A.P. Sahi, President
The complainants/ respondent nos. 1 to 4 herein preferred CC/47/2014 before the SCDRC, Madhya Pradesh, alleging deficiency and unfair trade practice on the part of the appellant-Insurance Company on repudiating the claim arising out of a Home Safe Plus - Secure Mind Policy, that was acquired for securing the payment of the loan extended to the insured for purchase of the property in question, in the event of the happening of the insured events as detailed in the policy. The dispute centres around a contest with regard to the nature of the major medical illness of "End Stage Renal Failure" as claimed by the complainants. The Insurance Company has taken a stand that there is no evidence nor is there any material to construe the existence of such a disease, as such the claim was not indemnifiable.
2. In order to appreciate the controversy in correct perspective the letter of repudiation dated 16.10.2012 is extracted herein under:
"16th October 2012
Ref. no. GEN000068022
To, Mr. Ajay Goyal,
Mainawali Gali, Dal Bazar, Lashkar, Gwalior-474001 Mob-9426337290
Dear Sir,
Re: Claim under Policy No: 4065/ICICI-HSP/1999849/00/000 lodged vide Claim No-GEN000068022
This is with respect to the claim under captioned policy. We acknowledge the receipt of claim documents from you. Please accept our heartfelt condolences on the sad demise of Late Mr. Ravindra Goyal.
On examination and verification of the documents submitted it is noted that the insured was diagnosed as a case of Hypertension, Type II DM, Pyrexia with thrombocytopenia with GTCS with AKI (Acute Kidney Injury) with ARDS with metabolic and respiratory acidosis with shock viral complicated malaria which is evident from the Death Summary of Sir Ganga Ram Hospital dated 23rd June 2012 and had expired due to Pyrexia with thrombocytopenia with Septic shock with multi-organ failure with Acute Kidney Injury with ARDS which is evident from the Death Certificate of Sir Ganga Ram Hospital dated 23rd June 2012 and the statement of treating Doctor Dr. Mohan B Goyal of Sir Ganga Ram Hospital. The claim falls outside the purview of policy coverage and there is no evidence of End Stage Renal Failure as defined under the policy.
As per SECTION 1: MAJOR MEDICAL ILLNESS & PROCEDURES: End Stage Renal Failure
"End stage renal disease presented as chronic irreversible failure of both kidneys to function, as a result of which either regular renal dialysis (Haemodialysis or peritoneal dialysis) is instituted, or Renal Transplantation is carried out".
In view of the above reasons stated we regret our inability to pay your claim. However we remain committed to you and assure you the best services at all times. In case of any further clarification, please feel free to write to ihealthcare@icicilombard.com or at the address below, quoting the Claim No-GFN000068022. We will be glad to respond with assistance.
SMC Claims, IL Health Care
ICICI Lombard General Insurance Company Limited,
ICICI BANK Tower, Pot No. 12
Financial District, Nanakramguda.
Gachibowli, Hyderabad-500032.
IN case you have any query, kindly contact us within a period of 8 weks. In case no response is received from your end within 8 weeks, the claim would be considered as closed/ accepted Rejection from our end."
Thanking you,
Yours Sincerely,
Sd/-
Manager
PA Claims "
3. The complaint was filed on the allegations that admittedly there was an Acute Kidney Injury (AKI) diagnosed in the death certificate. The symptoms of kidney failure was treated with dialysis and a report of no urine output established an end stage failure as per the Death summary hence the claim was indemnifiable.
4. The Insurance Company had taken up a plea that there was a malarial infection coupled with other complications as well and therefore the complaint before the State Commission was contested on the ground that the insured did not suffer from any enlisted major illness, whereupon the complaint was allowed holding that the insured had suffered from an End Stage Kidney Failure and there could be no other possible conclusion regarding the symptoms and the disease from which the insured was suffering. The ailment was therefore construed to be a major ailment as defined under the policy and the complaint was allowed.
5. The Insurance Company has come up in appeal urging that the policy does not cover all forms of kidney ailment and it is only the end stage failure of kidney that has been covered under the policy that has been specifically defined under Section 1 of the major medical illness and procedures.
6. Mr. Malhotra, learned counsel for the Insurance Company has invited the attention of the Bench to Clause 2.1 of Section 1 of the policy which is extracted herein under:
"2. Benefits under the policy
2.1 Section 1: MAJOR MEDICAL ILLNESS & PROCEDURES
Insured event: For the purposes of this Section and the determination of the Company's liability under it, the insured Even in relation to the insured shall mean any illness, medical event or surgical procedure as specifically defined below whose signs or symptoms first commence more than 90 days after the commencement of period of insurance and shall only include:
a) First Diagnosis of the below mentioned illnesses more specifically described below:
1. Cancer;
2. End Stage Renal Failure;
3. Multiple Sclerosis; or
b) Undergoing for first time of the following surgical procedures, more specifically described below:
1. Major Organ Transplant;
2. Heart Valve Replacement;
3. Coronary Artery Bypass Graft;
c) Occurrences for the first time of the following medical events more specifically described below:
1. Strokes;
2. Paralysis;
3. Myocardial Infraction;
4. The insured Event under this Section 1 and conditions applicable to the same are more particularly defined below."
7. The end stage renal failure has been further elaborated under the heading kidney failure (end stage renal failure) as follows:
"Kidney Failure (End Stage Renal Failure)
End stage renal disease presented as chronic irreversible failure of both kidneys to function, as a result of which either regular renal dialysis (haemodialysis or peritoneal dialysis) is instituted or renal transplantation is carried out.'"
8. Mr. Malhotra submits that the death summary dated 23.06.2012 issued by the Sir Ganga Ram Hospital, nowhere records the patient having suffered from any end stage renal failure. On the other hand it records that the patient was diagnosed and suspected of acute kidney injury, which does not amount to end stage renal failure. There is no indication in the said death summary that it was an irreversible situation even though dialysis had been done. He has then relied on the death certificate issued by Sir Ganga Ram Hospital categorically recording that the disease or the complication which was the cause of death was acute kidney injury as also the discharge summary indicating the causes of sepsis shock and cardiac arrest.
9. Learned counsel submits that the complainants set up their claim on the ground that it was a case of end stage renal failure that has been mentioned in the claim form. The Insurance Company had made enquiries through questionnaires from the Sir Ganga Ram Hospital as also the hospital where the insured had initially taken treatment namely, Nidan Heart & Maternity Hospital, Gwalior. Mr. Malhotra submits that the queries made and the answers given nowhere establish the diagnosis of any end stage renal failure and to the contrary the clarifications given are to the contrary which evidence has not been rebutted by the complainants. Learned counsel submits that the State Commission has virtually rewritten the terms of the insurance contract which could not have been done and the interpretation with regard to the diagnosis and the nature of ailment is contrary to the weight of evidence on record as stated above. He has urged that the literature on the subject categorically indicates that an acute kidney injury has nowhere been reported in any of the medical reports to be equivalent to a chronic kidney disease of an irreversible nature, resulting in an end stage renal failure. He has also relied on certain decisions cited at the Bar to urge that the terms of an insurance contract are not commercial in nature and therefore the argument of the respondents to apply the rule of contra proferentem is not applicable.
10. He further submits that even otherwise the rule of contra proferentem is meant to be applied where exclusion clauses are invoked and there is any ambiguity in the same. In the instant case it is not a matter of applying any exclusion clause. To the contrary the interpretation is with regard to the diseases as defined for which the claim is admissible where the rule of contra proferentem would not apply as there is no ambiguity. He therefore contends that the claim was rightly repudiated, but the State Commission on an erroneous appreciation of the facts and the terms of the policy has arrived at a wrong conclusion, hence the impugned order deserves to be set aside.
11. Mr. Malhotra has also advanced his submissions in detail stating about the nature of the ailment and the documents on record which he has read out to substantiate his submissions.
12. The appeal has been resisted by the learned counsel for the respondent, Mr. Tushar Mudgil, who had also earlier advance his submissions on 22.09.2025. Learned counsel for the respondent has urged that the policy itself has been couched in a language which deserves to be interpreted in favour of the insured, in as much as, the policy does not define any other form of major kidney failure to be excluded from the definition. The submission is that in the instant case on facts it is more than evident that the patient was put on dialysis as his creatinine had increased and there was a nil urine output recorded. The contention is that the renal failure was therefore clearly diagnosed and with there being no urine output, it was obvious that the kidneys of the insured had stopped functioning which clearly amounts to an acute stage of kidney failure which is an end stage. He therefore submits that even the death summary and the death certificate confirm the fact of the sufferance of an acute kidney problem, which further stands confirmed by the fact that it was within a couple of days that the insured died on 23.06.2012.
13. He further submits that the Insurance Company had been harping upon the kidney being infected on account of malarial infection. This plea of the Insurance Company has been rightly disbelieved by the State Commission, which is in conformity with the death summary dated 23.06.2012 of the Sir Ganga Ram Hospital that categorically records that the test for malaria was negative. He has therefore urged that the reasoning and conclusions drawn by the State Commission as recorded in paragraph 22 to 26 of the impugned order are clearly in accordance with the evidence on record. Explaining the queries raised and the answers given by Sir Ganga ram Hospital and by Nidan Heart & Maternity Hospital, Gwalior he submits that the question of any dialysis being administered to the patient prior to the admission does not arise, in as much as, the dialysis was undertaken on account of the acute stage, the facilities whereof was not available at Gwalior and therefore the patient had to be shifted to a super specialty hospital. He was admitted in Sir Ganga Ram Hospital where he was on dialysis and therefore the queries raised and the answers given by the Sir Ganga Ram Hospital do not in any way support the contention of the Insurance Company.
14. Coming to the queries answered by Nidaan Heart & Maternity Hospital, Gwalior, he submits that the question about the sufferance of chronic kidney disease has been answered as "not known" by the said hospital.
15. On the diagnosis part, it is urged that death summary and the medical records clearly indicate that the patient had not been treated for any kidney problem even though diagnosed, and when he arrived at Sir Ganga Ram Hospital the deranged kidney function test led to the patient being put on dialysis as the creatinine was high and there was no urine output. Thus, the answers to the queries and the interrogatories in any way have not dealt with the nature of the ailment of end stage renal failure.
16. He has relied on the literature published in medical journal titled HHS Public Access, where an article authored by four doctors has been reproduced. He submits with the aid of the same that there is a very close interconnect between an acute kidney injury and a chronic kidney disease and consequently no mistake has been committed by the State Commission in assuming the symptoms to be one of end stage renal failure.
17. On the issue of as to what would be a critical illness as defined under the policy, he has attempted to draw a parallel with the case of Tata AIG General Insurance Company Ltd. Vs. Vinay Sah, Insurance Ombudsman and Anr., 2025 SCC OnLine Bom 3134 to contend that the High Court of Bombay has applied the test of contra proferentem as well as an appropriate principle of interpretation to allow a similar claim.
18. With the aforesaid rival contentions at the bar the core issue that requires determination is as to whether the State Commission was justified in treating symptoms and the diseases to be one of end stage renal failure as defined under the policy or even otherwise where the definition of the same requires to be read so as to include an acute kidney injury within the fold of end stage renal failure.
19. At the outset we may point out that the learned counsel for the respondent no. 5 - ICICI Bank has also appeared online and she submits that there is no lis to be determined between the appellant and the complainants, in as much as, there is no deficiency alleged against the said respondent Bank and even otherwise the loan amount of the Bank has already been satisfied which stands closed way back in the year 2017 itself. The contest therefore has to be determined between the respondents/ complainants and the present appellant.
20. In order to appreciate the interpretation of the phrase "end stage renal failure", symptoms, the diagnosis, the treatment, the hospital papers, the death summary and the death certificate have to be examined inorder to arrive at a conclusion about the nature of the disease as to whether it falls within the definition of Major Medical illness as defined under the policy. The first document is of the treatment as recorded by Nidaan Heart and Maternity Hospital, Gwalior, Madhya Pradesh where the insured patient was first admitted on 19.06.2012. The discharge summary of the said hospital has been filed as Annexure III. We however, find that the typed copy of the entire document has not been correctly reflected that has been filed along with the Photostat copies of the originals. The discharge summary records that late Ravindra Goyal, the deceased insured was about 40 years of age and was admitted on a provisional diagnosis of Hypertension, Diabetic Mellitus II, Thromobytopenia, Hepatorenal dysfunction, UTI septicimia, virus, malais. He was discharged on the next date on 20.06.2012 and referred to a higher center for further management. The record of the said discharge summary indicates the admission with the aforesaid complaints and some pathological investigations that have been recorded therein. The investigations conducted on 20.06.2012 indicate a Liver function test coupled with the evaluation of Urea and Creatinine. The urea level was recorded at 74 and the creatinine level was 2.2.
21. The treatment given has also been recorded indicating that the patient was also vomiting and had fever and the treatment advised on discharge is recorded as follows:
"In view of rising urea/creatinine and falling urine output, the patient is being shifted to higher centers for further management".
The said treatment sheet and the advise on discharge have not been correctly recorded in the typed copy that has been filed.
22. What is significant is that the Hospital at Gwalior does not seem to have any arrangement for the management of the symptoms that had emerged as recorded at the time of discharge and therefore, the patient was shifted to a higher center for further management.
23. It is in the said condition that the patient arrived at Sir Ganga Ram Hospital where he was admitted on 21.06.2012 and ultimately died there on 23.06.2012. The symptoms, diagnosis and then the treatment as recorded in the death summary are reproduced herein under:
DEATH SUMMARY
Patient Name: Ravindra Goyal
Age/Sex: 40 Y/M
Room No.: ICU-16
DOA : 21/6/2012
Reg. No: 1130210
DOD: 23/6/20-12
DIAGNOSIS:
Hypertension
Type 11 DM
Pyrexia with thrombocytopenia with GTCS with AKI with ARDS with metabolic and respiratory acidosis with shock viral? dengue? complicated malaria
SUMMARY:
Patient presented with history of high grade fever associated with chills and rigors with vertigo and weakness since last 4 days. He was admitted in nearby hospital, on work up he was found to have thrombocytopenia, deranged LFT. He developed altered sensorium since last 1 day. He was referred to SGRH for further management. In casualty he was intubated for shortness of breath and put on mechanical ventilator and was shifted to ICU. Inotropic support was started 4 PRP and 2 FFP were transfused. On investigation he was found to have low platelet, deranged LFTs, deranged KFT, metabolic and respiratory acidosis. On chest x-ray there was bilateral homogenous opacities. On USG abdomen grade II fatty liver with hepatosplenomegaly noted. Patient was started on IV antibiotics, IV anti-fungal, IV anti-malarial, TV albumin and other supportive and symptomatic management. Attendants was explained about poor prognosis. Nephro reference was taken from Dr. A.K. Bhalla in view of nil urine output, deranged KFT and adviced followed. Patient developed GTCS, anti-epileptic started. Medicine reference was taken from Dr. P.S. Gupta and advice followed. HBsAg, IICV, HIV, malaria, leptospira were negative. Dialysis was done for increasing creatinine and nil urine output. Chest reference was taken from Dr. Arup Basu and advised followed. Patient developed sudden cardiac arrest, CPR, was done according to standard ACLS guideline. In spite of maximum efforts patient could not be revived and he was declared to dead on 23/06/12 at 2 am.
Resident Doctor
24. A perusal of the said death summary would demonstrate that he had been referred to and admitted in another hospital and on investigation he was diagnosed to have a deranged KFT apart from other symptoms that have been recorded in the death summary affecting the liver, kidney and other organs. What is significant is that a Nephro Specialists Dr A K Bhalla was consulted and the advise given by him in respect of the deranged KFT was followed. Accordingly, dialysis was done to check the increasing trend in creatinine, recording NIL urine output. The summary however, records that the patient was found to be malaria negative.
25. This is followed by the death certificate which gives the immediate cause of death as septic shock with multi organ failure. However, while mentioning the status of the disease/ complication which caused the death, the same mentions, "Acute Kidney Injury". The complainant's counsel has emphasized that this clearly amounts to an end stage renal failure and has attempted to explain that acute kidney injury and a chronic kidney disease are inter connected syndromes which he attempted to substantiate with the medical literature referred to by him as indicated above.
26. The insurance coverage as defined under the policy for a major medical illness includes an end stage renal failure. This has been specifically defined to be a chronic irreversible failure of both kidneys becoming dysfunctional as result of which either regular renal dialysis is instituted or renal transplant is carried out. Learned counsel for the complainant has attempted to urge that the symptoms of the insured are clearly covered under the said definition as he had been put on dialysis and there was a NIL urine output which has been rightly inferred and interpreted by the State Commission as an end stage renal failure. He submits that the reference of acute kidney injury in the death certificate read with the death summary dated 23.06.2012 establish that the dialysis had to be resorted to as the kidneys had failed to function that stood confirmed with a NIL urine output.
27. Learned counsel for the complainant emphasized on the opening clause of 2.1 quoted above to urge that the illness/ medical event of renal failure with diagnosed symptoms and signs of existence had commenced and therefore, the major medical illness of renal failure at its end stage clearly existed as per the death summary of Sir Ganga Ram Hospital.
28. This contention of the learned counsel for the complainant has been vehemently refuted by Mr Malhotra, learned counsel for the appellant by urging that Acute kidney injury and Chronic kidney disease of end stage renal failure are not synonymous. He submits that Acute kidney injury is a syndrome which can occur independent of any Chronic kidney disease and is treatable as well as reversible. This is also not a major medical illness of a kidney that is covered under the policy. He contends that the only nature of major medical kidney disease covered under the policy is that of kidney failure clearly defined as an "end stage renal failure" that does not and cannot by any definition include Acute Kidney injury (AKI). The attempt of the learned counsel for the complainant to equate the two is erroneous and would amount to redefining the definition of end stage renal failure as contained in the policy, contrary to its content and intent. He submits that unless the disease reaches the stage of irreversible failure of both the kidneys followed by regular dialysis or requires a complete renal transplant and is carried out, the same is not indemnifiable as a claim under the head of major medical illness. He has urged that the death summary records that the patient was received with a deranged kidney function test and, therefore, he was put on a dialysis to control creatinine as there was a NIL urine output. This symptom by itself has no evidence of end stage renal failure to confirm that both the kidneys had completely failed and were in an irreversible position. He further submits that there is no evidence of the insured being on dialysis, much less regular dialysis prior to the date of his admission on 21.06.2012. There was no history of any such treatment to construe that there was any progressive failure of kidneys in the past. Thus the definition of end stage renal disease pre-supposes the existence of a renal disease which by itself per se is not a covered risk unless there is evidence of end stage failure where both the kidneys stop functioning and the patient is on regular dialysis. He therefore contends that the attempt of the learned counsel to equate the symptoms of acute kidney injury as a chronic irreversible kidney failure is in correct, even if there is some inter connection between an injury and a chronic disease.
29. Having considered the said submissions and having read the literature relied upon above by the learned counsel for the complainant we find that an acute kidney injury can take place even without a chronic kidney disease and can occur even after a patient acquires a chronic disease. Thus an acute kidney injury can progress to result in a chronic kidney disease but by itself it is not an "end stage renal failure", as according to the article relied on, such an injury can be treated even if it is a risk factor.
30. The diagnosis of Acute kidney injury has not been challenged to be incorrect by the complainants and the attempt is to equate it as a synonymous symptom of "end stage renal failure". We cannot subscribe to the said contention of the learned counsel for the complainant in as much as the definition of end stage renal failure includes specific symptoms, and it is only that risk which is covered under the policy. The symptom is clearly designated as "chronic irreversible failure of both kidney function". The acute kidney injury has not been diagnosed to be a chronic irreversible failure of both the kidneys nor is there any history of a previous continuous dialysis administered to the insured on regular basis. The dialysis was introduced for the first time only when the insured was admitted in Sir Ganga Ram Hospital. There is no evidence on record to indicate any prior regular dialysis having been carried out.
31. The definition under clause 2.1 recites that the major medical illness "shall mean", any illness of medical event or surgical procedure "as specifically defined below". This definition which is caged and hedged with the aforesaid phrases does not admit of any other possible meaning to be assigned or given to the major illness of end stage renal failure.
32. Having said that the argument of the learned counsel for the complainant is also to effect that the insurance policy could have excluded renal diseases or types of failures and therefore, the policy is one sided. This argument cannot be accepted for the simple reason that by virtue of the language utilised to define a major medical illness as reasoned out above, the definition clause cannot be presumed to permit the inclusion of any other definition which may not have been mentioned as an exclusion. The argument of Mr Malhotra, learned counsel for the appellant is correct that where the policy in no less than uncertain terms categorically defines a major medical illness and in a particular way and form, it is not open for the tribunal to redefine and include an ailment which may be related to any other form of kidney disease or injury.
33. We find that even though the signs and first symptoms as well as diagnosis of the commencement of the dysfunctioning has been noted in the death summary after admission on 21.06.2012, but when it comes to the confirmation of the said diagnosis so as to construe any irreversible failures of both the kidneys preceded by regular dialysis, the same is not established and to the contrary, the insurance company had raised queries bonafidely from Sir Gang Ram Hospital, specially calling upon the hospital to intimate as to whether the patient was suffering chronic kidney diseases, and as to whether he was ever on dialysis before admission. Question no.8 of the said query has been answered in the "Negative" by the hospital. The patient was recorded to have been suffering from hypertension and diabetics mellitus II for long but again in question no.10, as to whether any advice was given for renal transplant before or during admission, the answer given is "No". Against question no.12 as to on what basis was the kidney injury diagnosed, the answer given is Sepsis (infection). While giving answer to question no.13 about the cause of death, the primary cause has been indicated as a combination of several symptoms including Acute kidney injury and the secondary cause of death was also mentioned as Hypertension and Diabetes mellitus. While answering question no.15 regarding the primary cause of death including AKI, its duration has been indicated as 4-5 days. As against question no.18 as to whether the insured died of any MI or Chronic Kidney disease, the answer is in the "negative". This enquiry and answer by the insurance company from Sir Ganga Ram Hospital has been filed as Annexure 6 and we find no rebuttal of the said document by the complainants.
34. Not only this the insurance company also made a query from the first Hospital Nidaan Heart and Maternity Hospital, Gwalior enquiring as to whether the complainant was suffering from any chronic kidney disease. The question no.6 was answered by the said hospital as 'not known', but the patient was being treated for hypertension and diabetes. While answering the cause as septicaemia, the said hospital stated that it was malais and UTI. While answering question no. 18 regarding the diagnosis of chronic disease, the answer clearly was in the "negative".
35. We may also mention from the pathological reports that have been recorded in the treatment chart of the hospital at Gwalior that creatinine level of the insured patient has been indicated as 2.2. This by itself may not be a symptom of end stage renal failure.
36. The discussion that has been made by us herein above regarding the nature of the ailment, symptoms and the diagnosis have not been appreciated or analysed by the State Commission in the manner it ought to have been done. Instead the State Commission has inferred that since the patient had been put on dialysis and there was NIL urine output, the same was construed to be an end stage renal failure. As noted in the death summary, the cause of death is recorded as Septic shock with Multi-organ failure with an Acute kidney injury.
37. Learned counsel for the complainant may be correct in his submission that there was no malarial infection as the pathological test of malaria at Sir Gang Ram Hospital has been recorded as 'Negative', but at the same time other infections might have caused the septic shock that has also been indicated as a symptom in the hospital at Gwalior.
38. In view of what has been reasoned out above and the findings recorded, it is not a case covered under the category of Chronic end stage kidney failure and to that effect the findings of the State Commission cannot be sustained.
39. We now come to the findings of the State Commission recorded in paragraph 23 where multiple cirrhosis and myocardial infraction have also been held to have contributed towards the death of the patient and which according to the State Commission are covered under the policy. The death summary nowhere records the existence of multiple cirrhosis nor does it record a myocardial infraction as a symptom or diagnosis to the contrary the patient developed a sudden cardiac arrest on account of multiple complications indicated therein due to septic shock and multi-organ failure. We do not find the findings of the State Commission to be supported by medical documents on record. In view of the aforesaid reasons, the impugned order of the State Commission is unsustainable.
40. Learned counsel for the complainant made an attempt to invoke the rule of contra proferentem on the strength of the observation made by the Bombay High Court in the case of TATA AIG General Insurance Co. Ltd., vs Vinay Sah - 2025 SCC Online Bombay 3134. That was a case that took place during the COVID period where the patient suffered sudden cardiac arrest. In that case, a medical opinion was obtained and expert evidence was adduced when the claim was examined by the Insurance Ombudsman. The Ombudsman allowed the claim that was challenged before the Mumbai High Court by the insurance company. The Mumbai High Court made observations in paragraph 23 onwards and the High Court on the facts of that case went to the extent of applying the principles of contra proferentem, as there was some evidence to indicate that the insured had suffered from cardiac arrest which was one of the critical illnesses covered under the policy in question. The High Court made a reference to the same, but while proceeding to uphold the order of the Ombudsman dwelt into the peculiar facts of that case taking into account the peculiar circumstances of the family where three male members of the family had passed away and further went on to hold that under Article 227 of the Constitution of India it was not necessary to interfere with the order passed by the Ombudsman once a possible conclusion can be arrived in an appropriate case. The aforesaid case turns on its own on the peculiar facts and was a case regarding cardiac arrest.
41. In the present case the only ground for the claim as per the claim form which has been brought on record is on the basis of "end stage renal failure". The claim was not on any other ground or multiple cirrhosis or myocardial infraction. When the claim itself was only on the basis of end stage renal failure, we do not see any reason for the State Commission to have entered into to examine the existence of other alleged diseases which are not even borne out from the medical documents. The judgment and the ratio relied upon by the learned counsel for the respondent / complainant is inapplicable on the facts of the present case as there is no ambiguity either in the terms specified in the policy nor is there any other possible interpretation. The definition is exhaustive and therefore, cannot be permitted to be read of being inclusive of any other symptom or disease as contended by the learned counsel for the complainant.
42. The appeal is therefore, allowed and the impugned order of the State Commission dated 11.04.2022 is set aside. We find that the execution proceedings had been stayed by this Court vide interim order dated 01.02.2023. The appeal having been allowed, the statutory pre-deposit, if any, made by the appellant towards the satisfaction of the order of the District Forum shall be refunded to the appellant together with any interest accrued thereon.
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