A.P. Sahi, President

We have heard Mr. Amandeep Singh for the Petitioners and Mr. Subhoday Banerjee for the Respondent.

2. The dispute pertains to a Group Insurance Policy that was acquired by M/s Kunvarji & Company for its employees where late Mr. Ratilal Lakhamshi Laika was serving as a Branch Manager. The policy duration was from 24.01.2012 to 24.01.2013. It was an accident-cum-death policy where any accidental injury suffered was indemnifiable or in the event of death within 12 months, the beneficiary under the policy was entitled to get Rs.1 lac. The case of the Complainant was that her husband fell down from the staircase on 29.04.2012 which is the date of the stated accident and he broke his forearm. This fracture injury, according to the Complainant, led to the filing of a claim for injury through an intimation dated 01.05.2012. A copy of the letter is extracted herein under:



The translated version of the same has also been filed which is extracted herein under:





3. According to the Complainant, the claim for accidental injury remained pending and a claim form was filed on 21.01.2013. A copy of the claim form is on record as Annexure-P5 where the accident has been described as "all of a sudden slipped from staircase and fell on the ground". Left hand fractured. According to the Complainant and as per the medical certificate obtained, there was a temporary disablement and therefore, the claim was clearly indemnifiable under the policy.

4. Unfortunately, the insured expired after 4 months on 15.05.2013. Despatching the death certificate, the Complainant claimed full indemnification on death.

5. The Insurance Company, on 20.03.2014, intimated the Complainant that the claim has been closed as no claim and that there was no question for reopening of the claim on the death of the insured.

6. The matter was contested by the Complainant by filing the Complaint before the District Commission and the same was allowed on 23.07.2019 holding that the Complainant was entitled to the indemnification as it was an accidental death because the insured had died sometime after sustaining the injuries. The claim was allowed with a direction to pay a sum of Rs.1 lac together with 9% interest w.e.f. 23.01.2015 and Rs.5,000/- as cost with Rs.5,000/- as compensation for mental agony.

7. The Insurance Company, aggrieved by the said order, filed FA/579/2019 before the SCDRC, Gujarat and the State Commission has confirmed the judgment of the District Commission by dismissing the Appeal. The reasoning given by the State Commission is contained in paragraphs-7&8 of the impugned order which is reproduced herein under:

7. We have considered the submissions of Ld. Advocate for the parties, we have also considered the impugned order passed by the LA District Forum as well as perused material on record. That looking to the record of the case, it appears that the complainant's husband was serving as Branch Manager in Kunvarji & Company and the said company has purchased individual policy for the benefit of their employees including the complainant's husband for the period 25.01.2012 to 24.01.2013 for sum insured Rs.1,00,000/-Thereafter, it also appears from the certificate issued by Dr. Bhavin Patel, M.S. (Ortho) of Mantra Orthopedic Hospital, the complainant's husband sustained injury on account of falling from the staircase at his home and the said fact of the injury sustained on account of falling down from the staircase also supported by Sterling Hospital's Department of Radiology page 34. Even if we peruse medical certificate of Dr. Bhavin Patel in the claim form page 38, the complainant's husband sustained accidental injury. Furthermore, if we peruse the reply of the legal notice given by the insurance company to the Ld. Advocate of the complainant, for the first time, insurance company informed the complainant's advocate that the complainant has not submitted necessary documents along with the claim form dated 21.01.2013 and for the first time, insurance company submitted vide its reply that the complainant submitted late document and therefore, the insurance company closed the case as 'no claim'. Furthermore, if we peruse the facts stated in para 1 of the complaint, the insurance company has not provided terms and conditions of the policy except policy schedule and to the said facts of para 1, reply is given by insurance company in written statement page 26 to 28 wherein, insurance company merely denied the same and contended that the terms and conditions are available from the terms and conditions of insurance policy to the complainant, so it cannot be said that complainant had committed any breach of terms and conditions of the policy by submitting late intimation or late claim form.

8. That herein, in this case, it appears that the main submission of the Ld. Advocate for the insurance company is that the husband of the complainant died after the policy period and there is no nexus of the death of husband with the accidental injury. But on perusal of terms and conditions of insurance policy i.e. clause 2.1 Base Covers, the company shall pay the benefit equal to 100% of Capital Sum Insured, specified in the policy schedule, on death of the Insured Person, due to an Injury sustained in an Accident during the policy period, provided that the insured person's death occurs within 12 months from the date of the accident. So, herein, in this case, the husband of complainant sustained injury on 29.04.2012 as per the certificate of Dr. Bhavin Patel and as per the death certificate of Joshi Clinic, Dr Naresh Joshi page 44, the husband of complainant died on 15.05.2013 i.e. within 1 year or 12 months from the date of accident, therefore, as per the terms and conditions of policy also, the complainant is entitled to get the sum insured of policy Rs. 1,00,000/-. Even if we peruse the impugned order of Ld. District Forum, it appears that the insurance company has not filed or produced terms and conditions before the Ld. District Forum which the insurance company has for the first time produced vide application dated 03.09.2025 before this State Commission. So in view of the facts and circumstances of the case, we are of the considered opinion that Ld. District Forum has considered all aspects of material on record for allowing the complaint against the insurance company and therefore, we do not find any perversity or error in findings of the order allowing the complaint. Hence, the appeal filed by the insurance company is devoid of merits and accordingly, is liable to be dismissed in terms of following order.

8. The State Commission came to the conclusion that the Insurance Company had not filed or produced the terms of the policy before the District Commission that was produced before the State Commission for the first time through an application. At the outset, learned counsel for the Petitioner urged that the findings recorded are perverse and contrary to the terms of the policy, as such, the orders of the District Commission as well as the State Commission deserve to be set aside. Mr. Singh submits that there is no proximity or connect at all between the cause of the accident or the cause of death. He submits that the death occurred due to some pulmonary disease and had got nothing to do with the accident in which the insured had simply broken his forearm. He further submits that the State Commission has also erroneously calculated the period of 12 months inasmuch as the accident took place on 29.04.2012 whereas the death took place on 15.05.2013 which is 17 days beyond one year. He therefore, submits that the claim was inadmissible inasmuch as in cases of death, the claim is payable provided the death occurs within one year of the incident. The complete policy and its terms were well known as the original claim remained for an accident during the lifetime of the insured. There was no grievance raised about not having received the terms of the policy.

9. Mr. Singh then submits that as a matter of fact, no claim was ever filed with regard to the death of the insured and it is on mere sympathy and equities that the District Commission and State Commission have proceeded to allow the death claim which was otherwise inadmissible as indicated above.

10. He submits that even though the Insurance Company has tendered the entire decretal amount before this Commission for being released to the Respondent, the impugned orders cannot be sustained as they suffer from manifest illegalities.

11. Learned counsel for the Respondent Mr. Banerjee has urged that the findings of fact have been recorded by the fora below and therefore, this Commission, in the exercise of revisional jurisdiction, may not upset the impugned orders as the fora below have found the claim to be admissible on the basis of evidence on record. Learned counsel has also cited the decision in the case of Deep Nursing Home & Anr. Vs. Manmeet Singh Mattewal & Ors. 2025 SCC Online SC 1934 to urge that the Petitioner had not filed the complete documents of the policy before the District fora and then took a stand before the State Commission, as such, Petitioner cannot be allowed to plead differently before a higher forum.

12. We had considered the arguments advanced by Mr. Singh at the initial stage and keeping in view the petty amount involved, Mr. Singh had sought instructions in terms of our order dated 08.04.2026 and then made a statement on 18.05.2026. The order dated 18.05.2026 is extracted herein under:

                   "Issue notice on the delay condonation application. Learned Counsel for the Petitioner may also take steps to serve the Respondent personally. Office to issue dasti. Proof of service be filed by the next date.

                   The Petitioner shall tender an amount of Rs. 25,000/- to the Respondent for meeting the travel and other ancillary expenses through a Bank Draft. A proof of the deposit shall be filed by the next date of hearing.

                   Apart from this Mr. Amandeep Singh, learned Counsel for the Petitioner also states that the entire decretal amount can be tendered before this Commission to be released in favour of the Respondent which he shall also do by the next date.

                   It shall be open to the Respondent to either file a reply or any submissions that can be tendered via post and it shall be open to them to either join personally or through some Counsel.

                   List on 22.06.2026.

13. Given the peculiar facts of the case, we had therefore, called upon Mr. Singh to indicate about the instructions of the Insurance Company and in compliance of our orders, a sum of Rs.25,000/- was paid to the Respondent for bearing the expenses of this Revision Petition. The same has been accepted by Mr. Banerjee, learned counsel appearing for the Respondent to have been received by the Respondent.

14. Apart from this, the entire decretal amount had also to be deposited as per the order dated 18.05.2026. The proof of deposit of the entire decretal amount has also been filed on 06.07.2026. A Demand Draft of Rs.2,12,723/- drawn on the State Bank of India in favour of the Registrar, NCDRC has been placed on record.

15. On the legal issue, we find the contentions raised on behalf of the Petitioner to be correct inasmuch as the fall from a staircase had only resulted in the forearm having broken. Whether it was an accident or otherwise, is a different issue, but the fact remains that because of the fracture, the insured did not die. There is no evidence to that effect. His death occurred due to a pulmonary disease which fact does not seem to be disputed. Accordingly, there is no nexus or even a close proximity with the cause of death and the injury of a broken forearm that too even, one year ago.

Apart from this, the coverage under the policy, under clause 2.1(a) provides that the benefit equal to 100% of the capital sum insured shall be indemnified if the insured dies within 12 months from the date of the accident In the instant case, as noted above, there is no evidence of the proximity of the cause of the death with the accident and even otherwise, the death occurred after a period of 12 months on a pure and simple calculation as urged by the learned counsel for the Petitioner and noted above. The conclusion of the State Commission on this score is perverse and against record.

Thus, on both counts, the claim does not seem to be indemnifiable but on equities, we appreciate the stand taken by the Insurance Company and their counsel Mr. Amandeep Singh who have agreed not to contest the amount awarded and to release it to the Respondent keeping in view the petty nature of the claim and the fact that the Respondent is a widow.

We therefore, do not approve of the impugned orders or the reasons recorded therein as they reflect non-consideration of the relevant facts and the legal position emerging on a simple reading of the terms of the policy. The impugned orders are therefore unsustainable and we dispose off this Revision Petition declaring that the orders impugned would not be treated as any precedent as they do not lay the correct law.

16. The Revision Petition is therefore, disposed of with a direction that the amount deposited in terms of the order passed by us on 18.05.2026 as referred to above, shall be released to the Respondent within 15 days from today. The Respondent shall not be entitled to any other amount except that has been tendered before us alongwith the Bank Draft as indicated above.

The Revision Petition stands accordingly disposed off.