A consumer court from Gujarat has directed an insurance company to reimburse the amount of expenditure on medical treatment for lung cancer after the insurer refused to pay the claim saying the patient was addicted to smoking, which caused the disease.
According to a report in ‘The Times of India’, the consumer court said there was no proof that the cancer had been caused by the patient’s smoking habit.
The case involved one Alok Kumar Banerjee from Thaltej, who underwent treatment for adenocarcinoma of the lung from Vedanta Institute of Medical Science in July 2014 and incurred a medical bill of Rs 93,297. Despite having mediclaim, his claim was rejected by the insurer.
After Banerjee passed away, his wife Smita, along with Consumer Education and Research Center had challenged this in the Ahmedabad Consumer Disputes Redressal Commission, where the insurance company took the defence that Banerjee was treated in different hospitals for his illness, which had a direct nexus with his smoking habit, and that this was reflected in his case papers.
During the hearing, the consumer commission said that no evidence has been found that the person was a habitual smoker and he got lung cancer due to it. Although addiction to smoking is written on the treatment documents, it does not prove that the person was addicted to smoking. The insurance company cannot make this as a ground for non-payment of compensation.
The consumer commission also cited a higher forum’s order and said that a discharge summary itself cannot be treated as primary or conclusive evidence in the absence of any independent proof. There court reprimanded the insurance company and said there was was no evidence in this case to show that the patient got cancer because of smoking.
The insurance company’s doctor gave a medical opinion that those who smoke have a 26 times higher risk of getting cancer. To this, the commission said that merely on the basis of this opinion it cannot be concluded that the patient got cancer due to his smoking habit. Those who do not smoke also get lung cancer and it cannot be believed that all those who smoke have lung cancer.
It cannot be accepted that the complainant’s husband got cancer because of his smoking habit and the insurer had wrongly rejected the claim, the commission added. Besides ordering the insurer to refund the medical expense, the commission has asked it to pay Rs 5,000 extra to the complainant towards compensation for mental harassment and legal expenditure.
"The complainant's husband had lung cancer, but there is no proof to ascertain that it was due to his addiction to smoking. The insurer has presented a report from a doctor that says that smokers are 25 times more likely to get lung cancer, but that alone does not prove that he suffered from lung cancer due to smoking," said the order passed by commission's president K S Patel and member K P Mehta.
"People who do not smoke also suffer from lung cancer, and all those who smoke do not necessarily suffer from lung cancer. Therefore, the Commission is of the opinion that the insurance company falsely rejected the claim without providing any conclusive proof in its support," it said.
The court ordered the insurance company to pay Rs 93,297 as claim with 7 per cent interest from the date of application on August 2, 2016. Further, the insurer will pay Rs 3,000 for mental torture and Rs 2,000 towards cost of litigation 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 over treatment which he claimed form the insurer.