- (1.) THE complaint relates to a mediclaim. The mediclaim was for a period from 30.3.1995 to 29.3.1996. The complainant claimed a sum of Rs. 28,362/ - towards the treatment cost met by him for his wife who was treated at Apollo Hospital for Gall Stones Disease. She was admitted in the hospital on 21.1.1996 and was discharged on 24.1.1996. Their main contention is that it was a pre -existing disease and, therefore, the exclusion clause would apply. According to the opposite party, the complainant s wife had history of illness for two years duration and she was having progressive pain for over two years and she was admitted as an inpatient with a known case of Symptomatic cholelithiasis . Therefore, on the basis of exclusive clause, the claim was repudiated.
(2.) EX . B2 is the xerox copy of the discharge summary. The diagnosis shows that it was a Gall Stone Disease. The operation done was Laparoscopic Cholecystectomy . It is noted that the patient had a history of abdominal pain especially in the right upper quadrant 2 years duration, colicky in nature, sometimes associated with fever and rigors. They have also mentioned it that she was a known case of Symptomatic cholelithiasis .
(3.) NOW , the point for consideration is whether it was a pre -existing disease? The discharge summary if at all shows that the patient complained of fever. Her bowel, bladder habits were normal. No history of loss of appetite. No history of loss of weight. She was not diabetic or hypertensive. She did not have any irregular menstruation periods. The discharge summary further shows that the patient had no history of vomiting and she did not have any history of jaundice. There was no history of breathlessness, cough with expectoration and the pain not associated with any particular dietary habits. Therefore, we have no materials to say or conclude that it was a pre -existing disease. The opposite party has not examined any doctor to suggest or show that the disease she had would have developed only prior to the date of insurance and that it would not have come about suddenly. There is nothing on medical records to suggest that the disease had set in long before and that it came to be noted only later or that the symptoms became patent only later at about the time she was admitted for surgery. Further, there is nothing to show that the complainant or his wife were aware of the same. So, when the opposite party rely upon a discharge summary it is their duty to adduce evidence to show that such disease as Symptomatic cholelitherasis would not have occurred or developed overnight and that the patient must have had the same much prior and the disease must have slowly progressed to such a stage that it became necessary to operate later on. Therefore, from a reading of the discharge summary, a conclusion that it was a pre -existing disease cannot be drawn. Thus the contention of the opposite party that it was a pre -existing disease is not made out. The cover was for a period from 30.3.1995. She was admitted in the hospital on 21.1.1996. Therefore, the repudiation by the opposite party cannot be held to be justified and thus there is deficiency in service. Therefore, we confirm the order passed by the lower Forum and dismiss the appeal with cost of Rs. 250/ -.;