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Judgment
Heard learned Counsel for the parties and perused the order dated 28.3.2012 passed by Kerala State Consumer Disputes Redressal Commission, Thiruvananthapuram (hereinafter referred to as "the State Commission") in Appeal No.543/2011, whereby the Appeal preferred by the Petitioner herein has been allowed in part and the order dated 30.10.2010 of the District Consumer Disputes Redressal Forum, Ernakulam (hereinafter referred to as "the District Forum"), whereby the District Forum had passed an order directing the Petitioner herein to pay ₹2,00,000/- to the Complainants with interest @ 9% per annum from the date of Complaint till realization, has been modified. The State Commission has modified the period of interest by observing that if the amount is paid within one month from the date of receipt of copy of the order, no interest is payable. Interest @ 9% is payable only if the amount is not paid within one month from the date of the order.
Learned Counsel for the Petitioner submitted that Mrs.Misiri, wife of the Complainant herein, who had been under the mediclaim policy issued by the Petitioner from 8.1.2004 onwards, had undergone kidney transplant and remained in the hospital from 10.1.2007 to 27.1.2007. The Complainant made a claim of ₹3,52,266/- for reimbursement under the mediclaim policy, as that amount was incurred towards the expenses of Mrs.Misiri. The Petitioner repudiated the claim on the ground that she was suffering from renal failure for the last three years, i.e. on the ground of pre-existing disease and therefore, under Clause 4.1 of the terms and conditions of the Policy, the Petitioner is not liable to pay the said amount. The repudiation was also based on a Discharge Summary issued by Dr. P.H. Mohamed Iqbal on 31.10.2006, wherein it has been mentioned that Mrs.Misiri was diagnosed with renal failure three years back. Learned Counsel for the Petitioner submitted that as Mrs.Misiri was suffering from renal failure since three years, i.e. on or before 31.10.2003 and as the first mediclaim policy was issued on 8.1.2004, the Petitioner Insurance Company is not liable to pay any medical expenses incurred for a pre-existing disease. The submission is wholly misconceived. For ready reference, the relevant portion of the Discharge Summary issued on 31.10.2006, by Dr. P.H. Mohamed Iqbal is reproduced below :
"DR. P.H. MOHAMED IQBAL M.D., D.M. (Neph)
DISCHARGE SUMMARY
Name : Ms.Misiri aged 38 years Sex F Hosp No.886768
DOA : 17.10.2006 DOD : 28.10.2006
Diagnosis
CHRONIC KIDNEY DISEASE - STAGE V - ON HAEMODIALYSIS
(HD INITIATED ON 18.10.2006)
NATIVE KIDNEY DISEASE
RENAL BIOPSY DATED 7.1.2003
HISTOPATHOLOGY SUGGESTIVE OF
MEMBRANOPROLIFERATIVE GLOMERULONEPHRITIS
SYSTEMIC HYPERTENSION
MENOPRHAGIA ON HORMONE THERAPY - ADVISED HYSTERECTOMY
DATE AFTER HYSTERECTOMY
SENSITIVE TO PERINORM (METOCLOPRAMIDE)
History :
Ms.Misiri presented with persistent vomiting of four days duration. She was diagnosed as having renal failure three years back and was on conservative treatment. Recent history of heavy menstrual bleed for which hormone therapy had been initiated.
ON EXAMINATION :
Alert Oriented Puffiness of face
PR - 92-mt BP - 130/80 mm of Hg Chest - clear
Investigations : (Copy of master chart enclosed)
Course in the hospital :
Ms.Misiri was clinically uraemic on arrival to this hospital. Her Urea was 250 mg/dL and creatinine 15.6 mg/dL. This necessitated early haemodialysis. Haemodialysis was initiated on 18.10.2006. Her general condition improved with further sessions of haemodialysis. Ms.Misiri was further evaluated by our department of OB. & Gynaecology. Advised to continue hormone therapy and vaginal hysterectomy at a later date. Further discussion was made with members of the family. The plan is work up for renal transplant at the earliest."
From a perusal of the Discharge Summary, issued by Dr. P.H. Mohamed Iqbal, reproduced above, it appears that there is some error while mentioning History of the patient in the Discharge Summary. The condition of the patient necessitated early haemodialysis which was started on 18.10.2006. thus, it is not a case of the patient having renal failure three years back. It is a common knowledge that a person having renal failure will not survive for three years unless undertakes Dialysis or kidney transplant. It is also mentioned in the Discharge Summary that Mrs.Misiri was on conservative treatment. A person with renal failure cannot survive for three years on conservative treatment, unless the patient is given dialysis or modern treatment. This shows that the Discharge Summary, which has been issued, contains some inadvertent mistake or error. It may be mentioned that no prescription or the treatment chart of Mrs.Misiri for the last three years has been enclosed either by the Petitioner or Dr. P.H. Mohamed Iqbal, while issuing the Discharge Summary. However, from the Discharge Summary given by Dr.A. Abraham on 11.4.2007, it has been mentioned that Mrs.Misiri was having the disease for the last three months and consultation was made on 10.11.2006. Learned Counsel for the Petitioner submitted that Mrs.Misiri had consulted Dr.A. Abraham on 10.11.2006, i.e. she was having disease prior to 10.11.2006 and therefore, repudiation was justified.
We are unable to agree with the contention raised by learned Counsel for the Petitioner for the simple reason that the Renal Disease can occur any time. It is not a case of pre-existing disease. It is also not a case of the Petitioner that Mrs.Misiri was suffering from Diabetes or High B.P. or any other Cardiac problem prior to taking the Mediclaim Policy. That being the position, we are of the considered opinion that the Petitioner was not justified in repudiating the claim made by the Complainant. The District Forum as well as the State Commission had directed payment of part of the amount i.e. ₹2,00,000/- out of the claim of ₹3,52,266/-. Findings recorded by the State Commission are based on appreciation of evidence and material on record, which do not call for any interference in exercise of our Revisional jurisdiction.
No other point was pressed.
Accordingly, the Revision Petition fails and is dismissed, with costs of ₹20,000/-.