No proof alcohol, smoking caused cancer, patient wins Rs 1.65 lakh insurance claim

5 min readNew DelhiJul 17, 2026 06:00 PM IST

The insurer submitted no proof of its claim that the complainant had been suffering from ulcers for years, the consumer forum noted. (AI-generated image)

Noting that the insurance company failed to prove that the complainant’s oral cancer had developed as a consequence of his long-standing habit of consuming alcohol, chewing tobacco, and smoking, a Chhattisgarh consumer forum held Star Health guilty of deficiency in service for wrongly rejecting a cancer patient’s health insurance claim on the ground of a pre-existing disease.

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.

Insurance purchase, diagnosis

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.

He submitted a reimbursement claim to the insurer, which rejected it on the ground that the disease was pre-existing and that he had suppressed material facts while obtaining the policy. The insurer also alleged that his long history of tobacco, alcohol, and smoking habits attracted the policy exclusions.

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

Insurer blames smoking, alcohol intake

The insurer asserted that the Family Health Optima Insurance Policy was issued to the complainant for a sum insured of Rs 3 lakh, valid from March 24, 2018, to March 23, 2019, subject to terms and conditions. Within the third month of the issuance of the policy, the complainant submitted a claim of Rs 1.33 lakh for the reimbursement of medical expenses.

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.

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Forum rejects insurer’s claims

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.

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Takeaway

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.

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Jagriti Rai works with The Indian Express, where she writes from the vital intersection of law, gender, and society. Working on a dedicated legal desk, she focuses on translating complex legal frameworks into relatable narratives, exploring how the judiciary and legislative shifts empower and shape the consciousness of citizens in their daily lives.

Expertise

Socio-Legal Specialization: Jagriti brings a critical, human-centric perspective to modern social debates. Her work focuses on how legal developments impact gender rights, marginalized communities, and individual liberties.

Diverse Editorial Background: With over 4 years of experience in digital and mainstream media, she has developed a versatile reporting style. Her previous tenures at high-traffic platforms like The Lallantop and Dainik Bhaskar provided her with deep insights into the information needs of a diverse Indian audience.

Academic Foundations:

Post-Graduate in Journalism from the Indian Institute of Mass Communication (IIMC), India’s premier media training institute.

Master of Arts in Ancient History from Banaras Hindu University (BHU), providing her with the historical and cultural context necessary to analyze long-standing social structures and legal evolutions. ... Read More

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