Complainant/petitioner obtained an endowment medical and accident benefit policy bearing No.383062073 for a sum of Rs.1 Lac.  Risk was covered from 28.3.2003 to 28.3.2019.  He met with an accident duirng the currency of the policy and suffered injuries for which he had to take prolonged medical treatment.  According to

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the petitioner, he became disabled to the extent of 50%.  Claiming that he was entitled to accidental claims, compensation and bonus, he filed claim with the respondent insurance company.  As per allegations made in the complaint, inspite of legal notice claim was not settled by the respondent insurance company.  Being aggrieved, petitioner filed the complaint before the District Forum.

          District Forum dismissed the complaint, aggrieved against which petitioner filed the appeal before the State Commission which has been dismissed by observing thus:

“It is, therefore, clear that the disability arising from the accident should have been total and permanent.  There appears to be no document on record to substantiate the claim in the above regard of the complainant.  It does not appear that the complainant suffered total and permanent disablement which was a pre-condition for the complainant to avail of benefit under the policy.”

          Counsel for the parties have been heard.  Clause 10.2 and 10.4 of the policy read as under:

“10.2 Accident Benefit.  If at any time when this policy is in force of the full sum assured, the life assured before the expiry of the period for which the premium is payable or before the policy anniversary on which the age nearer birthday of the life assured is 70, whichever is earlier, is involved in an accident resulting in either permanent disability as hereinafter defined or death and the same is proved to the satisfaction of the Corporation agrees in the case of :-

(a) Disability to the life assured : (i) to pay in monthly instalment spread over 10 year an additional sum equal to the sum assured under this policy.  If the policy becomes a claim before the expiry of the said period of 10 years, the disability benefit instalments which have not fallen due will be paid along with the claim. (ii) to waive the payment of future premiums.

The maximum aggregate limit of assurance under all policies on the same life to which benefits (i) and (ii) above apply shall not in any event exceed Rs.5,00,000 if, there be more policies than one and if the total assurance exceeds Rs.5,00,000 the benefit shall apply to the first Rs.5,00,000 sum assured in order of the date of the policies issued.

The waiver of premium shall extinguish all options under the policy and also the benefit covered by Para (b) of this clause except as to such assurance, if any, as exceeds the maximum aggregate limit of Rs.5,00,000 sum assured in order of date of the policy issued.

The waiver of premium shall extinguish all options under the policy and also the benefit covered by para (b) of this clause except as to such assurance, if any, as exceeds the maximum aggregate limit of Rs.5,00,000 and which have been kept in force by continued payment of premiums.

(b) Death of the life assured : to pay an additional sum equal to the sum assured 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 120 days of its occurrence solely, directly and independently of all other causes result in the death of the life assured.  However, such additional sum payable in respect of his policy, together with any such additional sums payable under other policies on the life of the life assured shall not exceed Rs.5,00,000.  The corporation shall not be liable to pay the additional sum referred in (a) or (b) above, if the disability or the death of the life assured shall

(i)  be caused by intentional self injury, attempted suicide instantly or immorally or whilst the life assured is under the influence or intoxicating liquor, drug or narcotic.

Or

(ii) take place as a result of accident while the life assured engaged in aviation or aeronautics in any capacity other than that of a fare-paying, part paying or non-paying passenger in any air craft which is authorized by the relevant regulations to carry such passengers and flying between established aerodromes, the life assured having at that time no duties on board the aircraft or requiring descent therefrom,

or

(iii) be caused injuries resulting from riots, civil commotion, rebellion, war (whether war be declared or not), invasion, hunting, mountaineering, steeplechasing or racing or any kind,

or

(iv)  result from the life assured committing any breach of law, or

(v)  arise from employment of the life assured in the armed forces or military service any country at war (whether war be declared or not) or from being engaged in police duty in any military, naval or police organization.

10.4 The disability above referred to must be disability which is the result of an accident and must be total and permanent and such that there is neither then or at any time thereafter any work, occupation or profession that the life assured can ever sufficiently do or follow to earn or obtain any wages, compensation or profit.  Accidental injuries which independently of all other causes and within 120 days from the happening of such accident result in the irrecoverable loss of the entire sight of both eyes or in the amputation of both hands at or above the wrists or in the amputation of both feet at or above the ankles or in the amputation of one hand at or above the wrist and one foot at or above the ankle, shall also be deemed to constitute such disability.”

As per this policy to get accidental benefit, the disability has to be ‘Total & Permanent’.  Total and Permanent Disability has been defined in Clause 10.2 and 10.4 as abovestated.

Admittedly, petitioner did not suffer from any of the injuries which can be termed as ‘Total and Permanent’ as defined in Clause 10.4.  The injuries suffered by him also did not incapacitate him to work or earn any wages, compensation or profit.  We do not find any infirmity in the order passed by the fora below.  Dismissed.