No connection between drinking and cancer: HC strikes down order denying insurance claim

The petitioner’s health insurance claim was denied as he occasionally consumed alcohol and had hypertension

MUMBAI: The Bombay high court on Friday struck down an insurance ombudsman order, refusing reimbursement of ₹17.77 lakh spent on cancer treatment by an 83-year-old businessman in the city on account of his drinking habit. A single judge bench of justice Sandeep Marne held that there was no material suggesting his cancer was connected to his drinking habit, so the health insurance claim should not have been by the ombudsman.

Mumbai, India - September 03, 2021: Bombay High Court at Fort, in Mumbai, India, on Friday, September 03, 2021. (Photo by Anshuman Poyrekar/Hindustan Times) (Anshuman Poyrekar/HT PHOTO)

“There is absolutely no evidence on record to indicate that petitioner’s occasional consumption of alcohol has contributed to cancer, for which he was required to take medical treatment,” said justice Marne while striking down the ombudsman order. “The insurance ombudsman has not even made an attempt to establish the nexus between petitioner’s occasional consumption of alcohol and the disease suffered by him,” the judge added.

The businessman had taken health insurance coverage for himself and his wife in September 2003 from Royal Sundaram General Insurance Company, which was renewed periodically. In 2020, he ported to Care Health Insurance Ltd and opted for top-up cover of an additional ₹50 lakh by paying a premium of ₹13.27 lakh. After this, Care Health Insurance issued a three-year policy, beginning on September 29, 2021.

In July 2022, while the policy was still valid, the petitioner was diagnosed with a tumour in his abdomen and underwent several tests which revealed he had cancer. After this, he underwent chemo and radiation therapies at Breach Candy Hospital.

On August 18, 2022, he initiated a claim for the expenses, but the insurance company denied it in a fortnight. The businessman then approached the insurance ombudsman, which, on June 10, 2024, upheld the repudiation citing non-disclosure of daily alcohol consumption and material facts i.e. existing ailment of hypertension at the time of taking the policy.

The high court, however, found no substance in the reasons cited by the insurance company and the ombudsman. The judge noted that while the company claimed he marked “no” against the column inquiring about habits like smoking, drinking, etc, on the insurance form, the petitioner had actually left it blank. In any case, the court said, “petitioner’s occasional consumption of alcohol could not have been a ground for repudiation of insurance claim.”

The court observed that the insurance ombudsman had no reason to cite hypertension as valid grounds since the insurance company had not cited the same initially. It said this was possibly pressed by the insurance company after realising that the first ground of occasional alcohol consumption may be insufficient to support its denial of the claim.