Link between tobacco and bypass surgery not established, insurer made to pay claim – ET HealthWorld

Ahmedabad: The Gujarat State Consumer Dispute Redressal Commission has ordered an insurance company to pay a medical insurance claim for a patient’s bypass surgery because it could not establish a connection between his medical condition and his habit of smoking and chewing tobacco.

However, the state commission reduced the payout amount by Rs 1 lakh from what was awarded by a district consumer commission because the patient admitted to tobacco addiction. The state commission said that lower forum should have considered the admission to the habit of smoking and chewing tobacco while ordering full reimbursement. This case involved Hitesh Jobanputra from Rajkot, who underwent a bypass surgery in Ahmedabad after suffering cardiac issues in 2020. He paid Rs 3.31 lakh in medical bills and sought reimbursement from the Oriental Insurance Co Ltd, as he had Rs 5 lakh insurance cover. The insurer rejected his claim saying he violated a policy clause as the hospital records reveal that he was in the habit of smoking and chewing tobacco, which would adversely affect the heart condition of a person.

The patient admitted to the habit, as revealed by hospital records, the company said. Jobanputra sued the insurer at the Rajkot District Consumer Dispute Redressal Commission, which ordered the company to pay the full claim with 9 per cent interest. The insurer challenged this before the state commission on the grounds of the patient’s admission to tobacco addiction as revealed in medical papers.

After hearing the case, the state commission’s in-charge president M J Mehta and members P R Shah and A C Raval said the insurer only cited medical papers to state that the patient used to smoke and chew tobacco but, did not provide evidence that this habit had resulted in the patient’s medical condition that led to the bypass surgery. The insurer did not bring any expert opinion on record to establish that smoking and chewing tobacco have any link with the bypass surgery. Hence, the insurer was liable to pay the patient. However, the state commission reduced the payout considering the patient’s admission to tobacco addiction and ordered the insurer to pay Rs 2.30 lakh instead of Rs 3.31 lakh.

  • Published On Jun 11, 2023 at 12:41 PM IST

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