Consumer Commission Rejects Epilepsy Defence: Religare Ordered to Pay ₹80,000 Mediclaim
A Noida District Consumer Disputes Redressal Commission has directed Religare Health Insurance Company Ltd. to pay ₹79,725 towards a mediclaim, along with 6% interest and ₹5,000 towards litigation expenses, after rejecting the insurer’s contention that the claim was invalid because the policyholder’s wife had allegedly failed to disclose a pre-existing condition.
The Commission found that the insurer had failed to establish that epilepsy was a pre-existing condition that had been deliberately concealed when the health insurance policy was purchased. It also questioned the connection between the alleged epilepsy and the medical condition for which the insured woman was actually hospitalised and treated.
What Was the Case About?
The dispute arose from a family health insurance policy purchased by Chandra Mouli Kumar T Sharma, a resident of Greater Noida.
The policy was taken in August 2015 for Sharma, his wife Nisha Sharma, and their two sons. The policy provided a sum insured of ₹5 lakh and was initially valid from September 15, 2015, to September 14, 2016. According to the report, the policy was subsequently renewed annually for three years.
The dispute concerned a medical treatment undertaken by Nisha Sharma in 2017.
On August 28, 2017, she was admitted to Fortis Hospital, Delhi, where she was diagnosed with uterine bleeding and underwent surgery.
The policyholder sought cashless treatment under the health insurance policy. The insurer initially approved the cashless request on October 27, 2017, but subsequently rejected the claim.
The insurer's reason was that Nisha Sharma allegedly had a history of epilepsy dating back to 2006 and that this condition had not been disclosed when the policy was purchased.
What Did the Insurer Argue?
Religare maintained that the claim could be rejected because the insured had allegedly failed to disclose a pre-existing medical condition.
According to the insurer, medical records showed that she had been treated at Sharda Hospital and that an August 28, 2017 OPD record described her as having epilepsy for around 10 years and as a "known epileptic."
The insurer also argued that its earlier approval of cashless treatment was conditional and did not prevent it from subsequently examining the claim and repudiating it on the basis of the policy terms.
The central defence was therefore non-disclosure of a pre-existing disease.
What Was the Policyholder's Defence?
The policyholder disputed the insurer's version.
He stated that his wife had undergone treatment for epilepsy for approximately three years and had fully recovered by 2009.
The health insurance policy, however, was purchased only in 2015, several years after the alleged recovery.
The policyholder therefore argued that the insurer could not treat the old medical history as a deliberately concealed pre-existing condition for the purpose of rejecting a claim arising from an entirely different medical problem.
What Did the Consumer Commission Hold?
The Commission rejected the insurer's defence.
One of the important findings was that the burden was on the insurer to establish that the insured was suffering from epilepsy when the policy was issued and that she had deliberately concealed the condition.
According to the Commission, that burden had not been discharged.
The Commission noted that the epilepsy had reportedly been cured in 2009, whereas the policy was issued in 2015. On that basis, the Commission found that the insurer could not establish concealment at the time the policy was taken.
This distinction is important in health insurance disputes: simply pointing to a medical history does not necessarily establish that a policyholder deliberately concealed a material pre-existing disease when purchasing the policy.
Commission Questions Link Between Epilepsy and Uterine Bleeding
The Commission also focused on the relationship between the alleged pre-existing condition and the treatment for which the claim was made.
Nisha Sharma had been hospitalised for uterine bleeding, for which she underwent surgery.
The Commission observed that Religare had not explained how epilepsy was connected with the uterine bleeding for which she was actually treated. It questioned whether the uterine bleeding could even have been caused by epilepsy.
This became an important factor in rejecting the insurer's justification for repudiating the claim.
The finding does not mean that an insurer can never rely on a pre-existing disease exclusion. Rather, in this case, the Commission found that the insurer had failed to establish the necessary factual basis for applying that defence.
₹79,725 Claim Ordered to Be Paid
After finding the repudiation unjustified, the Noida District Consumer Commission allowed the complaint.
Religare was directed to pay:
₹79,725 towards the mediclaim;
6% interest from the date the consumer complaint was filed in 2018 until final payment; and
₹5,000 towards litigation expenses.
The insurer was directed to make the payment within 30 days.
The case is therefore significant not because of the size of the award, but because of the Commission's approach to an insurer's pre-existing disease and non-disclosure defence.
Similar Approach in Another Religare Case
The Noida decision comes against the backdrop of another 2026 consumer dispute involving Religare Health Insurance.
In Religare Health Insurance Co. Ltd. v. Subhash Chand Gupta, decided by the National Consumer Disputes Redressal Commission on April 9, 2026, the insurer challenged an order requiring payment of a health insurance claim, arguing that the policyholder had failed to disclose COPD and breathlessness.
The NCDRC dismissed the insurer's appeal and upheld the District Commission's decision. The NCDRC emphasised that insurance policies are standard-form contracts and that claims should be honoured where there is no established fraud, concealment or suppression of material facts. It also found that the insurer had applied the relevant exclusion without an adequate factual foundation in that case.
The two decisions arose from different facts and should not be treated as establishing an across-the-board rule against insurers relying on non-disclosure clauses. However, they demonstrate the importance of evidence, materiality and the specific circumstances of each claim.
What Does This Mean for Policyholders?
The case offers several practical lessons for health insurance policyholders.
1. Disclose relevant medical history
When purchasing or renewing a health insurance policy, applicants should provide accurate information about their medical history as required by the proposal form and policy terms.
2. Keep medical records
Old treatment records, discharge summaries, diagnostic reports and prescriptions can become important if an insurer later alleges that a medical condition was concealed.
3. Ask the insurer for the specific reason for repudiation
If a claim is rejected on the ground of pre-existing disease or non-disclosure, the policyholder should examine the precise exclusion or policy clause relied upon by the insurer.
4. Examine whether the alleged condition is actually relevant to the claim
The Noida Commission specifically considered the absence of an established connection between epilepsy and the uterine bleeding for which the insured was treated.
5. Consumer forums can examine wrongful repudiation
Where an insurer rejects a claim without adequately establishing the contractual or factual basis for doing so, a policyholder may have remedies under the applicable consumer protection framework, subject to the facts and maintainability of the case.
The Larger Consumer Protection Issue
Health insurance is intended to provide financial protection when policyholders face unexpected medical expenses. Disputes frequently arise when insurers rely on exclusions relating to pre-existing diseases, non-disclosure or misrepresentation.
The Noida case demonstrates why such disputes often turn on the evidence rather than merely on the existence of a medical condition in a patient's history.
The Commission did not hold that insurers are prohibited from rejecting claims involving pre-existing diseases. Instead, its decision turned on the insurer's failure, in this particular case, to establish that the alleged epilepsy had been deliberately concealed at the time of obtaining the policy and its failure to explain the relevance of epilepsy to the condition actually treated.
Key Takeaway
The Noida District Consumer Commission's decision to direct Religare Health Insurance to pay ₹79,725 with 6% interest highlights an important principle in health insurance disputes: an insurer cannot necessarily reject a claim merely by pointing to an old medical condition and alleging non-disclosure.
In this case, the Commission found that the insurer had not proved deliberate concealment of epilepsy when the policy was issued in 2015, particularly since the policyholder said the condition had been cured in 2009. It also found that the insurer had failed to establish a connection between epilepsy and the uterine bleeding for which the insured was treated.
The decision reinforces the importance of evidence, materiality and a clear connection between an alleged pre-existing disease and the claim being repudiated.
Disclaimer: This article is for general informational purposes only and does not constitute legal advice. Insurance disputes are fact-specific, and the applicability of policy exclusions depends on the terms of the policy, the evidence available and the circumstances of each individual case.
The Author :
Dr. Sunil Khattri
+91 9811618704
Dr Sunil Khattri MBBS, MS(General Surgery), LLB, is a Medical doctor and is a practicing Advocate in the Supreme Court of India and National Consumer Disputes Redressal Commission, New Delhi.
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