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"When walking at house skid away from steps" disc prolapse L-4-5, L-5-S1 levels.  The name of the doctor who treated the insured is shown as professor, Dr.Sunny Pazhayattil, Ortho Peadic Surgeon, Mother Hospital, Thrissur.  The period of treatment as inpatient is shown as 20/5/2002 to 27/5/2002.  It can be seen that the patient was discharged from Mother Hospital, Thrissur on 27/5/2002 and the expenses incurred is shown as Rs.34,189.29.

8.      There is no dispute that the respondent/complainant being the insured under P1 Jeevan Raksha Insurance Policy is entitled to get the treatment expenses as an inpatient in a hospital/nursing home for an amount up to Rs.1.lakh.  It is to be noted that the aforesaid treatment must be in connection with bodily injury sustained in an accident.  As per R2 claim form, the complainant/insured sustained the injury on 19/5/2002 at 8 pm  in his house at Elathuruth and the said accidental injury sustained while walking he skid away from steps and thereby sustained disc prolapse L-4-5, L-5-S1 levels and for the said injury he was admitted in Mother Hospital on 20/5/2002 and discharged from the hospital on 27/5/2002.  He was treated by the Orthopeadic Surgeon, Professor Dr.Sunni Pazhayattil and the complainant/insured incurred a sum of Rs.34,189.29.

9.      The case of appellant/opposite party/insurance company is that the complainant/insured had disc prolapse L-4-5, L-5-S1 levels even prior to the taking of P1 insurance policy and that the said disc prolapse was pre-existing disease and he had no such fall or accidental injury as alleged.  The appellant/opposite party/insurance company much relied on Ext.X1 case sheet, maintained at Mother hospital, Thrissur in connection with the treatment of the complainant/insured at that hospital.   The appellant has also relied on the testimony of RW1 Dr.Sunny Pazhayattil who treated the complainant/insured at Mother Hospital, Thrissur.  Ext.X1 case sheet would make it abundantly clear that the complainant had consultation at Mother hospital, Thrissur on 17/3/2000 and on that day the respondent/complainant had consultation with Dr.Sunny Pazhyattil.   For the aforesaid consultation at Mother Hospital, the complainant was allotted MRD No.52852.  The diagnosis is shown as IVDP (Intra Vertebral Disc Prolapse), Sciatica.  Ext.X1 case sheet would also show, thereafter the complainant/insured had the consultation at Mother Hospital, Thrissur on 20/5/2002.  The diagnosis on 20/5/2002 was weakness of left foot and on examination foot drop left side was detected.  The complainant was admitted as an inpatient in that hospital on 20/5/2002.  Ext.X1 case sheet would also make it clear that the complainant (patient) is having left side L5 Radiculopathy with foot drop since one week and that MRI Lumbar Spine showed degeneration of L-4-5 and L-5-S1 disc.  Severe disc herniation, extrusion and cordial migraine of L4-5 disc, and moderate disc herniation at L5-S1, especially of (L) side compressing L5 and S1 roots.  It was suggested in L-4-5 and L-5-S1 discectomy.  Ext.X1 case sheet would also show that on 21/5/2002 the complainant as patient was posted for laminectomy and discectomy under general anesthesia on 22/5/2002.  It was also suggested to get the consent for the said surgical procedures.  Thereby on 22/5/2002 Hemi laminectomy at L-4, L-5 level and discectomy at L-4-5 L5-S1 level.  The surgery was conducted by the Professor Dr.Sunny Pazhayattil under general anesthesia.  The complainant as patient continued as inpatient.  He was discharged from the hospital on 27/5/2002.  He had numbness of left lower limb following walking.  On discharge he was advised for review after 7 days.  Thereafter on 3/6/2002 the sutures were removed.  The complainant came for review on 10/6/2002 and he was referred to another doctor for partial weakness and numbness of left foot.

13.    The doctor who treated the respondent/complainant at Mother Hospital, Thrissur has been examined before the Forum below as RW1.  Ext.X1 case sheet was proved through RW1.  Dr.Sunny Pazhayattil as RW1 has categorically deposed that the complainant as patient had the first consultation on 17/3/2000 and on that day the complainant had Intra Verticular Disc Prolapse with Sciatica.  The complainant had the next consultation on 20/5/2002.  On that day he was having weakness on left foot of one week duration.  After the surgical procedures he was discharged on 27/5/2002.  He also admitted the letter received from the insurance investigator and R3 reply dated:28/4/2003 issued by him.  The evidence of RW1 would show that the surgery was conducted because the patient had foot drops and for the foot drop, RW1 conducted surgery of L-4-5 and L5 - S1 level and that the surgery was conducted to remove the disc prolapse.  It is categorically deposed by RW1 that the aforesaid surgery was conducted to remove the disc prolapse.  It is further deposed that the compression of L4-L5 caused foot drop.  It is also deposed by RW1 that on 17/3/2000 the patient (complainant) was having IVDP (Intra Verticular Disc Prolapse) and on 17/3/2000 the patient complained of pain and the doctor detected IVDP.  There is no case for RW1 that the complainant told him that he had a fall on his back at any place.

15.    The Forum below has given a wrong interpretation to the testimony of RW1, Dr.Sunny Pazhayattil.  The mere fact that RW1 has given an answer to a general question as to whether surgery is the only mode of treatment for disc prolapse.  It is true that RW1 has stated that in majority cases of disc prolapse and foot drop there are alternative mode of treatment other than surgery.  But the Forum below was of the view that the surgical procedure was adopted only for foot drop.  But the Forum below failed to anlyse and appraise the evidence of RW1 in its correct perspective.  It is pertinent to note that RW1 has categorically deposed that the surgery was done for disc prolapse and that the disc prolapse caused compression of nerves and had resulted in foot drop.  The evidence on record would make it abundantly clear that the foot drop was caused due to compression at L-4 - L-5 level and that the said compression was on account of the disc prolapse.  Thus, it can be concluded that the surgery was conducted for disc prolapse.  There is nothing on record to show that the disc prolapse was caused on account of any accident like a fall etc.  It is also to be noted that RW1 has only deposed that a patient having disc prolapse may get the disease of disc prolapse aggravated by a fall from certain height.  The mere fact that fall may aggravate the disc prolapse cannot be taken as a ground to hold that the disc prolapse occurred on account of the fall.  More over, in the present case in hand there is nothing on record to show that the complainant/insured had any such fall as alleged.  The aforesaid case of alleged fall cannot be believed for a moment because of the inconsistency regarding the date of the alleged fall.  At one place it is stated that the fall occurred on 15/5/2002 and yet another place it is stated that the alleged fall was on 19/5/2002.   It is further to be noted that there is no whisper in Ext.X1 case sheet regarding the fall when the complainant approached RW1, Dr.Sunny Pazhayattil on 20/5/2002 at Mother Hospital, Thrissur.  All these circumstances would go to show that the alleged case of fall is only a cooked up story which was created or developed for getting the insurance claim.  So, the Forum below cannot be justified in allowing the complaint in OP.761/02 by giving benefit of doubt infavour of the complainant.  On the other hand, it can be seen that the IVDP at L4-5, L5 - S1 level was a pre-existing disease.  The appellant/opposite party/insurance company is perfectly justified in repudiating the insurance claim.