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2. Brief facts of the case are that the complainant/respondent Baby Simran Kaur daughter of Nirmal Jeet Singh, was a minor and she filed the complaint in question through her father for reimbursement of the expenses incurred on her treatment availed against medi-claim policy, obtained in her favour and other members of the family for the period from 16.06.99 to 15.07.2000. Baby Simran Kaur was admitted in the hospital on 10.09.99 for operation of Lumber Spine. A total sum of `1,46,520/- was spent on the treatment, alongwith other expenses and a claim was lodged for reimbursement with the OP Insurance Company. However, the claim was repudiated by the OP on the ground that the claimant had a pre-existing congenital disease, which was not disclosed, while taking the policy in question. The claim of the complainant is based on the opinion of Dr. Rajendra Prasad, Surgeon, Apollo Hospital who stated that the disease for which the appellant was operated upon, was not congenital. The Insurance Company renewed the mediclaim policy for the next year, without settling her claim. The complainant / respondent filed the consumer complaint in question before the District Forum, requesting for a sum of `1,46,350/- to be paid for treatment/medicines/operation, `20,000/- for sundry expenses and `50,000/- as compensation for harassment, alongwith interest. The OP took the stand before the District Forum that the complainant was guilty of withholding material information, as she had been already suffering from a congenital disease. The claim received from the complainant was referred to the panel doctor, Dr. Prem Nath, who stated that the patient was first seen on 28.08.90 in Apollo Hospital for enuresis urgency and was having dribbling inconvenience since birth with fever and swelling of lower back. The claim was repudiated on the basis of affidavit filed by Dr. Pran Nath. The District Forum dismissed the complaint in question, saying that the claim had been rightly repudiated by the OP as the complainant was suffering from that disease since birth. An appeal was filed against the order of the District Forum before the State Commission, which was allowed vide impugned order dated 09.08.2007 and it was directed that payment of `1,46,520/- should be made to the complainant alongwith `5,000/- as compensation for mental harassment and cost of litigation. It was observed by the State Commission that as per the opinion of experts of Apollo hospital, the complainant was not suffering from a congenital disease, but even if it was so, there was no question of concealment made by the policy-holder. It is against this order that the present petition has been made.

6. The learned counsel then referred to the report made by their own panel doctor, Dr. Pran Nath in which, it has been stated that the patient was having symptoms of illness since birth and hence, the claim in question was not payable. In reply to the query that the policy in question was taken in July 1999, whereas the hospital record pertained to August / September 1999, the learned counsel replied that since it was a case of congenital disease, the same should have been disclosed before taking the policy. The District Forum had rightly dismissed the complaint based on the documents produced before them. However, the State Commission had erroneously observed that it was not a case of congenital disease.

If these diseases are pre-existing at the time of proposal they will not be covered even during subsequent period of renewal too.

9. We have examined the entire material on record and given a thoughtful consideration to the arguments advanced before us.

10. The exclusion clause 4.3 of the Insurance Policy as reproduced above, based on which the District Forum dismissed the consumer complaint, mentions about, Congenital Internal disease. As per the report made by Dr. Pran Nath, the panel Doctor of the Insurance Company, It is not only a case of internal congenital but external also as well as pre-existing in nature; considering this the claim is not admissible. The discharge summary made by the Apollo Hospital says that the patient had incontinence of urine due to neurogenic bladder. The MRI showed lipomyelomeningocele with tethering of cord. In the treatment done in this hospital, operation was done for untethering of cord. From the documents concerning the treatment of the complainant in the Apollo hospital, it is made out that the complainant had a congenital problem. It is, however, to be determined whether this problem could be described as congenital internal disease or it is an external disease.

Children with LMM may develop progressive neurological deterioration characterized by varying degrees of lower extremity paralysis, decreased sensation and neurogenic bowel and bladder.

12. The research paper quoted above shows that children suffering from LMM suffer from protrusion of a fatty mass in posterior region, but the issue is whether it can be stated that this type of condition is an internal disease. The report given by Dr. Pran Nath, the panel Doctor of the Company says that there was external swelling in sacral region since birth. However, he concludes that it is a case of internal congenital and external also, as well as pre-existing in nature. It appears that the report of the panel Doctor is confusing on the issue of internal versus external. It may be stated here that if a person is suffering from something like a defect in the heart-valve since birth, abberant pancreas, ectopic pancreas or any other ailment in the internal organs of the body, it could be termed as an internal congenital disease. In the present case, reference to the medical literature quoted above indicates that the condition may be more befitting to be called a congenital external disease. The exclusion clause in the insurance policy is not attracted, therefore, in the present case.