A consumer court ordered an insurance company to reimburse the amount of medical treatment expenses for lung cancer after the insurer refused to pay the claim saying the patient was addicted to tobacco, which caused the disease.
The court said there was no evidence to prove that the patient suffered from lung cancer as a result of his tobacco addiction, other than the mention of “tobacco addiction” on the treatment papers. which, according to her, cannot serve as a basis for the insurer to reject her claim. He also said that people who do not smoke also suffer from lung cancer.
The insurance company had rejected the claim of Rs 93,297 incurred by the insured Alok Kumar Banerjee for the treatment of his “adenocarcinoma of the lung” or lung cancer, in a private hospital, on the grounds that he was addicted to tobacco as indicated on its treatment. papers.
Banerjee’s wife, Smita, challenged this at the Ahmedabad Consumer Dispute Resolution Commission with the Consumer Education and Research Center.
On September 30, the consumer court granted her request and found that there was no evidence that her husband was addicted to tobacco, apart from the mention “addiction to tobacco” on the treatment papers.
Likewise, no clarification of the evidence was sought from the doctor who made the same observation. Observations made in the discharge summary or treatment documents alone cannot be considered conclusive evidence.
Independent evidence must be presented to substantiate the claim, he said. “The complainant’s husband had lung cancer, but there is no evidence to establish that it was due to his addiction to tobacco. The insurer presented a report from a doctor who says smokers are 25 times more likely to have lung cancer, but that alone does not prove that he has lung cancer from smoking Said the ordinance adopted by commission chairman KS Patel and member KP Mehta.
“People who don’t smoke also have lung cancer, and not everyone who smokes has lung cancer. Therefore, the Commission is of the opinion that the insurance company falsely rejected the claim without providing any conclusive evidence to support it, “It said.
The court ordered the insurance company to pay Rs 93,297 as a claim with 7% interest from the date of the claim on August 2, 2016. In addition, the insurer will pay Rs 3,000 for torture mental and Rs 2,000 for the cost of the dispute within 30 days. , It said.
The policy was valid between May 2014 and 2015, and the complainant’s husband was treated on July 29, 2014 and incurred a cost of Rs 93,297 in addition to the treatment he claimed from the insurer. The insurer rejected the claim and stated in its letter of repudiation that the complainant was not qualified for the claim under the terms and conditions of the policy because he was addicted to tobacco.
This is based on hospital papers that mention “tobacco addiction,” he said. The complainant was an avid smoker, suffered from lung cancer and had been treated in various hospitals. He got cancer from his smoking habit, as smoking and lung cancer are directly related, the insurance company said in its response to the court.
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