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Accident insurance claim denied due to death under influence of alcohol. NCDRC reverses order – here’s why

Even if it is assumed that 59.45 mg% ethyl alcohol was present in the blood of the deceased at the time of death, the NCDRC found it was not enough to say that the person was intoxicated.

Accident insurance claim denied due to death under influence of alcohol. NCDRC reverses order – here’s why
Accident insurance claim was denied to a person who died due to drowning. Representational image/Pixabay

In an interesting case, the National Consumer Disputes Redressal Commission (NCDRC) recently reversed a decision that denied accidental insurance cover to a complainant after the death of his son due to drowning. The claim was denied by the insurance company on the ground that the deceased was under the influence of alcohol at the time of death.

The case

As per the NCDRC order dated 14th September 2022, the complainant’s son had purchased LIC Jeevan Anand policy with profits and with accident benefits. The risk covered was Rs 4,70,000 (Rs 2,35,000 on account of the sum assured and Rs 2,35,000 on account of accident benefit). The insured person died on 08-06-2014 due to accidental drowning in the river. After his death, the insurer paid only Rs 2,35,000 against the sum assured but denied the accident cover on the ground that the insured was under the influence of alcohol (drunk) at the time of the accident. The insurance company claimed that being drunk at the time of the accident was a violation of condition no. 10(b)(i) of the policy.

The complainant approached the District Forum, which held that “it has not been conclusively proved that the deceased was under the influence of alcohol.” From the Post Mortem (PM), the District Forum also observed that the death of the insured was due to ‘asphyxia’ and ‘wet drowning’, and not due to ‘intoxication’.

While the Forensic Science Laboratory report showed the presence of 59.45 mg% ethyl alcohol in the blood of the deceased, the District Forum found the claim inconclusive as no urine sample was taken during the post-mortem examination. Therefore, the Forum observed, “it cannot be said that the deceased was under the influence of alcohol”.

Also Read: Your life, health, car and other insurance claims will not be denied if you know these details

The District Forum allowed the complaint and directed the insurance company to pay Rs 2.35 lakh to the complainant with 9% per annum interest from the date of complaint till payment. It also directed the company to pay Rs 25,000 to the complainant as compensation for mental harassment etc. and Rs 5,000 towards litigation charges.

However, the insurer challenged the District Forum’s order in the State Forum, which allowed the appeal and set aside the previous order in favour of the insurance company. Following this, the complainant approached the NCDRC.

Why NCDRC ordered in favour of the complainant

The NCDRC also noted that there was no evidence to prove that the “stomach contents had smell of alcohol and whether blood and urine samples of the deceased were collected or not.”   

Even if it is assumed that 59.45 mg% ethyl alcohol was present in the blood of the deceased at the time of death, the national panel found it was not enough to say that the person was intoxicated to be out of his senses or with reflexes impaired.

Also Read: Insurance: How to ensure your claim isn’t rejected

The NCDRC quoted AIIMC Manual for Physicians in National Drug Dependence Treatment Centre. According to this manual, blood alcohol concentration (BAC) of less than or equal to 80 mg/dl would have effects like “euphoria, feeling of relaxation and talking freely, clumsy movement of hands and legs, reduced alertness but believes himself to be alert.”

“Thus, on the one hand, there are material lapses and errors apropos the PM and the FSL reports and on the other hand even if BAC level 59.45 mg% is taken on its face the same is far less to say that the human was under the influence of alcohol as to be intoxicated beyond his senses or with reflexes impaired,” the NCDRC order noted.

While allowing the revision petition, NCDRC said, “in our considered view, the insurance co. mechanically repudiated the accident benefit claim by taking recourse to its said condition no. 10(b)(i) in the routine without examining the relevant and material documents with the due and requisite application of mind, its act is neither correct nor justifiable.”

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