedings before Consumer Forums are quasi judicial proceedings. It is also well settled law that under section 162 of Code of Criminal Procedure 1973 no statement made by any person to police official In course of Investigation would be used as evidence. It is well settled law that statement recorded by police official during Investigation could be used by the accused and with the permission of court by prosecution to contradict the witness in the manner provided by section 145 of Indian Evidence Act 1872. In the present case opposite party did not contradict the FIR In the manner provided by section 145 of Indian Evidence Act 1872. Hence adverse Inference is drawn against the opposite party on the principle of natural justice and in the ends of justice.

11. While considering the observation of the above mentioned judgment and the facts of the present case, it is clear that, the insurance company has failed to prove that the death of the complainant's son Late Mahendra Bhope has occurred in a natural manner due to heart attack……”

10.   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. The Petitioner/OP, 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 hemorrhage as a result of rupture of ascending aorta," providing 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 hemorrhage supports this assertion. The OP'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. 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 Commission rightly concluded that the death of the deceased was accidental rather than natural.

11.   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. "

12.   State Commission has given a well-reasoned order. We are in agreement with the findings of State Commission. There is no illegality or material irregularity or jurisdictional error in the order of the State Commission, hence the same is upheld. Accordingly, the RP is dismissed.

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