Exclusion – Accidental vs Illness Case 2
1. Brief background
The Insured’s death claim was repudiated by the Insurer on the ground that the death does not fall under the policy coverage since the death was not accidental death but due to medical cause namely due to “Acute pontine bleed”. This policy only covers accidental death and not death due to illness or disease.
The Case Manager handling this dispute gave her recommendation favouring the Insurer. The Complainant who did not accept the recommendation has now referred the dispute for Adjudication by the Ombudsman.
The only issue to determine here is whether the death was solely and directly due to accident.
3. The Law
The burden of proof is on the claimant to prove that the death was due to a risk insured by the policy. In other words the onus is on the claimant to show that the insured died as a result of an accident and not as a result of any other cause (American International Assurance v Nadarajan Subramaniam (2013) 5 MLJ 195, CA).
4. Key Findings: -
The relevant policy provisions states as follows:
“NOW THIS POLICY OF INSURANCE WITNESSETH that if during the Period of Insurance the Insured Person shall sustain Injury caused by Accident which shall solely and independently of any other cause result in the Insured Person’s death or Disablement as hereinafter defined, or necessitate medical and/or Hospital and surgical treatment as hereinafter defined the Company will subject to terms, provisos, exclusions and conditions of and endorsed on this Policy(which terms, provisos, exclusions and conditions shall so far as the nature of them respectively will permit be deemed conditions precedent to the right to recover under this Policy) pay to the Insured Person or in the event of death to the Insured Person’s legal personal representative, the sum or sums of money specified in the Schedule and in accordance to the Scale of Benefits.”
PART 1 – DEFINITIONS
Accident means any sudden or unexpected and violent event, resulting directly and independently from the action of an external cause, other than any intentionally self-inflicted injury.
Injury means bodily injury suffered anywhere in the world caused solely by an Accident and not by sickness, disease or gradual physical or mental wear and tear occurring during the Period of Insurance.
Medical report of the attending doctor reveals the following:-
Insured had a fall due to generalized body weakness with reduced level of consciousness. Insured had no external and visible injuries. Insured had a bleeding stroke which led her to a reduced level of consciousness. The medical report concluded that the Insured suffered from “Acute pontine bleed with mild hydrocephalus”.
Pontine bleed is a type of brainstem haemorrhage which is a serious medical condition that can often lead to come or death.
The death certificate states the cause the death as Acute Pontine Bleed.
5. Adjudication and reasons:-
Based on the above key findings, we find that the death was caused by the insured’s intracranial bleeding and not because of the fall. The claimant has failed to prove that the death was due solely and directly from the fall. Accordingly the claim does not fall within the policy coverage. Although we sympathize with the claimant’s situation, we wish to state that it is a principle of law that the rights and liabilities of the parties to the contract are governed by the terms and conditions as stipulated in the policy contract.
The Adjudication is in favour of the insurer.