“Pancreatitis admittedly has no nexus with the intake of alcohol, and alcohol is a sugar content and, if taken in limit, is not a poison”, observed Chandigarh Consumer Forum in its judgment, while directing insurance firms to pay Rs 1.93 lakh to a Mohali resident for rejecting his medical claim by mentioning that liquor caused him the disease.
Sarbjit Singh Kahlon of Mohali has stated that he has been continuing with the medi-claim policy for more than 27 years, along with his wife. On June 20, 2017, Kahlon felt uneasy following abdominal pain and was taken to Hope Clinic, where, after conducting tests, he was referred to Fortis Hospital, Mohali, on the same date. At Fortis, he was admitted to CCU under the gastro department for treatment. Following this, Kahlon’s son informed the insurance firms, New India Assurance Company and Raksha Health Insurance, regarding the admission of his father. However, two days after the cashless facility was denied by the insurance firms without any reason, on June 26, Fortis Hospital discharged Kahlon. They made a payment of Rs 1.58 lakh. Thereafter, the complainant took up the matter with Raksha Health Insurance, along with all the medical record and reports of the Fortis Hospital, but he received a rejection letter.
Meanwhile, Kahlon again got ill and was admitted to Max Hospital on August 3, wherein an operation of gall bladder was done and he was discharged on the next day. But, when he raised the bills for the removal of stone, the insurance firm again did not provide the cashless facility and the claim was settled by Raksha Health Insurance for an amount of Rs 31,729. Kahlon then moved the forum and filed a complaint.
The New India Assurance Company Limited, in reply, submitted that the complainant had a history of acute pancreatitis, with hypertension and there is a doctor’s prescription from Hope Nursing Home that Kahlon had taken Ethanol day before hospitalisation and alcohol is the main factor in causing the disease. As per the policy conditions, ailments or its complication arises due to alcohol is permanently excluded from the scope of policy. Whereas when the complainant fell ill and was admitted again and his claim was settled with Rs 31,729 as per the terms of the policy agreed by the complainant. Meanwhile, Deep Chand from Raksha Health Insurance made a statement that they adopt the reply filed by the New India Assurance Company.
The forum observed, “…We shall refer here hypertension in itself is not a disease. The blood pressure increases or decreases with the aging process, but, it is treatable and can be kept under control and a person can outlive his normal life…” The judgment further read, “…The doctors though had referred the history of the complainant taking alcohol a day earlier, but, it has not been mentioned, the quantity of alcohol being consumed was on higher side which could have led to his ailment. The Pancreatitis admittedly has no nexus with the intake of alcohol…”
“…Alcohol in itself is not a poison, if taken in small quantity as it is admixture of water, sugar and fermenting agent. In other words, it is a sugar content and, if taken in limit, it cannot be said he was an alcoholic or it could have caused Pancreatitis…”, read the judgement.
The Forum opined in the judgement released on November 6, that repudiation of the claim was deficiency in service unless the disease was caused with excess intake of alcohol i.e. to say Pancreatitis. Thus, there is clear-cut case of deficiency in service on the part of the insurance firms.
The Forum thus directed the insurance firms to jointly pay a sum of Rs 1,58,025 towards claim of the medical bill at Fortis Hospital along with interest at 9 percent per annum. The Forum also ordered firms to pay Rs 25000 to the complainant as compensation and Rs 10000 as litigation charges.