Alcohol As Contributing Factor In Deceased's Illness, Madhya Pradesh State Commission Dismisses Appeal Against ICICI Lombard General Insurance Co.

Brief Facts:

The Complainant's late husband had taken a medical insurance policy of Rs. 25 lakhs, for which he paid a premium of Rs. 75,000/- to ICICI Lombard General Insurance Co. Ltd. (“Insurance Company”). The insurance policy was valid from 19.03.2019 to 18.03.2024 and the Complainant was named as the nominee.

In December 2019, he fell ill and was admitted to Birla Hospital in Gwalior, where he passed away on 11.12.2020. The Complainant incurred Rs. 2 Lakh in medical expenses. When she approached the Insurance Company to claim the insurance amount, the claim was denied. Feeling aggrieved, the Complainant filed a consumer complaint in the District Consumer Disputes Redressal Commission, Morena, Madhya Pradesh (“District Commission”).

The Insurance Company stated that the deceased husband had died due to Haemorrhagic Pancreatitis with Septic Shock with MODS, which was not covered under the policy terms. It also contended that his medical documents indicated that he had Alcoholic Chronic Liver Disease, which violated the policy's 'General Exclusion' clause.

Observations by the State Commission:

The State Commission observed that the discharge summary from BIMR Hospitals indicated that the deceased husband's final diagnosis was Haemorrhagic Pancreatitis, Septic Shock, and Multiple Organ Dysfunction. Detailed progress notes revealed that he was also suffering from 'Alcoholic Chronic Liver Disease'. The Insurance Company denied the claim on the grounds that there was no evidence of any major medical illness or procedures covered under the policy and that the deceased had 'Alcoholic Chronic Liver Disease'.

The State Commission found that the Insurance Company's grounds for denial were valid. The illness of the deceased was not specified to be covered under the policy. Furthermore, any illness caused directly or indirectly by or arising out of the use, consumption, or abuse of alcohol was excluded from coverage.

Based on these findings, the State Commission concluded that there was no deficiency in service by the Insurance Company. The order of the District Commission was upheld and the appeal was dismissed.

Case Title: Smt. Komesh Singh vs P.N.B. Housing Finance Ltd. and Anr.

Case No.: Appeal No. 1100/2023

Advocate for the Appellant: Shri Parag Kale

Advocate for the Respondent: Shri Sanjeev Jaiswal

Date of Order: 16.07.2024

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