Exclusion clause for alcohol-related illness applies only if the disease is solely and directly caused by alcohol consumption.

O R D E R

The petitioner is the Insurance Company and has filed this writ petition challenging the award dated 24.11.2025, whereby, the petitioner was directed to settle the claim of the second respondent/insured.

2. The second respondent had taken Insurance policy with the petitioner Insurance Company for the period from 24.12.2024 to 23.12.2025. The inception of the policy is 24.12.2013. The claim is submitted during 12^th year of the policy period. The second respondent submitted request to avail cashless facility claiming a sum of Rs.3,66,031/- towards medical expenses for the treatment of Chronic Liver Disease. The said claim was rejected by the petitioner/Insurance Company on the ground that the insured failed to disclose and concealed the fact that he consumes alcohol in the proposal form and he is a known alcoholic since 15 years. Therefore, the claim is not payable as per Standard Exclusion No.12 of the policy. The second respondent, aggrieved by the same, approached the first respondent Insurance Ombudsman and on hearing both sides, the Insurance Ombudsman rejected the contentions of the Insurance Company and directed the Insurance Company to settle the claim as per the terms of the policy with applicable interest as per IRDAI norms.

Challenging the same, the present writ petition has been filed.

3. Heard the learned counsel appearing for the petitioner who reiterated the grounds raised in the affidavit filed in support of this writ petition and submitted that the impugned order passed by the first respondent is in contravention of the terms and conditions of the policy which states that as per Condition No.12 of the Policy, after the expiry of Moratorium period, no health insurance claim shall be contestable except for proven fraud and permanent exclusions specified in the policy contract.

4. This Court has gone through the materials placed before it and heard the submissions made by the learned counsel appearing for the petitioner. 5. It is seen that in the discharge summary of the second respondent/insured, Alcoholic Hepatitis was not found in the diagnosis part and therefore, it cannot be exclusively established that the disease was caused solely and directly due to alcohol consumption. That apart, Exclusion Clause No.12 says “the Company shall not be liable to make any payments under this policy in respect of any expenses whatsoever incurred by the insured person in connection with or in respect of: Treatment for Alcoholism, drug or substance abuse or any addictive condition and consequences thereof illnesses or injuries caused by intoxicating drugs or alcohol”. From the very wordings, it can be inferred that illness should have been solely caused by alcohol consumption. However, in the present case, since the diagnosis mentioned in the discharge summary does not indicate that the disease suffered by the second respondent is caused mainly due to consumption of alcohol and therefore, he cannot be disentitled from the coverage. The Insurance Ombudsman, after perusal of the documents placed before it, had held that the Insurance Company has to settle the claim as per the terms of the policy which need not be interfered with. As the first respondent Insurance Ombudsman is an Expert Body dealing with insurance claims, this Court finds that the award passed by the first respondent Ombudsman is justifiable. Therefore, the impugned award need not be interfered with.

6. Accordingly, this Writ Petition is dismissed. There shall be no order as to costs. Connected miscellaneous petitions are closed.