STATE CONSUMER DISPUTES REDRESSAL COMMISSION, MAHARASHTRA, MUMBAI APPEAL NO. A/22/213 (Arisen out of order dated 29/11/2021 passed in Complaint No.232 of 2017 by District Commission South Mumbai) Care Health Insurance Ltd.

(Formerly “Religare Health Insurance Co. Ltd.)

Having address at:

1. Taj Building, 1^st Floor, 210, Dr.D.N. Road, Fort,. Mumbai – 400 001.

2. Vipul Tech Square, Tower-C, 3^rd floor, Sector-43, Golf Course Road, Gurugram, Haryana – 122 009.

3. 5th Floor, Chawla House, Nehru Palace, New Delhi - 110 019. ....... Appellant(s)

Versus Ms. Malihah Shaikat Faizi, (Claimant & Insured)

Through Mr. Shaukat Zoeb Faizi ………Respondent(s)

(Principal Policy Holder)

R/at: 902, Bridge View (North Wing), 16, Hansraj Lane, Byculla, Mumbai -400 027.

BEFORE:

Mr. M.V. Sharma, Presiding Member Ms. Poonam Maharshi, Member For Appellant : Advocate D. Joshi For Respondent : Respondent Through representative Mr.Shaukat Faizi

JUDGMENT

(Dated 11/09/2024)

Per : Mukesh V. Sharma, Hon’ble Presiding Member (1) This appeal has been filed by Care Health Insurance Ltd. against the order dated 29th November 2021 passed by the District Consumer Disputes Redressal Commission, South Mumbai, in Complaint No. 232 of 2017. The District Commission directed the appellant to revive the insurance policy and compensate the respondent, Ms. Malihah S. Faizi, for medical expenses incurred due to injuries sustained in a road accident. The appellant challenged this order, claiming that the respondent's alleged non- disclosure of epilepsy constituted a material breach of the insurance contract, thereby invalidating the insurance coverage.

(2) Upon a thorough examination of the submissions, documents on record, and the First Information Report (FIR) lodged at N. M. Joshi Marg Police Station on 17th November 2015, the undisputed facts are as follows: On the morning of 17th November 2015, at around 9:30 a.m., the respondent, while walking inside Phoenix Mills, Lower Parel, Mumbai, was suddenly crushed between a tempo and a truck. According to the FIR, the accident was caused solely by the rash and negligent driving of the drivers of the two vehicles, who failed to maintain a safe distance between them. As a result of the accident, the respondent sustained severe injuries, including a right femur compound fracture, requiring immediate hospitalization.

(3) The respondent was rushed to Nair Hospital and subsequently admitted to Global Hospital, where she underwent extensive treatment, including skin grafting for the crush injury. She remained hospitalized from 17th November 2015 to 8th January 2016, incurring a total medical expenditure of Rs. 19,86,439/-. Following her discharge, the respondent filed a claim for Rs. 4,00,000/- (limited to the sum insured) with the appellant for injuries that resulted directly and solely from the accident, arguing that the accident occurred during the validity of the insurance policy period (31/01/2015 to 30/01/2016) and was caused by the third party’s rash and negligent driving, independent of any illness or pre-existing medical condition.

(4) The appellant rejected the claim on the grounds that the respondent allegedly failed to disclose a pre-existing condition of epilepsy, which, according to the appellant, invalidated the insurance coverage. However, during the final arguments, we asked both parties to provide the clinical definition of epilepsy. Both parties referred to Page 156 of the Appeal Memo, which cites the Indian Epilepsy Centre Article and Dr. S. M. Katrak (M.D., DM, FIAN, FRCP (Edin)), where it is stated: " Seizures and convulsions are one and the same and mean a fit. However, if patient gets multiple Unprovoked seizure (fits) at frequent intervals (1-6 months) then that patient is said to suffer from epilepsy and requires anti-epileptic drug therapy." The medical records submitted by the respondent, including reports from neurologists, confirm that the respondent did not meet this criterion. Her medical condition was described as isolat