Ahmedabad: A shopper court docket right here has ordered an insurance coverage firm to reimburse the quantity of expenditure on medical therapy for lung cancer after the insurer refused to pay the claim saying the affected person was addicted to smoking, which caused the illness.
The court docket mentioned there was no evidence to prove that the affected person suffered from lung cancer due to his dependancy to smoking, other than the point out of “addiction smoking” on the therapy papers, which, it mentioned, can’t kind the idea for the insurer to reject his claim. It additionally mentioned that individuals who don’t smoke additionally undergo from lung cancer.
The insurance coverage firm had rejected the claim of Rs 93,297 incurred by policyholder Alok Kumar Banerjee on the therapy of his “adenocarcinoma of lung” or lung cancer, at a non-public hospital, on the bottom that he was addicted to smoking as talked about on his therapy papers.
Banerjee’s spouse, Smita, challenged this within the Ahmedabad Consumer Dispute Redressal Commission along with Consumer Education and Research Centre.
On September 30, the buyer court docket allowed her petition and noticed that there isn’t any evidence to prove that her husband was addicted to smoking, other than the point out of “addiction smoking” on the therapy papers. Neither was any clarification of evidence sought from the physician who made the identical remark. Observations made in discharge abstract or therapy papers alone can’t be counted as conclusive proof. Independent proof is required to be introduced to assist the claim, it mentioned.
“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,” mentioned the order handed by fee’s president Ok S Patel and member Ok 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 mentioned.
The court docket ordered the insurance coverage firm to pay Rs 93,297 as claim with 7 per cent curiosity from the date of utility on August 2, 2016. Further, the insurer will pay Rs 3,000 for psychological torture and Rs 2,000 in direction of price of litigation inside 30 days, it mentioned.
The coverage was legitimate between May 2014 and 2015, and the complainant’s husband was handled on July 29, 2014, and incurred a value of Rs 93,297 over therapy which he claimed kind the insurer.
The insurer rejected the claim and mentioned in its repudiation letter that the complainant is just not certified for the claim as per the coverage phrases and situations, as he was addicted to smoking. This is predicated on the hospital papers which mentions “addiction smoking,” it mentioned.
The complainant was a sequence smoker and was affected by lung cancer and had sought therapy in several hospitals. He acquired cancer due to his smoking behavior, as smoking and lung cancer are immediately associated, the insurance coverage firm mentioned in its reply to the court docket.