Cameron travelled to Boston to celebrate Christmas with friends. Cameron’s friends had booked a private table at a popular bar in Boston. Cameron remembered having a couple of drinks at the bar, losing consciousness and waking in hospital. Cameron’s friends explained that after blacking out Cameron had vomited and was unable to stand. Cameron’s friends called an ambulance. The ambulance took Cameron to hospital for treatment, costing a total of USD3,192.
Cameron submitted a claim to his insurer. After checking the notes relating to Cameron’s treatment, Cameron’s insurer declined his claim referring to the policy’s alcohol exclusion clause.
Cameron’s view
Cameron did not accept the insurer’s decision saying he only had three beers. Cameron considered his drink must have been spiked while he was dancing. The hospital had not taken a blood test, so the insurer was unable to prove that he was intoxicated. From Cameron’s perspective, the insurer was obliged to accept the claim.
Review
The insuring clause, and excluding clause
Cameron’s insurance policy covered him for emergency medical treatment if he was sick while overseas. However, the policy excluded cover if the claim arose directly or indirectly, or was in any way connected with, Cameron being under the influence of alcohol or drugs.
Differing recollections
The insurer submitted that Cameron had changed his recollection, and only mentioned the possibility that his drink had been spiked after the claim was declined. Cameron responded that he had only had three beers, and we accepted that this quantity of alcohol would not usually require medical treatment.
We needed to decide what, more likely than not, happened at the party on Christmas Eve.
Medical evidence
The best evidence available to us was the opinion of the doctors treating Cameron. The doctor’s notes made just before Cameron’s discharge recorded:
“Patient is awake. Patient relates alcohol use last night, unsure of the amount of alcohol. Patient feels nauseous at this time and is embarrassed that he is in the emergency department.”
No blood tests were taken so we could not be sure of Cameron’s blood alcohol levels, or whether there were other drugs involved. However, the first responder medical practitioner’s notes recorded that there were no signs of other drugs in Cameron’s system. In our opinion, Cameron’s doctors would be experienced in dealing with situations like his, and if they were uncertain about the cause of his illness those doctors would have done further tests, or made relevant notes.
We also noted that Cameron presented at the hospital at 2:06am, which would suggest he had been at the bar for quite some time. In addition, the medical notes did not support Cameron’s submission that he was simply having dinner and a few drinks at the bar when he collapsed.
Weighing the medical evidence, we agreed that the insurer was entitled to rely on the alcohol exclusion to decline his claim.
Further submissions from Cameron
Cameron did not accept our decision. Cameron acknowledged that he had been drinking, but said it was absurd for the insurer to decline his claim simply because he had consumed three beers. Cameron did not accept his inability to say, at the time, how much alcohol he had consumed was because the drug used to spike his drink caused him to be confused.
Outcome
We reconsidered all the evidence, and confirmed our earlier view that the insurer was entitled to decline the claim. The insurer did not have to prove whether or not drugs were involved, it simply had to prove that it was more likely than not that Cameron required medical treatment because of alcohol intoxication. On the strength of the medical evidence submitted, we were satisfied the insurer was entitled to decline the claim.
Our insight
We are often asked for our view on what most likely occurred in situations where there are differing recollections. We acknowledge that we can never been completely certain of what occurred, but our role is to consider, on the balance of probabilities what was most likely. We take into consideration the recollections of those directly involved, but the best evidence is a record taken at the time, preferably by an unrelated party. In this case the opinion of the medical practitioners carried considerable weight when trying to decide what most likely happened.
