The insurer, through its third-party affiliate Health India, contested the case, insisting that the perforation was caused due to drinking, and so was not payable under the terms of the policy. The District Forum upheld the insurer's objections and dismissed the complaint.
The Consumers Welfare Association, along with Prashant, challenged this decision before the State Commission. It was pointed out in the appeal that the Forum had erred in believing the medical summary without there being any proof to establish veracity regarding the patient being an alcoholic. Besides, the medical literature showed that there could be several causes for duodenal ulcer and perforation, and no evidence had been furnished to show that the patient had suffered the ailment solely due to alcoholism.
The Commission relied on a similar dispute it had adjudicated earlier, where it had been held that a claim for cirrhosis of the liver could not be repudiated on an assumption that it was solely due to alcohol consumption. Similarly, in this case there was no evidence to show that duodenal perforation had occurred solely due to alcohol.
By its order of February 20, 2017, delivered by A K Zade for the Bench along with Usha Thakare, the Maharashtra State Commission set aside the Forum's order and directed the insurer to settle the claim within sixty days. The insurance
company was ordered to reimburse the medical expenses of Rs 151,880, pay Rs 10,000 as compensation, pay Rs 5,000 towards cost of the complaint, and another Rs 3,000 towards costs of appeal.
The writer is a consumer activist