Mediclaim Denied of Smoker Consumer Court

‘Smoker can’t be denied Mediclaim for cancer’

The consumer court said there was no proof that the cancer had been caused by the patient’s smoking habit.

The consumer court here has ordered an insurance company to reimburse the expenditure on medical treatment for lung cancer after the company refused Mediclaim on the grounds that the patient was a chain smoker and contracted cancer due to his smoking.

Also Read- Pardeep kumar v. Religar Health Ins.Co.Ltd – CaseMine

FACTS

The case involved one Alok Kumar Banerjee, 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. He had medical insurance cover But his claim was rejected by the insurer: After Banerjee passed away, his widow Smita sued the insurer in 2016 in the Consumer Dispute Redressal Commission. Ahmedabad (additional) where the insurance company took the defense 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.

Also Read- ‘No Evidence To Prove Smoking Addiction Caused Lung Cancer’: Court Asks Insurer To Pay Claim

The consumer commission did not agree. It 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 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.

Also Read- Non Smokers get cancer Too: Gujarat Court slams Insurer for Rejecting Claim Sans Evidence

LEGAL OPINION

As rightly pointed out by the consumer court, cancer can be caused by many factors and it cannot be provided that the smoking by the deceased caused cancer. Also , while buying an insurance, the deceased revealed that he smoked and the risk was covered under the insurance.

Cancer is caused by various carcinogenic factors, and each person is sensitive to some other type of carcinogen. Just on the basis that people who smoke have higher risk of cancer than the people who don’t smoke does not provide any rationale as it cannot be proved as to what acted as a carcinogen for the deceased. Also, cancer can occur to any person. Therefore just distinguishing on the basis of whether the person smoked or not is not completely valid.

The consumer court has rightly given the judgement.

 Also Read- Rajesh Rana vs Apollo Munich Health Insurnace 

JUDGEMENT

The consumer commission did not agree to the contention put forward by the respondents. It 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 was no evidence in this case to show that the patient got cancer because of smoking.

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.

Also Read- Insurance firms cannot deny mediclaim citing existing illness

Besides ordering the in surer 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.

For case specific advice please contact consumer forum advocates lawyers in Chandigarh Panchkula Mohali Kharar Zirakpur Derabassi .