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A bench of president Dakeshwar Prasad Shama, and members Nirupma Pradhan and Anil Kumar Agnihotri of the District Consumer Commission, Raipur, also ordered the insurance company to pay Rs 1.50 lakh, Rs 10,000 compensation, and Rs 5,000 costs.

“The opposite parties (insurer) contended that the complainant had been consuming alcohol, chewing tobacco, and smoking for several years. However, they failed to produce any medical evidence to establish that the complainant’s oral ulcers were caused by (it). Accordingly, they failed to prove that the complainant was suffering from cancer before obtaining the insurance policy or that the disease had developed as a consequence of his long-standing habit…,” the commission said on June 22.

The bench referred to the documents produced by the complainant and said it clearly established that, before obtaining the policy, he did not know he was suffering from the said disease.

The order concluded that the insurance company was not justified in rejecting the complainant’s medical reimbursement claim on the ground that he had concealed his medical condition. “Such repudiation amounts to a deficiency in service as well as an unfair trade practice,” it added.

A man purchased a Star Health Family Health Optima Insurance Policy in March 2018 with a sum insured of Rs 3 lakh. In June 2018, after developing an ulcer in his mouth, he was admitted to Mittal Institute of Medical Sciences, Raipur, where he was diagnosed with squamous cell carcinoma (oral cancer) and underwent treatment and surgery, incurring medical expenses of around Rs 1.5 lakh.

Aggrieved by the repudiation, he approached the commission, alleging deficiency in service and seeking reimbursement of medical expenses along with compensation and litigation costs.

It was submitted that upon examination of the medical documents, it was found that the complainant had a habit of consuming alcohol for the last 10–11 years, chewing tobacco for the last 15–20 years, and smoking for the last five to six years. Smoking is the primary cause of cancer of the palate, and under the insurance policy, medical expenses arising from this cause are not covered.

It was further argued that the complainant had been suffering from ulcers for the last year, but he had not submitted the investigation documents related to the same. Before taking the policy, the complainant had symptoms of the disease, which were not disclosed.

The commission refused to agree with the insurer’s rejection of the claim on the grounds of non-disclosure of relevant facts. It noted that the certificate issued by the treating doctor clearly proves that the complainant had approached them for the first time on June 11, 2018, with the problem of mouth ulcers, and he had been suffering from the ulcer for the last 25 days.

Upon examination, it was found that they were cancerous ulcers. This clearly indicates that before June 11, 2018, the complainant did not know he had cancer, the commission held.

The insurer has not submitted any documents on its claim that the complainant had been suffering from the disease for years, it noted and rejected the argument that he had already been suffering from the disease.

The commission directed Star Health to reimburse Rs 1.5 lakh towards medical expenses with 6 per cent annual interest from the date of filing the complaint. It also awarded Rs 10,000 as compensation for mental agony and Rs 5,000 towards litigation costs, payable within 45 days.

This ruling reinforces that insurers cannot reject health insurance claims merely by alleging a pre-existing disease or lifestyle habits without credible medical evidence. It protects policyholders from arbitrary claim repudiation, clarifies that undiscovered illnesses need not be disclosed, and places the burden on insurers to substantiate allegations of concealment before denying coverage.

Consumers facing similar grievances may contact the consumer helpline in their respective states (Chhattisgarh helpline: 1800-233-3663) or dial the National Consumer Helpline at 1915 for assistance.