Author: Maitrayai, Symbiosis Law School, Hyderabad
Introduction
Alka Shukla vs. of Life Insurance Corporation of India is a notable Supreme Court judgement that helps to understand where and how an accident has to be interpreted in terms of accident- benefit in the context of taking insurance. The difference between the appeal and the repudiation of accidental-death benefits was observed on April 24, 2019 when a Bench of Justices D.Y. Chandrachud and Hemant Gupta dismissed the appeal, upholding the narrow conditions under which the insurance companies can halt the payment of accidental-death benefits.
Facts of the Case
The late Shri Anil Shukla had three policies of LIC, each having an accidental death benefit rider. Because of the stipulations of Condition 10(b) (New Bima Gold) and similar to other policies payout of the rider sum assured was conditional upon the following cumulative factors:
The injuries have to be caused solely and as a direct consequence of the accident.
Accidents should entail external, violent, observable measures.
Fatality due to such wounds has to be within 180 days regardless of others.
Shri Anil Shukla was riding a motor bike during which he experienced pain in his chest and the left shoulder on March 3, 2012, had a heart attack and fell off his motor bike. He was treated by Dr. Ajay Goverdhan at 10:10 PM, and then referred to Dr. S. S. Dhillon, and it was found he had Acute Myocardial Infarction (MI). He subsequently died on his way to the hospital. The LIC fulfilled the basic sum assured and bonuses but declined to grant accidental death benefit on the ground that death was because of medical illness (heart attack) rather than because of injury due to an accident.
Procedural History
Basic and accidental benefits as well as interests were granted by the District Consumer Forum (Durg), considering it an accident claim.
The award was upheld by the State Commission (Chhattisgarh).
National Commission Dispute Redressal Commission (NCDRC) overturned giving reasons that the insured succumbed to a heart attack and did not establish his/her injuries through outward, violent and visible means.
The appeal filed in the Supreme Court was rejected in favour of NCDRC.
Issues of the Case
The Supreme Court determined two main issues:
Did the insured die from bodily injury caused by an accident through outward, violent, visible means?
Did such bodily injury cause proximal and sole cause of death?
The Appellant argued that the heart attack was a direct result of the injuries he received because of falling off the bike, an ensuing series of events leading to the death benefit clause.
On the other hand, the Respondent argued that the death was by simple acute MI and not due to any injury sustained by the accident. According to the policy, injuries needed to be of an outward, violent and visible cause in direct relation to death, and this has not been fulfilled.
Judgement
In the case of Alka Shukla v. Life Insurance Corporation of India, the Supreme Court affirmed the order of National Consumer Disputes Redressal Commission (NCDRC) and rejected the appeal of appellants. The appellant had demanded the accidental death benefit under three life insurance policies of her deceased husband Shri Anil Shukla. Although the basic sum assured and other bonuses issued in the policies had already been paid by LIC, it had refused to provide accidental death benefit, on the basis that the death was as a consequence of heart attack and not as a result of accidents. The Supreme Court followed this argument, and ruled that the insured’s death was not due to the bodily injuries incurred under the accident, hence the accidental death rider conditions attending to bring the policy in force were not fulfilled. Therefore, the appeal was dismissed.
Legal Reasoning
The reasoning provided by the Court was based on the specific terms of the contract regarding the accidental death benefits, as per the policies. These criteria mandated the claimant to prove that the death of the insured was not merely a result of an accidental injury, but was directly caused, and this injury was caused by “outward, violent and visible methods." Moreover, the injury should have been the proximate and the only cause of death, and death should have occurred within 180 days after the accident. The Court considered the chain of events and medical evidence thoroughly. It was observed that the insured had chest and left shoulder pains when he was riding a motorcycle and proceeded to have a heart attack, resulting in a fall from the bike. The medical report, as well as Dr. Ajay Goverdhan and Dr. S. S. Dhillon, reported that the cause of death was Acute Myocardial Infarction (MI), which is commonly referred to as a Heart Attack. Most importantly, the fall left no traces of any serious damage or trauma on the body of the person. It was by chance that the heart attack led to the fall rather than the other way around.
The Court pointed out that there has to be a clear and actual causal nexus between an accident and death and not a coincidental happening of two events. It was not enough that the insured fell off the motorcycle. The fall has not caused or resulted in any serious bodily injury or a heart attack. The Court once again stated that insurance contracts were to be construed strictly, more so where the policy included other benefits such as an accident death rider, which is an exception to the general coverage. The onus was on the claimant to prove that the terms of the policy were fulfilled and, in this instance, no such burden had been proved.
Analysis
The judgment helps in reminding the general rule that insurance contracts, especially those that have riders or other special clauses, are to be applied strictly according to what is written and as stated. The meaning based on the interpretation by the Court is an indication that even the accidental death benefits cannot be granted unless the death of the policyholder is caused by bodily injury as a direct and sole consequence of a clearly discernible accident. This decision also puts a certain emphasis on the causation aspect of insurance claims, as it is not sufficient that the insured has fallen and has had a medical emergency at the same time. The trick is to find out whether the death was because of the fall which was assumed to be the accident. In the present case, according to the evidence, it was quite clear that the heart attack caused the death but the fall was merely an effect of the cause.
In addition, the decision is also favourable to the insurers by defining the extent of their liability in regards to the matters covered by the insurance, applicable in case of accidental death riders where the insurers are not bound to cover the insured in case of death caused by pre-existing and internal medical conditions, even though they are accompanied by some form of a fall or physical impact. This strict-interpretative view is consistent with precedent, as well as being not on a slippery slope where any involuntary physical movement resulting in death is treated as an accident.
Although the legal basis of the decision is correct in the light of the documentary evidence, it can also be said that such an approach can be seen as disadvantageous to the claimants in a scenario where medical causation may not be easy to establish beyond doubt. Yet, the decision provides a much-needed clarity as to the definition of an accidental death in the insurance policy, and serves as a reminder to the policyholders and the insurers to take due consideration of the policy stipulations.
