A man who woke up in hospital and had no recollection of how he got there after a night out during a vacation in Bali has won a claim dispute for medical expenses.

The holidaymaker, who held travel insurance with Lloyd’s Australia, had no memory of events after returning to his accommodation until he awoke to find himself hospitalised.

He contacted Lloyd’s, which appointed an investigator and concluded the man had climbed to the top of a two-metre wall at his accommodation and suffered a head injury.

Lloyd’s denied the claim for medical costs, saying he acted unreasonably and without care for his own safety by being on the wall and a loss from that conduct was excluded.

The man disagreed that Lloyd’s had established how the injury occurred and also argued that even if he was on the wall, that was not so unreasonable for the insurer to rely on its exclusion. Records from a Lloyd’s doctor described him as falling from a balcony, which the man said showed “no one really knows what happened”.

The Australian Financial Complaints Authority (AFCA) ruled Lloyd’s was liable as it failed to prove the man had not taken adequate care for his own safety.

AFCA’s panel was “satisfied on balance that the complainant likely was on the wall and came off the wall, however, the evidence does not establish why the complainant was on the wall, or whether the complainant fell, slipped, jumped or was pushed from the wall, or if and to what extent the wall played a role in the complainant’s injuries”.

“The panel cannot be satisfied if and to what extent the injuries resulted from that conduct,” it said. “The panel agrees with the complainant to the extent that the circumstances of the incident are not clear.”

The travel policy exclusion stated "If you don't take reasonable care of yourself, or you put yourself in a situation where a reasonable person should have known that an injury or illness was likely to happen, you won't be covered.”

The man told the Lloyd’s investigator he had no recollection of the incident or the hours leading up to the incident, so Lloyd’s based its decision on witnesses and other evidence.

The Lloyd’s investigator attended the site of the incident, though only three people consented to being interviewed and providing formal statements.

One witness, the owner of a restaurant across the road, remembered selling the man food earlier in the evening. He stated his breath smelt of alcohol and he saw the man walking along the wall of the accommodation before he suddenly vanished and shortly later heard screams.

Lloyd’s relied heavily on this statement in determining the man climbed to the top of the wall and either fell, jumped or dived from there and that this caused his injuries.

However, AFCA said it had “concerns over the reliability” of this evidence as no alcohol was recorded in his system in the hospital notes, and several guests at the accommodation said he was not drunk.

The restauranteur “recalls that the complainant smelt of alcohol approximately three hours prior to the incident. The evidence available from the guests and employees at the accommodation as well as the medical records from the treating hospital, make it clear this was unlikely the case,” AFCA said.

“Given the likely inaccuracies … the panel is unwilling to accept his evidence of the cause of the complainant’s injuries without additional corroborating evidence. The insurer has been unable to obtain this,” AFCA’s ruling states.

The night manager of the accommodation recalled seeing the man order a round of four beers, though he did not see the him consume any alcohol and said he was otherwise unremarkable. The manager was asleep at the time of the incident.

The investigation found a version of events taken by the hospital of a fall from the wall was most likely provided by a nurse staying at the same accommodation who did not see what happened but accompanied the man to hospital.

The holidaymaker argued there were several plausible ways the incident could have occurred, such as slipping, an accidental injury caused by using the pool, or an assault. The fact guests were unwilling to be involved in the investigation suggested there may be more details to how the incident occurred that have not been uncovered, he said.

“The insurer was unable to find one witness who saw the incident happen, any CCTV footage or obtain evidence from the complainant himself. As such, it cannot satisfy the panel that, on balance, if and to what extent the complainant being on the wall and his injuries are connected,” AFCA said.

“There is an absence of evidence to establish that the complainant was aware of danger and courted that danger. The insurer has not established a valid exclusion and is required to accept and pay the claim.”

See the full ruling here.