Insurance Companies Cannot Refuse Claims Citing Alcohol Consumption Conditions, Rules Consumer Forum

Health insurance companies often promise assistance during challenging times, but many cases reveal that companies resort to excuses to avoid paying claims. One common excuse is the allegation that the insured was addicted to alcohol, cigarettes, or tobacco and had hidden this fact. However, the Bhopal District Consumer Forum has clarified that insurance companies cannot reject claims merely on such grounds without proper verification.

 

In a recent case, Narela resident Jaswinder Choudhary had purchased a health insurance policy from Care Health Insurance, paying a premium of ₹38,191. When he fell ill in March 2023 and experienced difficulty breathing, he was hospitalized. His treatment expenses amounted to ₹2,41,805. However, the insurance company refused to reimburse the treatment costs, alleging he consumed alcohol, cigarettes, and tobacco.

 

Choudhary approached the District Consumer Forum. He argued that he had never consumed such substances and that no disclosure was made to that effect when he bought the policy. A doctor’s report submitted in the case also confirmed that he was not addicted to these substances.

 

After hearing both sides, the Consumer Forum, chaired by Yogesh Dutt Shukla with member Pratibha Pandey, ruled that the company’s excuse was baseless. The Forum held that without credible evidence, such claims cannot be rejected.

Accordingly, the Forum directed the company to pay ₹2,41,805 to the complainant. Additionally, the Forum awarded ₹5,000 as compensation for mental harassment and ₹3,000 toward legal expenses.