Date of filing : 20-03-2008 Date of order : 14-05-2009 IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD CC.38/08 Dated this, the 14th day of May 2009 PRESENT SRI.K.T.SIDHIQ : PRESIDENT SMT.P.RAMADEVI : MEMBER SMT.P.P.SHYMALADEVI : MEMBER Subha Patali, S/o.Rama Patali, Sanjivani Nilaya, } Complainant Kelu Gudde, Po. Ramdas Nagar, Kasaragod. Manager, National Insurance Company Ltd, } Opposite party High lane Plaza, M.G.Road, Kasaragod. O R D E R SRI.K.T.SIDHIQ, PRESIDENT The beef of the complainant in brief is that he received personal injuries due to a fall on 14-06-07 during the subsistence of a valid policy covering medical expenses issued by the opposite party. Though a claim was preferred with all medical records and bills the opposite party repudiated his claim on the ground that the disease is not covered under the Personal Accident Policy and that as per Medical records complainant was suffering from Back Ache for the last 2 years which is not covered under the policy. According to the complainant the particular injury was caused on 14-06-07 that was not a continuation of any back ache or any other prior ailment. After the injury he could not continue with his profession as Master Tailor. Hence alleging deficiency in service on the part of opposite party the instant complaint is filed. 2. According to opposite party the complainant was a policy holder. It was a renewed one. But the complainant had not sustained any injury on 14-06-07 by sudden fall and suffered injury. As per the terms and conditions of policy, the injury shall be sole and direct cause for either permanent total disablement or temporary total disablement. The complainant had no permanent total disablement or temporary total disablement. The policy issued is not a medi-claim policy but a personal accident policy. According to opposite party the complainant approached Dr. Mrinal Raghavan, consultant Ortho Surgeon on 14-6-07 for treatment. He complained about the back ache since two years. The doctor considering the situation of the complainant suggested to admit at Carewell Hospital and had operation on the same day. The complainant was suffering due to Lumbar spondylosis as per the MRI scanning impression. Therefore the alleged injury is not resulting solely and directly from the accident caused by external and violent and visible means and not covered under personnel accident policy. Further the doctor who alleged to have treated the complainant has reported that the complainant is suffering from only temporary partial disability. On this ground also the complaint is not maintainable and therefore the complaint is liable to be dismissed. 3. Complainant gave evidence by way of affidavit as PW1 and Exts A1 to A3 marked. He was cross examined by counsel for opposite party. Dr. Nagraj Bhat who issued Ext.A2 disability certificate to the complainant examined as PW2. On the side of opposite party Exts B1 to B7 marked. Both sides heard and the documents perused carefully. 4. PW2 Dr. Nagaraj Bhat issued Ext.A2 Disability Certificate. In that it is noted that the complainant had sustained Cauda Equina Syndrome due to the disc prolapse admitted on 14-06-07 and underwent surgery on 14-6-07 and discharged on 23-6-07. Presently he is having loss of erection of penis and blunting of sensation over perianal area. His disability is about of 25%. During examination as PW2, he stated that this disability is caused due to fall. Ext.A3 is the copy of discharge summary issued from Carewell Hospital to the complainant. In that it is noted that sudden after history of fall complaint of blunting of sensation over perineum and not able to pass urine. Both these documents prove that the complainant had sustained Cauda Equine Syndrome due to an accidental fall. 5. The American Academy of Orthopedic Surgeon (a medical authority) says that Cauda Equina syndrome is a rare disorder affecting the bundle of nerve roots (Cauda Equina) at the lower (lumbar) end of the spinal cord is a surgical emergency and if patients with Cauda Equina Syndrome do not get fast treatment to relieve the pressure it can result in permanent paralysis, impaired bladder, and/or bowel control, loss of sexual sensation and other problem. Even with immediate treatment some patient may not recover complete functions. 6. The Causes of Cauda Equina Syndrome may be caused by a ruptured disk, tumor infection, fracture or narrowing spinal cord. It may also happen because of violent impact, such as a car crash, a fall from significant height or a perforatory injury such as gunshot or slabbing injury. From the above it is clear that one among the various reasons for Cauda Equina Syndrome is a fall from a significant height. 7. It is clear that the claim of the complainant is a genuine one and the reason stated for the injury caused to the complainant is an acceptable one and the disability caused to him is due to the fall. 8. PW2 has not recorded in Ext.A2 certificate the nature of disability, that whether it was a permanent partial disablement or a temporary total disablement. But in cross examination he has stated that he noted partial disability relating to body to the tune of 25%. Now the question to be considered is whether the disability caused to the complainant is a temporary partial disability or a permanent partial disability. 9. The complainant undergone surgery on 14-06-07 and PW2 examined the complainant on 11-10-08 i.e. after one year and 4 months. Even on that day the complainant was having 25% partial disability. Definitely it is a case of permanent partial disability and it comes within the purview of the personal accident benefit policy issued to the complainant. Hence the repudiation of the claim of the complainant amounts to deficiency in service. 10. As per the policy the complainant is entitled to get insurance benefits as envisaged in clause (e) (Xii). As per this clause the insurer is liable to pay the percentage of the capital sum insured as per the percentage of disability as assessed by the doctor. In this case as per Ext.A2 the disability assessed is 25%. Hence the complainant is entitled to get the 25% of the capital sum insured i.e. Rs.50,000/- that would fetch Rs.12,500/-. Therefore the complaint is allowed and the opposite party is directed to pay Rs.12,500/- to the complainant with a cost of Rs.2000/- within 30 days from the date of receipt of copy of the order. Failing which the said amount of Rs.12,500/- will carry interest @ 12% from the date of complaint till payment. Sd/- Sd/- Sd/- MEMBER MEMBER PRESIDENT Exts. A1. 18-01-08. Repudiation Order A2. 11-10-2008 Disability Certificate A3. Discharge Summary B1. Personal Accident Insurance Claim form. B2. Personal Accident Insurance Medical Certificate Form (Attending Doctor’s Report) B3. 14-06-07 Prescription of complainant. B4.Personal Accident Insurance (Individual)Policy B5. Personal Accident Insurance Policy B6.Copy of policy B7. Series Bills. PW1. Subha Patali PW2.Dr. Nagaraj Bhat. Sd/- Sd/- Sd/- MEMBER MEMBER PRESIDENT Pj/ Forwarded by Order SENIOR SUPERINTENDENT
......................K.T.Sidhiq
......................P.P.Shymaladevi
......................P.Ramadevi | | 
