Noida: District consumer disputes redressal commission has directed Delhi-based Religare Health Insurance Company Ltd to settle a nine-year-old mediclaim, ordering it to pay Rs 79,725 with 6% interest from the date of filing the complaint in 2018 till final payment, within 30 days. The insurer must also pay Rs 5,000 in litigation expenses.Disposing of the matter on Sept 10, commission president Anil Kumar Pundir and member Anju Sharma rejected Religare’s contention that the claim was invalid because the policyholder’s wife had an undisclosed pre-existing condition — epilepsy. The bench said the insurer had failed to explain how epilepsy was connected to uterine bleeding, the condition for which she was actually treated, and questioned whether uterine bleeding could even be caused by epilepsy.The case traces to a complaint filed by Greater Noida resident Chandra Mouli Kumar T Sharma against Religare. Sharma had taken a family health policy in Aug 2015, paying Rs 25,783 to cover himself, his wife Nisha Sharma and sons Harsh and Yash, with a Rs 5 lakh cover valid from Sept 15, 2015, to Sept 14, 2016. The policy was renewed annually for three years.On Aug 28, 2017, Nisha was admitted to Fortis Hospital Delhi, diagnosed with uterine bleeding, and underwent surgery. Sharma applied for cashless treatment as guaranteed under the policy. Religare initially approved it on Oct 27, 2017, but later rejected the claim, saying his wife had been suffering from epilepsy since 2006 and that this had not been disclosed at the time of purchase. Sharma countered that she had been treated for epilepsy for about three years and had fully recovered by 2009.Religare, in its written statement, said the Oct 27 approval was conditional. It said medical records showed the insured had been treated at Sharda Hospital’s OPD on Aug 28, 2017, where she was listed as having epilepsy for 10 years, with the discharge summary describing her as a “known epileptic.” On that basis, it maintained it had committed no deficiency in service and that the claim was rightly denied.The commission held that the burden of proof lay with the insurer to show the insured was suffering from epilepsy at the time the policy was issued and had deliberately concealed it. It found that since the epilepsy had been cured in 2009 and the policy was issued only in 2015, concealment could not be established. It further noted that Religare never clarified any link between epilepsy and the uterine bleeding actually treated, and ruled the insurer guilty of deficiency in service, allowing the complaint.
