Tata AIG To Pay Rs 30 Lakh Accidental Death Claim After Commission Finds Alcohol Evidence Unreliable

A pensioner’s family will receive Rs 30 lakh under an accidental death policy after the Tamil Nadu State Consumer Disputes Redressal Commission found that Tata AIG General Insurance had not established the grounds for excluding the claim.

The commission dismissed the insurer’s appeal and upheld the Vellore District Consumer Commission’s direction to pay the claim, nine per cent annual interest from September 1, 2023, until the district commission’s order, Rs 50,000 as compensation for deficiency in service and mental agony, and Rs 25,000 towards litigation costs. The district commission had directed payment within one month, with a further nine per cent interest applicable in case of default.

Govindasamy’s group personal accident cover came with his State Bank of India (SBI) pension account. He was injured in a road accident on April 9, 2022, and taken to Christian Medical College in Vellore. He died there on April 18. His wife and two daughters then asked the insurer to pay the Rs 30 lakh benefit.

Tata AIG turned down the claim in January 2023, saying the policy excluded injuries sustained under the influence of alcohol. Govindasamy’s wife and daughters took the matter to the Vellore District Commission, which ordered the insurer to pay in January 2024. The insurer then appealed to the state commission.

Why The Insurer’s Evidence Fell Short

Tata AIG relied on a hospital death summary that recorded Govindasamy as being under the influence of alcohol at the time of the accident. The document also mentioned a plasma alcohol reading of 106.1 mg/dL. The state commission said these entries were relevant, but their presence in a summary did not, on its own, settle whether the policy exclusion applied, according to a recent report by The Times of India.

The record did not clearly say who had provided the information about alcohol or whether it reflected a doctor’s independent clinical assessment. The insurer also did not produce the underlying laboratory report for the stated reading. Without it, the commission said, there was no clear evidence about the identity of the blood sample, when it was collected, which laboratory tested it, or how the result was linked to Govindasamy.

The commission also compared two death summaries filed in the case and found material inconsistencies. One recorded Govindasamy’s age as 60, while the other gave it as 54. The summaries carried different medical record numbers, addresses, and hospital details. They also differed on the admission and death dates: the insurer’s document recorded death on April 11, although the parties accepted that Govindasamy died on April 18.

Taken together, the discrepancies affected the reliability and traceability of the records, the commission said. The insurer had relied on the summaries and the alcohol reading to invoke an exclusion, so it had to establish that the documents related to the insured and supported the conclusion it drew from them.

What The Ruling Means For Claim Disputes

The commission said the case did not turn on a blanket rule that an insurer must always produce a blood or breath test to apply an alcohol-related exclusion. Referring to the Supreme Court’s decision in IFFCO Tokio General Insurance Company versus Pearl Beverages, it noted that the relevant condition may be proved through the totality of reliable circumstances.

The question here was whether Tata AIG had shown, with reliable evidence, that Govindasamy was under the influence of alcohol at the time relevant to the accident. The commission said a history of alcohol consumption, a reported test figure and evidence of being under the influence are not automatically interchangeable. In this case, the source of the hospital entry and the laboratory result’s connection to the deceased were not adequately established.

It also held that the family did not have to explain every unresolved inconsistency in the insurer’s records. The burden of establishing the facts needed to invoke the exclusion rested with the insurer. The commission upheld the district commission’s conclusion, though it clarified that its decision did not endorse every reason given in the lower forum’s order.

The decision is specific to the evidence here: an insurer relying on an exclusion must support it with records reliably tied to the insured and circumstances of the claim.

FAQs

Can an insurer reject an accidental death claim because of alleged alcohol use?
It may rely on an alcohol-related exclusion if the policy contains one, but the insurer must support its decision with reliable evidence showing that the exclusion applies.

Why did the commission uphold this claim?
It found gaps in the medical records, including an unexplained alcohol entry, a missing laboratory report, and inconsistencies in the summaries.

What did the insurer have to pay?
Tata AIG was directed to pay Rs 30 lakh, 9 per cent annual interest from September 1, 2023, until the district commission’s order, Rs 50,000 compensation, and Rs 25,000 in litigation costs.