Chennai Ombudsman Centre
Case No. 11.07.1173 / 2004-2005
Mr. Munnangi Bhaskara Rao
Vs.
TATA AIG General Insurance Co Ltd.
Mr. Munnangi Bhaskara Rao of Vijayawada was covered under the Master Personal Accident Policy issued by the Insurer to Road Safety Club Private Limited For loss of hearing arising out of accident, the amount payable as per terms of policy was 25% of the sum insured of Rs 30,000/- . It is reported that the insured met with an accident on 25.10.2003 at 10.00 PM on Deepawali day due to fall from a two wheeler when he was hit by a Deepawali cracker blast on his ear, He was admitted in Usha Hospital immediately and discharged on 28.10.2003 with an advice to contact an ENT Specialist.
The insured approached Government Hospital Guntur and hospital outpatient records dated 23.12.2003 made a diagnosis “traumatic perforation left ear – exposure to crackers’. The insured contacted Singari ENT Hospital who certified about the hearing loss in the left ear at 110 decibel. The claim was rejected by the Insurer on 5.3.2004 on the ground that the claimant was suffering from large central perforation in the left ear due to “chronic suppurative otitis media” for a long time and hence not payable as it was pre-existing condition before the policy was taken by the insured.
A joint hearing was held. The complainant was physically examined by the panel doctor of the Insurer at Vijayawada on 3.2.2004 who opined that the perforation in the left ear was due to “Chronic suppurative otitis media’: Based on this record, M / s. Paramount General Hospital, Mumbai also opined that CSOM was a long standing condition and has no relation with the alleged vehicular accident.
The case sheet summary issued by Usha Hospital, the out patient record given by Guntur Government Hospital, the audiogram report of Singari ENT Hospital were perused The suppurative (producing pus – discharging pus) otitis (inflammation of the ear) media (middle) was not the pre-existing condition as the same was not recorded by the hospitals at Vijayawada / Guntur / Singari ENT Hospital. The possibilities of formation of a pus and inflammation after some time could not be ruled out.
