DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD

Dated this the 22^nd  day of  December,  2021

Present    :  Sri.Vinay Menon V.,  President

                :  Smt.Vidya A., Member                                                   Date of Filing: 11/10/2019 

     CC/242/2019

George Xavier

S/o.Xavier,

Madathilparambil House,

Olimkadavu Post,

Poothamkuzhi, Palakkad – 678 706 .

(Party in Person)                                                                    -           Complainant

                                                                                      Vs

1.The Service Manager

    IFFCO-TOKIO General Insurance Co.Ltd.

    Near PSM College of Dental Science & Research

    Akkikavu, Thrissur

2.The General Manager

     IFFCO-TOKIO General Insurance Co.Ltd.

    IFFCO Sadan, C1,District Centre,

    Saket, New Delhi – 110 017

    (OPs by Adv.P.Prasad )                                                        -           Opposite parties   

O R D E R 

By Sri. Vinay Menon V.,  President

1. Abridged pleadings of the complainant necessary to adjudicate this lis are  as follows:

The complainant,  a  rubber tapper by profession,  suffered a fall on 28/3/2019 in the field and sustained injury to  his right hip. He was treated in Avitis Hosptial at Nemmara, and the opposite party insurer had sanctioned his claim for insurance arising out of this accident to a tune of Rs.16,000/-. Thereafter,  two months later,  he developed a pain and underwent Ayurvedic treatment  at Taluk Ayurvedic hospital at Vadakkanchery.   He incurred an amount of Rs.5,000/- as medical expenses and incurred a loss of around Rs.30,000/- by  way of loss of income.   The insurance company repudiated his claim. Aggrieved thereby  this complaint is filed.

2. The opposite parties filed version contending the pleadings of the complaint stating that the insurance availed by the complainant was a personal accidental policy and the same covered only specified risks mentioned in the schedule of the policy documents. Complainant had underwent Uzhichil (massage) at Ayurvedic Hospital for “sciatica”  which was a disease  / illness, which is not covered by the policy.  They had also contended that the allegation of fall and stated that the complainant had not produced any documents to prove that he had a fall.  The complaint is only liable to be dismissed.
3. Pleadings considered, the following issues arise for consideration.

1. Whether the opposite parties have succeeded in  proving that the sciatica is a disease ?
2. Whether the opposite parties are bound to honour the  complaint claim   ?
3. Whether the complainant is entitled to complaint reliefs sought for ?
4. Whether there deficiency in service on the part of opposite parties ?
5. Reliefs, if any ?

4. Evidence considered of oral evidence of the complainant and  Ext.A1 to A5.  Proof affidavit was filed  on the part of opposite parties.  As Ext.A1 was not clear, its original was also produced. Though it forms part of the document it is not marked.

Issue No.1

5.  Crux of the complaint revolves around the question whether sciatica is a disease or a condition that arose out of the accident.
6. Initially we will have to check the definition of accident as contemplated by the opposite parties in definition 11 of Ext.B1.

“11. Accident : It means a sudden, unforeseen and involuntary event caused by external visible and violent means.”

This definition does not mention  the degree or extent or intensity of the accident. So from this definition a crash arising out of a fall from a tree can also be contemplated to be an accident.

7. The complainant underwent Ayurveda treatment from 8/5/2019 to 27/5/2019 and was treated there as an inpatient.  Ext.A2 is the discharge card issued by the Chief Medical Officer, Govt.Ayurveda Hospital, Vadakkencherry. The presenting complaint in Ext.A2 is seen as this:

“2 months before  he had a fall and admitted in allopathic hospital (Avitis) and underwent allopathic medication and the pain over hip joint reduced.  After some time, due to strain the pain over the hip joint aggravated which is radiating to right leg. So he admitted here for better treatment.”

 The diagnosis is seen as sciatica as per Ext.A2. Even though none of the parties had examined the treating doctor as to ascertain the cause of sciatica, it is seen from Ext.A2, which was marked without any objection, that the treating doctor was convinced that the prognosis of the condition was the accident that occurred 2 months ago.  

8. Ext.A3 is the letter of repudiation dated 24/7/2019 with regard to sciatica, the statement made by the opposite party in paragraph 3 is relevant.

“Sciatica’ is an illness / disease and the policy No.54457492 covers accidental physical bodily harm excluding illness or disease, solely and directly caused by external, violent and visible and evident means which is verified and certified by Medical Practitioner.”

9. Mosby’s Medical Dictionary (1996 edition) defines sciatica as “an inflammation of the sciatic nerve, usually marked by pain and tenderness along the  course of the nerve through the thigh and leg.  It may result in a wasting of the muscles of the lower leg.”

The Taber’s Cyclopedic Medical Dictionary  defines sciatica as a pain emanating from the lower back that is felt along the distribution of the sciatic nerve in the lower extremity. It typically occurs as a result of lumbar disk disease and is felt in the back of the thigh and sometimes the rest of the lower extremity.  The etiology  of sciatica is given as follows :

“The condition may be caused by compression or trauma  of the sciatic nerve   or its roots, especially that resulting from a ruptured intra vertebral disk or osteoarthrosis of the lumbosacral vertebrae., inflammation of the sciatic nerve resulting from metabolic, toxic, or infectious disorders, or pain referred to the distribution of sciatic nerve from other sources.”

From a reading of the above we find that sciatica  was not an illness or a disease. It is a condition that arise out of causes like ruptured intra vertebral disk or osteoarthritis of the lumbosacral vertebrae and like causes.

10. Nothing prevented the opposite parties from  examining  the doctor who treated the complainant at Govt. Taluk Ayurveda Hospital, Vadakkancherry.  The opposite parties also has no case that the said doctor is not qualified to issue Ext.A2.
11. After having contented that sciatica was disease, it was incumbent upon the opposite parties to prove that the same was a disease that was not covered under the policy in question by examination of an expert or by adducing evidence to that effect. 

Having failed to do so, we have no option but hold that the opposite parties have  failed to prove that sciatica is a disease.

Issue No.2

12. Admittedly the opposite parties honoured the claim of the complainant for the expenses incurred for the treatment the complainant had underwent in Avitis for the fall on 28/3/2019. Ext.A1 is the policy schedule cum tax invoice. Serial No.7 under the heading “Benefit Description” states that the benefit include medical expenses necessarily incurred by the insured in connection with the injury, provided the claim otherwise is admissible under the policy. As already stated supra, the claim for expenses of treatment availed in Avitis was honoured by the opposite parties. Ext.A2 dated 27/5/2019, in the absence of any evidence to the contrary, would go far to prove that the conditions suffered by the complainant arose out of the fall that occurred two months before his admission in Ayurveda Hospital. 
13. It is therefore safe to conclude that the complainant’s condition is a medical expense necessarily incurred by the insured in connection with the injury of a claim that was already held admissible under the policy, as under Serial No.7 of the Benefit Description in Ext.A1.

             Hence we hold that OP2 is bound to honour the claim of the complainant. 

Issue No.3

14. The complainant has raised  a claim for Rs.35,000/-, which as per his estimate includes Rs.30,000/- being the amount he lost during the period of treatment by way of loss of income.  We are unable to  accept this claim  that the insurance company is bound to indemnify the complainant with every expense or loss the complainant has incurred.  The insurance company is liable only to pay the amount that which is bound by the terms and conditions of the policy. Ext.A5 and A5(b) are not enough to prove that the complainant has incurred Rs.5,000/- towards treatment costs. He is only entitled to the amounts that he can prove to have been expended by him by way of bills / receipts.

Hence we hold that the complainant is not entitled to receive the amounts as sought for the complainant.

Issue Nos.4 & 5

15. In view of the findings in the aforesaid issues 1 & 2 we hold that there is deficiency in service on the part of the opposite parties. The opposite parties  are liable to make good the expense incurred by the complainant in accordance with Sr.No.7 of Benefit Description of the policy schedule of Ext.A1 Individual Personal Accident Policy.
16. In the result we hold as follows:

1. The opposite parties are directed to pay the admissible amount to the complainant in terms of Sr.No.7 of Benefit Description of the policy schedule of Ext.A1 Individual Personal Accident Policy upon the complainant submitting necessary documents, if not already submitted. Upon submission a final decision shall be made within 30 days of receipt of the documents.

     If the documents are already in the custody of opposite party 2,  they are to  evaluate the said documents and effect payment within 30 days of receipt of this order.

2. The complainant is entitled to interest on the amount so arrived at the rate of 10% from the date on which claim 51091912 was submitted by the complainant before the opposite parties till date of actual payment.
3. The complainant is entitled to a compensation of Rs.10,000/- (Rupees Ten thousand only)
4. The complainant is entitled to a cost of Rs.5,000/-  (Rupees Five thousand  only)

  Pronounced in the open court on this the 22^nd day of December,  2021

                                                                                    Sd/-

                                                                              Vinay Menon V.

                                                 President

Sd/-

Vidya A.

                    Member      

APPENDIX

Exhibits marked on the side of the complainant

Ext.A1 –  Copy of policy schedule cum tax invoice of the Individual Personal Accident Policy

                  bearing No.54457492

Ext.A2 –   Copy of discharge card dated 27/5/2019 issued from Govt. Taluk Ayurveda

                   Hospital, Vadakkenchery.

Ext.A3 –   Original of the repudiation letter dated 24/7/2019

Ext.A4 –   Copy of Medical Fitness Certificate dated 10/6/2019

Ext.A5 & A5(b) – Copy of medical bills   

Exhibits marked on the side of the opposite party

 Nil

Witness examined on the side of the complainant

PW1- George Xavier (Complainant)

Witness examined on the side of the opposite party

NIL

Cost :  Rs.5,000/- allowed as cost.

NB : Parties are directed to take back all extra set of  documents submitted in the proceedings in accordance with Regulation 20(5) of the Consumer Protection (Consumer Commission Procedure) Regulations, 2020 failing which they will be weeded out.