Supreme Court Denies Accident Claim: Heart Attack Not an ‘Accident’ Under Insurance Policy (24 April 2019)

Date of the Judgment: 24 April 2019
Citation: Civil Appeal No. 3413 of 2019 (Arising out of SLP (C) No. 32335 of 2016)
Judges: Dr. Dhananjaya Y Chandrachud, J and Hemant Gupta, J
Can a fall from a motorcycle due to a heart attack be considered an accident under an insurance policy? The Supreme Court of India addressed this question in a recent case, clarifying the interpretation of accident benefit clauses in insurance policies. The court held that a heart attack leading to a fall is not an accident caused by “outward, violent, and visible means” as required by the policy, denying the claim for accident benefits. This judgment was delivered by a two-judge bench comprising Dr. Dhananjaya Y Chandrachud, J and Hemant Gupta, J, with the opinion authored by Dr. Dhananjaya Y Chandrachud, J.

Case Background

The case involves an appeal against a decision by the National Consumer Disputes Redressal Commission (NCDRC). The appellant’s spouse had three insurance policies with the Life Insurance Corporation of India (LIC). These policies included an accident benefit clause, which stipulated that an additional sum would be payable if the insured’s death resulted from an accident caused by “outward, violent, and visible means.”

On March 3, 2012, the appellant’s spouse, while riding his motorcycle, experienced chest and shoulder pain, suffered a heart attack, and fell from the bike. He was taken to multiple medical facilities but was declared dead upon arrival at the final hospital. The cause of death was determined to be an acute myocardial infarction (heart attack). While the basic insurance cover was settled, the accident benefit claim was rejected by the insurer, leading to a consumer complaint.

Timeline:

Course of Proceedings

The District Consumer Disputes Redressal Forum, Durg initially ruled in favor of the appellant, ordering the insurance company to pay the accident benefit along with interest. This decision was upheld by the Chhattisgarh State Consumer Disputes Redressal Commission (SCDRC). However, the National Consumer Disputes Redressal Commission (NCDRC) reversed these decisions, stating that the death was not the result of an accident caused by “outward, violent, and visible means.” The appellant then appealed to the Supreme Court of India.

Legal Framework

The core of the dispute lies in the interpretation of the accident benefit clauses in the insurance policies. Specifically, the clauses required that the death result from a bodily injury caused by an accident due to “outward, violent, and visible means.” The Supreme Court examined the terms “accident,” “bodily injury,” “violent,” and “visible” using definitions from legal dictionaries and insurance law texts.

The court referred to Union of India v Sunil Kumar Ghosh, where an accident was defined as an unforeseen and unexpected event. The court also cited P Ramanatha Aiyar’s Law Lexicon which defines ‘accident’ as: “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.”

The court also examined the definitions of bodily injury, violent and visible from Colinvaux’s Law of Insurance and Black Law’s Dictionary respectively. According to Colinvaux’s Law of Insurance, “It is usual for the policy to require an accident to manifest itself as “bodily injury” to the assured. The most obvious form of bodily injury is external trauma causing physical injury, but the phrase is not limited to injury to the exterior of the body: the term “bodily injury”, when used in a personal accident policy, is not limited to lesions, abrasions or broken bones. Nor is it essential that there should be an external mark of injury on the assured’s body…”. According to Black Law’s Dictionary, ‘violent’ means: “1. Of, relating to, or characterised by strong physical force <violent blows to legs>. 2. Resulting from extreme or intense force <violent death>. 3. Vehemently or passionately threatening <violent words>. ” and ‘visible’ means: “1. Perceptible to the eye ; discernible by sight . 2. Clear, distinct, and conspicuous.”

The court also discussed the divergence of opinions across international jurisdictions on the distinction between ‘accidental means’ and ‘accidental result’ while deciding accidental insurance claims. The court referred to Clidero v Scottish Accident Insurance Co, Landress v Phoenix Mutual Life Insurance, Dhak v Insurance Company of North America (UK) Ltd, American International Assurance Life Company Ltd and American Life Insurance Company v Dorothy Martin, and Quek Kwee Kee Victoria v American International Assurance Co. Ltd to discuss the different viewpoints.

Arguments

Appellant’s Submissions:

• The appellant argued that the heart attack was a direct result of the injuries sustained from the fall, which was an accident covered by the policy.
• The appellant contended that the fall was an unforeseen event and the subsequent heart attack was a direct consequence of the fall.

Respondent’s Submissions:

• The respondent argued that the medical reports indicated the death was due to a heart attack, not an accident.
• The respondent emphasized the policy’s requirement that the accident be caused by “outward, violent, and visible means,” which was not met in this case.
• The respondent also argued that there is a distinction between ‘accidental means’ and ‘accidental result’ and the insurance cover is more restrictive.

Issues Framed by the Supreme Court

The Supreme Court framed the following issues:

1. Whether the assured’s death was due to a bodily injury resulting from an accident caused by outward, violent, and visible means?
2. Whether the injury was proximately caused by the accident?

The court clarified that the complainant would be entitled to claim under the policy only if both the questions are answered in the affirmative.

Treatment of the Issue by the Court

The following table demonstrates as to how the Court decided the issues:

Authorities

The Court considered the following authorities:

Judgment

How each authority was viewed by the Court?

The court relied on the definition of ‘accident’ from Union of India v Sunil Kumar Ghosh [(1984) 4 SCC 246]* and P Ramanatha Aiyar’s Law Lexicon. The court also referred to MacGillivray on Insurance Law and Colinvaux’s Law of Insurance to understand the meaning of ‘accident’ in the context of an accident insurance policy and ‘bodily injury’ respectively. The court also referred to the definitions of ‘violent’ and ‘visible’ from Black Law’s Dictionary. The court discussed the distinction between ‘accidental means’ and ‘accidental result’ from Clidero v Scottish Accident Insurance Co [(1892) 19 R . 355]* and Landress v Phoenix Mutual Life Insurance [291 US 491, 496 (1934)]*. The court also discussed the contrary view taken in American International Assurance Life Company Ltd and American Life Insurance Company v Dorothy Martin [[2003] 1 SCR 158]* and Quek Kwee Kee Victoria v American International Assurance Co. Ltd [[2017] 1 SLR 461]* and the view of the court in Dhak v Insurance Company of North America (UK) Ltd [[1996] 1 WLR 936]*. The court also discussed the view of the Patna High Court in Kamlawati Devi v State of Bihar [(2002) 3 PLJR 450]* and Branch Manager, United India Insurance Co v State of Bihar [(2003) 51 (2) BLJR 117]*. The court also discussed the decisions of the NCDRC in LIC of India v Smt Mamta Rani [II (2014) CPJ 624 (NC) : RP No. 4468 of 2012]* and Swaranjit Kaur v ICICI Lombard General Insurance Co Ltd [2015 SCC OnLine NCDRC 4168]* and the decision of the High Court of Madras in Life Insurance Corporation v Minor Rohini [2012 (1) MWN (Civil) 740]*. The court also discussed the decision of the NCDRC in Krishna Wati v LIC of India [1 (2006) CPJ 21 (NC)]*.

What weighed in the mind of the Court?

The Supreme Court’s decision was primarily influenced by the lack of evidence to support a direct causal link between the fall and the heart attack. The medical reports indicated that the heart attack was the primary event, and the fall was a consequence of the heart attack. The court emphasized that the accident benefit clause required the accident to be caused by “outward, violent, and visible means,” which was not the case here. The court also noted that there was no post-mortem report or police investigation to determine the nature of injuries sustained by the insured due to the fall.

Logical Reasoning:

The court considered the arguments and medical evidence and concluded that the heart attack was the primary cause of death and the fall was a consequence of the heart attack. The court also considered the policy requirements and held that the fall was not caused by outward, violent and visible means. The court also considered various precedents on the issue.

The court quoted from the judgment as follows: “In the present case, there is no evidence to show that any bodily injuries were suffered due to the fall from the motorcycle or that they led to the assured suffering a heart attack.” The court also quoted that, “There is no evidence to show that the accident took place as a result of any outward, violent and visible means. The assured died as a result of a heart attack which was not attributable to the accident.” The court further quoted that, “In the absence of any evidence to the contrary, the medical evidence on record is itself proof that the insured died due to a heart attack and not due to an accident of falling from the motorcycle.”

There was no dissenting opinion in this case.

Key Takeaways

• Insurance policies with accident benefit clauses require a direct causal link between the accident and the bodily injury leading to death.
• A heart attack leading to a fall is not considered an accident caused by “outward, violent, and visible means” under typical insurance policy terms.
• Medical evidence plays a crucial role in determining the cause of death in insurance claims.
• The onus is on the claimant to prove that the death was a result of an accident and not a natural cause.

Directions

No specific directions were given by the Supreme Court in this judgment.

Development of Law

The ratio decidendi of this case is that for an accident insurance claim to succeed, it must be established that the assured sustained a bodily injury which resulted solely and directly from an accident caused by outward, violent and visible means. This case clarifies that a heart attack leading to a fall does not meet the criteria for an accident under such policies. There is no change in the previous positions of law.

Conclusion

The Supreme Court dismissed the appeal, upholding the NCDRC’s decision that the death was due to a heart attack and not an accident as defined by the insurance policy. The court emphasized the need for a direct causal link between the accident and the resulting death and reiterated that the accident must be caused by “outward, violent, and visible means.”

Category:

• Insurance Law
  • Accident Insurance
  • Accidental Death Benefit
  • Life Insurance Corporation of India
  • Consumer Protection Act, 1986
  • Outward, Violent and Visible Means
• Consumer Law
  • Consumer Protection Act, 1986
  • Consumer Disputes Redressal Forum
• Contract Law
  • Insurance Policy
  • Accident Benefit Clause
• Insurance Law
  • Section 10, New Bima Gold Policy
  • Section 10, LIC Jeevan Tarang Policy
  • Section 11, Twenty Years Money Back Policy

FAQ

Q: What was the core issue in the Alka Shukla vs. Life Insurance Corporation of India case?
A: The core issue was whether the death of the insured, which occurred due to a heart attack while riding a motorcycle, and resulting in a fall, could be considered an accident under an insurance policy that required the accident to be caused by “outward, violent, and visible means.”

Q: What did the Supreme Court decide in this case?
A: The Supreme Court decided that the death was not an accident under the terms of the insurance policy. The court held that the heart attack was the primary cause of death, and the fall from the motorcycle was a consequence of the heart attack, not an accident caused by “outward, violent, and visible means.”

Q: What does “outward, violent, and visible means” mean in the context of insurance policies?
A: “Outward, violent, and visible means” refers to an external cause of an accident that involves strong physical force and is clearly perceptible. In this case, the court determined that a heart attack does not meet these criteria.

Q: What is the significance of this judgment for insurance policyholders?
A: This judgment highlights the importance of understanding the specific terms and conditions of insurance policies, especially accident benefit clauses. It clarifies that not all unexpected deaths are covered under accident insurance and that there must be a direct causal link between an accident caused by outward, violent and visible means and the resulting death.

Q: What kind of evidence is required to prove an accidental death claim in similar cases?
A: To prove an accidental death claim, it is important to provide medical evidence that clearly establishes the accident as the direct and proximate cause of death. In cases where the cause of death is unclear, a post-mortem report and police investigation may be necessary. The claimant has the onus to prove that the death was a result of an accident and not a natural cause.