Mediclaim – Exclusion of expenses for surgery for prolapse disc on the ground that it was not related to trauma  but chronic condition

Judgment dated 25.9.2023 of the High Court of Bombay – Star Health and Allied Insurance Co. Ltd Vs. Office of Insurance Ombudsman Mumbai & Goa and others in Writ Petition (L) No.5140 of 2020 with connected matter.

Mediclaim – Exclusion of treatment and spinal injury surgery of disc diseases since it was not related to trauma  but chronic condition – illegal

Respondent no.2, had taken Star Health Comprehensive Insurance Policy (Family Floater) for 2018 to 2019 and his wife respondent no.3 with their son were also covered by the said policy.

In December, 2018, the respondent no.3- wife met with a road accident. On the advise of doctor, she had undergone surgery and was discharged from the hospital on 22.1.2019.

Thereafter, the respondent no.2 lodged the claim for Rs.3,35,000/-.

The claim was rejected on 20.2.2019 on the ground that the surgery for prolapse disc was not covered within first 2 years of the policy and there was no proof of the road accident.

The representation for re-consideration of the claim was also rejected on 20.4.2019 by the Insurer now on another ground that the diagnosis was not trauma related to the road accident but existing chronic condition excluded under clause 3(a) of the Policy.

On the complaint of the respondent no.2, the claim was allowed for Rs.3,13,201/- by the Award dated 30.3.2020 of the Insurance Ombudsman under the Insurance Ombudsman Rules, 2017.

HELD, while dismissing the writ petition of the Insurer, that there is nothing to show that the spinal injury was chronic, it is not the case of the petitioner that she was suffering from chronic condition prior to the policy,