Page 57 - Insurance Times June 2023

first appeal upheld the State Commission's Order in regard to Insurance Company (Insurance Company) after her son,
a claim filed by the insured with the insurance company. The Chayan Mukherjee died at Command Hospital, Kolkata. The
instant appeal was filed under Section 19 of the Consumer Insurance Company vide letter dated 22-09-2022, rejected
Protection Act, 1986 challenging the Order passed by the State the insurance claim as the cause of death was dengue, a
Consumer Disputes Redressal Commission, Maharashtra. disease not covered under its policy. Aggrieved by the
Complainant Firm took an insurance policy to cover its plant decision of the Insurance Company, the petitioner filed a writ
and machinery, electrical installations and stock-in-trade. The petition before this Court, challenging the letter of the
premium was paid for the valid policy. In 2005, an incident of Insurance Company which refused to admit the claim of
fire took place and the insurance company was intimated after petitioner.
which survey was conducted. The complainant had claimed an
Parties' Contentions: The petitioner contended that the
amount of Rs 17,00,000 but the surveyor assessed the loss at
primary cause of death was purely accidental as petitioner's
Rs 1,54,500. Since the Complainant Firm failed to submit the
son had no idea that he would be afflicted with dengue in
relevant record for verification, as mentioned in the Surveyor's
the hospital. On the hand, the Insurance Company
Report. Hence, Insurance Company filed the claim as 'no claim'.
contended that the cause of death in the present case is
State Commission vide its impugned Order dated 22-09-2015
Dengue as well as renal disease as recorded in the Medical
allowed the Complaint at the loss assessed by the Insurance
Certificate and the Autopsy Report and the same is not an
Co.'s Surveyor i.e. at Rs 1,54,500 and awarded the said amount
accident as defined under clause 5 of the document which
with interest at the rate of 9% per annum. Complainant Firm
deals with 'Accident Insurance'.
appealed before this Commission for enhancement in
compensation, specifically for accepting its claimed loss of Rs Moot Point: Whether death caused from a mosquito bite
17,00,000. would count as an 'accident'?
Investigation and Survey by an insurance company are Observations: The Court observed that (1) the petitioner
fundamental in determining the amount payable to the can claim the benefit of the Policy as the registered nominee
insured. of the account, (2) the conditions directly resulted in death
of the petitioner's son as recorded in Autopsy Report and
Bench observed that an insurance company is duty-bound to
medical certificate is both "Dengue" and "End-stage renal
appoint its surveyor in accordance with the provisions of the
disease - IgA Nephropathy". The Court further observed that
Insurance Act, 1938 (Section 64 UM Surveyors or loss assessors
it is clear from the clinical history of the patient, that the
specifically refers). A Survey cannot be disregarded or dismissed
death cannot be attributed solely to Dengue or seen as the
without cogent reasons. Further, the Commission also observed
sole and direct contributory factor resulting in the death of
that the onus, [a] of showing that the Report of the Surveyor
the petitioner's son, therefore, substantially diluting the
appointed by the Insurance Co. was flawed and [b] of showing
argument that the cause of death was accidental since the
that actually, in fact, the loss was Rs 17,00,000, was on the
mosquito bite was an unexpected "accident".
Complainant Firm, which onus it failed to discharge. Hence, in
view of the above discussion, the Commission held that the State The Court noted that the Personal Accident Insurance Policy
Commission had passed a reasoned order. State Commission's must be interpreted in the factual context of the definition
impugned order was upheld and confirmed.[Wilson Home of accident, i.e. "Death or Disability must result solely and
Appliances v. New India Assurance Co. Ltd., 2020 SCC OnLine directly from an accident caused by an external, violent and
visible means. The causation must necessarily involve:
NCDRC 493, decided on 10-12-2020].
Accident ? death" and the insurance policy makes it clear
Death due to mosquito bite not that death caused by a disease is not covered. The Court
observed that accident does not include disease and implies
'accident'; Calcutta High Court upholds
the intervention of an external cause which is fortuitous and
Insurance Company's decision happens by chance. The Court stated that "the definition of
Calcutta High Court: While dismissing a writ petition filled accidental death includes accidental injuries, but excludes
to challenge the refusal to admit insurance claim, Moushumi illness. The consensus also tilts towards the exclusion of
Bhattacharya*, J., held that death due to mosquito bite death by disease alone, not accompanied by an accident."
cannot be termed as an 'accident' and therefore the same The Court remarked that "…an accident is an event which
will not be covered as an insurable claim under 'accident startles a person when it takes place but does not startle
insurance'. one when it does not take place.
Brief facts : In the instant matter, the petitioner filed an [Chitra Mukherjee v. Union of India, 2023 SCC OnLine Cal
insurance claim before the respondent 4 - United India 1118, order dated 10-05-2023].
52 June 2023 The Insurance Times