IMPORTANT POINT
A genuine mediclaim cannot be repudiated by Insurance Company.

Dr. S.M. Kantikar, Presiding Member—This revision petition has been filed under Section 21(b) of the Consumer Protection Act, 1986 against the order dated11.04.2012 passed in first appeals No. 887 of 2010 & 930 of 2010 by Andhra Pradesh State Consumer Disputes Redressal Commission, Hyderabad (in short, ‘the State Commission’) whereby the State Commission dismissed the appeal No. 887 of 2010 of the petitioner/Mr. P. Hanumantha Rao and allowed F.A. No. 930 of 2010 of the OP/Royal Sundaram Alliance Insurance Co. Ltd.

2. The brief facts relevant for the disposal of the case are that the respondent/complainant in the year 2005 obtained Medisafe Insurance Policy, and it was regularly renewed for the year 2005-06, 2006-07 and 2007-08. The complainant obtained another insurance policy under ‘Hospital Benefit Plus Insurance Scheme’ with effect from 28.02.2008 till 27.02.2009. The complainant was admitted in Asian Gastro Institute of Gastroenteroogy ( in short, ‘Asian Institute’) on 20.05.2008 and he was diagnosed as a Sub Acute Intestinal Obstruction, further he had undergone surgery in the same hospital and was discharged on 02.06.2008. The complainant lodged claim for Rs.1,24,103.50 under 1st policy, (No. HS 00026257000102) and Rs.35,000/- under 2nd policy (No. SL 00004953000100). The OP repudiated the claim on the premise that it was the claim in respect of pre-existing disease and the treatment taken by the complainant in Asian Institute was a complication of pre-existing disease. Being aggrieved by the repudiation, the complainant P.Hanumanth Rao, filed a complaint before District Consumer Disputes Redressal Forum-II, Hyderabad.

3. The OP resisted the claim on the premise that the complainant had history of splenectomy in 1993. In 1996 and 1998, complainant had obstruction and had similar episode of pain and vomiting. That time he was managed conservatively, thus his present suffering was due to pre-existing disease. The claim arising from pre-existing disease is specifically excluded by the terms of the insurance policy.

4. The District Form did not rely upon the medical record because it was only photocopy submitted by the OP. The District Forum allowed the complaint and directed the OPs to pay a sum of Rs.1,35,000/- towards insurance coverage plus hospital benefits. Also awarded Rs, 5,000/- towards mental agony and Rs.10,000/- as costs.

5. Being aggrieved by the order of District Forum, both the parties filed cross appeals before Andhra Pradesh State Consumer Disputes Redressal Commission, Hyderabad ( in short, ‘the State Commission’). The petitioner/ complainant filed an appeal No. 887 of 2010 for enhancement of compensation and the insurance company filed appeal No. 930 of 2010 for dismissal of complaint. The State Commission by a common order allowed the appeal filed by OPs and dismissed the appeal of the complainant. Hence, this revision petition.

6. Heard learned counsel for the parties. There is delay of 68 days in filing this revision petition. For the reason stated in the application, the delay is hereby condoned. Counsel for the petitioner/ complainant submitted that the complainant suffered a disease in 1993 which has no relevance with the present disorder after almost 2 ½ decades, therefore, it was not an pre-existing ailment. Arguments on behalf of the respondent/OP are that the complainant was suffering from pre-existing disease and suppressed the same. The admission and progress notes from Asian Institute of Gastroenterology disclosed the history of similar pain lasting for 24 hours during 1996 and 1998. He underwent splenectomy in the year 1993, therefore, as per exclusionary clause ‘D’ of the terms of the insurance policy, any claim in connection with pre-existing disease is not admissible. On 20.05.2008, the complainant was admitted in Asian Institute of Gastroenterology, he was diagnosed as sub-acute intestinal obstruction and had undergone surgery there. He was hospitalized till 2.6.2008.

7. I have peru