National Consumer Disputes Redressal
Sbi Life Insurance Co. Ltd. vs Mrs. Y. Dayamani on 25 May, 2010
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION
NEW DELHI
REVISION PETITION NO.
3375 OF 2009
(From the order dated 14.07.2009
in Appeal No.1586/2008 of the
State
Commission, A.P.)
SBI LIFE INSURANCE CO.LTD.
REGD. OFFICE AT STATE BANK
BHAWAN,
MADAME CAMA ROAD, NARIMAN
POINT,
MUMBAI 400021 Petitioner
Versus
MRS. Y. DAYAMANI
W/O LATE SHRI J. BABU RAO
R/O D NO. 5-6/4-11, NEAR
KALARA HOSPITAL,
CHITTI NAGAR, VIJAYAWADA
ANDHRA PRADESH Respondent
BEFORE:
HONBLE MR.JUSTICE
B.N.P. SINGH, PRESIDING MEMBER
HONBLE MR. S.K. NAIK, MEMBER
For the Petitioner : Mr. Rakesh Malhotra, Advocate
For the Respondent : Mrs. K. Radha, Advocate
Pronounced on : 25th May, 2010
ORDER
PER S.K. NAIK, MEMBER Petitioner SBI Life Insurance Company Ltd. was the opposite party before the District Consumer Disputes Redressal Forum-II :
Krishna at Vijayawada where the respondent widow, being the legal heir of the life assured had filed a complaint on the ground that the petitioner SBI LIC had unjustifiably repudiated her claim.
Before the District Forum, the petitioner/opposite party had advanced three grounds :-
According to them, this being a Group Insurance Policy, there was no privity of contract between them and the life assured. This objection had been over-ruled by the District Forum holding that since the complainant was a beneficiary under the policy for which premium was paid by the life assured, though as a member of a Group Insurance Scheme, the petitioner insurance company was bound to render the service under the policy and, therefore, it cannot be said that there was no privity of contract between them.
The second contention raised by the petitioner/opposite party was that there was suppression of material fact inasmuch as the life assured has failed to disclose that he was suffering from Diabetes Mellitus for over a period of five years prior to the taking of the policy. The District Forum rejected this contention too holding that Diabetes Mellitus was not included in the list of critical illness in the declaration.
However, taking cognizance of clause 6 of the schedule II of the policy which contained an exclusion period of 45 days, subject however, to any death due to accident and holding that the life assured having died due to Acute Myocardial Infarction (heart attack) which did not amount to an accident, the District Forum had dismissed the complaint.
Aggrieved thereupon, an appeal was preferred by the respondent/complainant before A.P. State Consumer Disputes Redressal Commission. The State Commission, however, over-ruled the view taken by the District Forum that death due to Acute Myocardial Infarction (heart attack) was an accidental death and, therefore, the claim of the respondent/complainant very much fell within the ambit of the policy. The appeal, accordingly was allowed by setting aside the order of the District Forum directing the petitioner insurance company to pay a sum of Rs.5.5 lakhs along with 9% interest p.a. from 1.12.2006 till payment and further the petitioner - insurance company was directed to adjust the payment towards the loan account of the deceased life assured.
Dissatisfied with this order dated 14.7.2009 of the State Commission that the opposite party insurance company has filed this revision petition.
We have heard the learned counsel for the parties and have perused the records of the case.
Facts with regard to the life assured having been admitted as a member of the Super Suraksha Group Insurance Scheme w.e.f. 9.11.2006 is not in dispute. Nor is there any dispute with regard to the life assured having borrowed a home loan of Rs.5.5 lakhs linked to the insurance. There is also no dispute with regard to the death of the life assured on 1.12.2006 due to Acute Myocardial Infarction (heart attack) which is within 22 days of the date of commencement of risk. Having said so, we may take note of clause 6 of schedule II of the policy which reads as under :-
6. BENEFITS :
In the event of the death of the member at any time, after 45 days (except for Accidental Death), from the date of commencement of risk, subject to the policy being in full force, but not later than the member completing the age of 70 years, to pay the Grantees or any person so authorized by the Grantees the sum assured.
It is clear from this clause that in the event of the death of a member, the insurer (petitioner in this case) is not liable to pay the assured sum within the first 45 days of the commencement of the policy ; subject to the exception of an accidental death. In other words, the insurer would be liable even within the first 45 days in case of only an accidental death. In this case, life assured having died within 22 days of the inception of the policy, the short point for consideration would be as to whether the death due to Acute Myocardial Infarction (heart attack) would fall in the category of accidental death or otherwise.
While the District Forum has held that it would not fall in the category of an accidental death, the State Commission has held otherwise as myocardial infarction developed all of a sudden for which the life assured had to be rushed to the railway hospital where he died while undergoing treatment.
The State Commission further held that in the absence of any prior treatment for heart ailment, such a sudden heart attack can very well be said as an accidental death. No doubt a sudden stroke i.e. heart attack may occur all of a sudden, without any prior apprehension or any symptom and perhaps cannot be foreseen or anticipated. However, given the medical history of the life assured that he was suffering from Diabetes Mellitus for over a period of five years, as reported by the doctor from the railway hospital which cannot be disbelieved, the case of death resulting out of Acute Myocardial Infarction (heart attack), in this case cannot but be held to be a natural death. It is by now well established and acknowledged that diabetic individual more than non-diabetic persons are prone to heart attacks/strokes and such pre-disposition in case of the life assured could not be totally ignored. The State Commission, in our view has taken a completely erroneous view to declare it as a case of an accidental death. The nearest, Acute Myocardial Infarction (heart attack) can be said to be an accidental death would be if such an attack takes place as a result of some external and sudden incident such as trauma or shock induced by external ffactors/forces but it cannot certainly be said that a death due to heart attack in the normal course would fall in the category of an accidental death. We are, therefore, unable to agree with the view of the State Commission. Resultantly, the order of the State Commission is set aside and the revision petition is accepted, however, with no order as to costs.
Sd/-
(B.N.P. SINGH) PRESIDING MEMBER Sd/-
(S.K. NAIK) MEMBER St/