Chandigarh

StateCommission

A/80/2020

Manipal Cigna Health Insurance Company Ltd. - Complainant(s)

Versus

Rekha Sharma - Opp.Party(s)

Inderjit Singh & Yugansh Siwach Adv.

19 Apr 2021

ORDER

 STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

U.T., CHANDIGARH

Appeal No.	:	80 of  2020
Date of Institution	:	08.06.2020
Date of Decision	:	19.04.2021

1. Manipal Cigna Health Insurance Company Limited (Formerly known as Cigna TTK Health Insurance Company Limited), First Floor, SCO No.149/150, Sector 9-C, Chandigarh.
2. Manipal Cigna Health Insurance Company Limited (Formerly known as Cigna TTK Health Insurance Company Limited), 10^th Floor, Comerz, International Business Park, Oberoi Garden City, Goregaon East, Mumbai, Maharashtra.

Both the appellants through Mr.Akhil Kulhari, its AVP-Legal, posted at Manipal Cigna Health Insurance Company Limited, 401/402, Raheja Titanium, Western Express Highway, Goregaon (East), Mumbai-400053.

 ……Appellants/Opposite parties

V e r s u s

Rekha Sharma widow of Late Sh.Mahesh Kumar Sharma, Flat No.11, Divya Apartment, Golden Enclave, Zirakpur, District Mohali, Punjab

 

…..Respondent/Complainant

 

BEFORE:            JUSTICE RAJ SHEKHAR ATTRI, PRESIDENT

                          MRS. PADMA PANDEY, MEMBER

                          MR. RAJESH K. ARYA, MEMBER

 

Present through video conferencing:                

                          Sh.Inderjit Singh, Advocate for appellants.

        Sh.P.S. Sobti, Advocate for the respondent.

 

JUSTICE RAJ SHEKHAR ATTRI, PRESIDENT

         

M.A. No.325 of 2020:-

                    After hearing the contesting parties and also on going through the record of this application, we are of the considered view that the reasons stated therein, are sufficient to condone the delay of 78 days in filing this appeal and as such, the said delay is condoned. Accordingly, this application stands disposed off.

 

Appeal No.80 of 2020:-

                    This appeal has been filed by the appellants, as they are aggrieved of the order dated 04.02.2020 passed by the District Consumer Disputes Redressal Commission-II, U.T., Chandigarh (in short the District Commission), whereby the consumer complaint bearing no.532 of 2018 filed by the respondent was allowed and the appellants were directed as under:-

1. “To pay the sum insured amount of Rs.5.50 lacs to the legal heirs of the late Sh.Mahesh Kumar Sharma (insured) in equal shares, along with interest @9% p.a. from the date of death 10.11.2017 till actual payment;

2. To pay a compensation amount of Rs.10,000/- to the complainant for causing immense mental agony, harassment due to their deficient act;
3. To pay litigation cost of Rs.7,000/-;

This order shall be complied with by Opposite Party No.1 & 2 within a period of 30 days from the date of receipt of copy of this order…..”

 

2.           The District Commission noted down the following facts out of the case of the respondent:-    

“….Briefly stated, the complainant and her husband Sh.Mahesh Kumar Sharma took Accident Care Enhanced Insurance Policy No.LTPRAC020004531 from Opposite Parties for an insured amount of Rs.5.48 lacs & Rs.5.50 lacs respectively for single premium payment effective from 15.1.2016 to 13.1.2019 for three years (Ann.C-1). It is averred that on 4.11.2017 at about 5 PM late Sh.Mahesh Kumar Sharma, while going to fetch some tools from the tool bench, entangled his trouser in rods laying on the floor and fell down on the floor.  It is also averred that his assistant Deepu, who was arranging finished products in other corner of the workshop, rush to the spot and found Sh.Mahesh Kumar Sharma unconscious due to brain hemorrhage and there was no external injury on his body.  Then Sh.Mahesh Kumar Sharma was taken to Govt. Medical Hospital, Sector 32, Chandigarh where he underwent NCCT Brain.  Then he was shifted to Fortis Hospital for further investigations and treatment, where he remained admitted from 4.11.2017 to 10.11.2017, but despite that he could not survive and expired on 10.11.2017.  Thereafter, a claim was lodged with OPs under the policy in question, but they repudiated the same vide letter dated 25.1.2018 on the ground that there is no evidence of accident and the intra cranial hemorrhage happened in the insured, is caused due to intra cranial artery aneurysm.  Alleging the said repudiation of claim as illegal and a deficient act on the part of Opposite Parties, hence this complaint has been filed….”

3.           The appellants responded to the complaint filed by the respondent, as under:-

“..The OPs have filed joint reply and while admitting the factual matrix of the case, stated that as per the claim form dated 2.1.2018, the deceased insured was hospitalized due to sudden giddiness and unconsciousness leading to fall.  It is averred that as per death summary submitted by the complainant dated 10.11.2017, the diagnosis is ‘left ICA paraclinoid aneyrism’ and the reason for death is ‘neurogenic pulmonary edema with refractory shock with MODS’   (Ann.OP-3).  It is submitted that as per the documents submitted by the complainant, it is clear that there is no evidence of accident.  It is further submitted that the deceased policyholder suffered Intra Cranial hemorrhage due to intra cranial artery aneurysm which is a medical reason and accordingly the claim cannot be considered for accidental death benefit.  It is further submitted that the deceased life assured died a natural death and the complainant is wrongly projecting his death to be accidental just to bring his death within the policy coverage.  Denying all other allegations and pleading no deficiency in service, the OPs have prayed for dismissal of the complaint… ”

 

4.           The respondent filed rejoinder wherein she reiterated all the averments contained in the complaint and controverted those in the reply filed by the appellants.
5.           After hearing the contesting parties and on going through the evidence and record of the case, the District Commission  allowed the consumer complaint vide the order impugned, in the manner, stated above. 
6.           Hence this appeal.
7.           We have heard the contesting parties and have also gone the entire record of the case, including the written arguments filed by the parties, very carefully.
8.           The short question which needs to be decided in this appeal is, as to whether, the cause of death of the insured-Mr.Mahesh Kumar Sharma, could be termed as accident or not? It may be stated here that in order to constitute an event as accident, it must be in the nature of an occurrence which is unnatural, unforeseen or unexpected. Thus, an event that takes place without one’s foresight or expectation; and event that proceeds from an unknown cause, or is an unusual effect of a known cause, and therefore not expected, chance, causality, contingency. Deaths from car crashes, slips, choking, drowning, machinery, and any other situations that can't be controlled are deemed accidental.
9.           No doubt, in the insurance policy in dispute, it has been mentioned in Clause VI thereof that accident means a sudden, unforeseen and involuntary event caused by external, visible and violent means, yet, what the word ‘accident’ exactly means has not been defined therein. In  Jyothi Ademma v Plant Engineer, Nellore, Appeal (civil)  6201 of 2004 decided on 11 July, 2006, the Hon’ble Supreme Court of India  has defined the word ‘accident’ as under:-

 

 “7…the expression accident means an untoward mishap which is not expected or designed.”

 

In Union of India v Sunil Kumar Ghosh 1984 AIR 1737, 1985 SCR (1) 555 the Hon’ble Supreme Court of India dealt with the expression ‘accident’ and held thus:

 

“13…An accident is an occurrence or an event which is unforeseen and startles one when it takes place but does not startle one when it does not take place. It is the happening of the unexpected, not the happening of the expected, which is called an accident. In other words an event or occurrence the happening of which is ordinarily expected in the normal course by almost everyone undertaking a rail journey cannot be called an “accident”. But the happening of something which is not inherent in the normal course of events, and which is not ordinarily expected to happen or occur, is called a mishap or an accident.”

 

P Ramanatha Aiyar’s Law Lexicon, also defines the expression ‘accident’:

 

“an event that takes place without one’s foresight or expectation; and event that proceeds from an unknown cause, or is an unusual effect of a known cause, and therefore not expected, chance, causality, contingency.”

 

In the present case, admittedly the insured fell down as his trouser entangled in the rods lying on the floor and thereafter when he was taken to the hospital, he died due to ‘intra cranial hemorrhage’. Under these circumstances, the question which arises for consideration is, as to whether, the appellants were right in repudiating the claim holding that since it was not a case of accident but a case of disease, as such, the claim is not payable under the expression “accident”. It is significant to mention here that the appellants have failed to place on record any cogent evidence to prove that the death of the insured was caused due to any pre-existing disease. It is not the case of the opposite parties that since the insured was suffering from a pre-existing disease, which resulted into his death, and, as such, the claim was not payable to the complainant. Even in the discharge summary-Annexure OP-3 dated 10.11.2017, prepared by the treating doctor of Fortis Hospital where the insured took his last breath, against the Column ‘PAST History’, it has been written as “NOT SIGNIFICANT”, meaning thereby that no pre-existing disease was found by the treating doctor and also it was not required in the matter. 

                    In the present case, it is an admitted fact that in the first instance, on 4.11.2017 at about 5 PM late Sh.Mahesh Kumar Sharma, while going to fetch some tools from the tool bench, entangled his trouser in rods laying on the floor and fell down, which ultimately resulted into his death due to ‘intra cranial hemorrhage’. May be, the death in the medical terms be described as ‘intra cranial hemorrhage’, but the main cause leading to ‘intra cranial hemorrhage’ was an event that took place without the insured foresight or expectation i.e. felling down on the floor in the manner stated above. Thus, the said event was an accident, which took place in the first instance and became the basis of cause of ‘intra cranial hemorrhage’, which resulted into the death of the insured. In Krishna Wati v LIC of India, Revision Petition No. 2973 of 2003, decided On, 22 November 2005, the Hon’ble National Commission had to deal with, as to whether the accidental injuries which resulted in the death of the assured due to a heart attack after three days of the accident could be termed as an accidental death or a natural death. The assured while riding his bicycle was attacked by a cow and upon arriving at the hospital complained of pain in the legs and in the chest, because of a fall from his bicycle. The Hon’ble National Commission relied on the investigation report and the allowed the claim for accident insurance. It held thus:

“… In our view, from the record as it is, it is apparent that first the accident took place, resulted in injuries and chest pain which ultimately resulted in 'death'. May be, the death in the medical terms be described as 'due to heart-attack, but the main cause for leading to heart-attack was injury caused due to accident. Accident is the basis for causing chest pain and thereafter heart-attack…”

 

10.           In our considered opinion, the District Commission was also right in holding that the event aforesaid, which took place and further resulted into death of the insured due to ‘intra cranial hemorrhage’ could very well be classified as “accident”.
11.           For the reasons and law stated herein above, we do not find any illegality or irregularity in the impugned order passed by the District Commission and the same is upheld. Consequently, this appeal is dismissed with no order as to cost.
12.           Certified Copies of this order be sent to the parties, free of charge.
13.           The file be consigned to Record Room, after completion.

Pronounced.

19.04.2021

 

Sd/-

 [RAJ SHEKHAR ATTRI]

PRESIDENT

 

 

Sd/-

(PADMA PANDEY)

         MEMBER

 

 

Sd/-

(RAJESH K. ARYA)

 MEMBER

 

Rg