Bombay High Court
STAR HEALTH AND ALLIED INSURANCE CO.LTD.versusOFFICE OF INSURANCE OMBUDSMAN , MUMBAI
- Decided
- Disposal
- Disposed Off
Holding
The High Court held that there is no legal infirmity in the Ombudsman's award and it stands unaltered.
Summary
The petitioner, Star Health and Allied Insurance Co., appealed against an award by the Insurance Ombudsman directing it to pay Rs.80,000 to the insured who had claimed Rs.1,46,057 for a laparoscopic cholecystectomy performed at an excluded hospital. The insurer had repudiated the claim on the ground of the exclusion clause, but the Ombudsman partially allowed the complaint, citing the emergency nature of the treatment, the policy’s three‑year operation, and the claimant’s first claim. The petitioner argued that the Ombudsman could not override the contractual exclusion. The High Court, exercising its supervisory jurisdiction, found no legal infirmity in the Ombudsman's award, noting the genuine emergency justification and the reasonableness of the quantum awarded. Consequently, the court dismissed the writ petition, leaving the Ombudsman's award intact.
Issues considered
- Can the Insurance Ombudsman direct an insurer to pay a claim when the treatment was obtained from an excluded hospital under the policy terms?
- Does the emergency nature of treatment justify overriding the exclusion clause in a health insurance policy?
- Should the High Court interfere with the Ombudsman's award under its supervisory jurisdiction?
Subjects
- Health Insurance
- Insurance Ombudsman
- Excluded Hospital
- Emergency Treatment
- Contractual Exclusion
- Supervisory Jurisdiction
- Claim Settlement
Judgment
2026:BHC-AS:35139
9 wp 4885 of 2026.doc
IN THE HIGH COURT OF JUDICATURE AT BOMBAY
CIVIL APPELLATE JURISDICTION
WRIT PETITION NO.4885 OF 2026
Star Health and Allied Insurance Co. Ltd. ... Petitioner
versus
Office of Insurance Ombudsman and Anr. … Respondents
Ms. Jagruti Vemula i/by Mr. Rahul Karnik, for Petitioner.
CORAM: N.J.JAMADAR, J.
DATE : 17 AUGUST 2026
P.C.
1. Heard the learned Counsel for the Petitioner.
2. The challenge in this Petition is to an award dated 11 December 2025
passed by the Insurance Ombudsman (R1), thereby directing the Petitioner –
Insurer to pay an amount of Rs.80,000/- to the Respondent No.2 –
insured/complainant, towards the full and final settlement of the claim.
3. Respondent No.2 was covered by the Petitioner – Insurer for a Star
Comprehensive Policy for the period commencing from 11 August 2024 to 10
August 2025, for sum of Rs.10 Lakhs. The inception of the policy was from 11
August 2021.
4. On 6 October 2024, Respondent No.2 was admitted in Goel’s Krishna
Nursing Home for unbearable abdomen pain. Respondent No.2 was
diagnosed with Acute Calculous Cholecystitis. Respondent No.2 underwent
laparoscopic cholecystectomy. Respondent No.2 submitted a claim of
SSP 1/3
9 wp 4885 of 2026.doc
Rs.1,46,057/-. The Petitioner repudiated the claim on the ground that the
Respondent No.2 was admitted and treated in an excluded hospital / service
provider.
5. Being aggrieved, the Respondent No.2 lodged a complaint with the
Insurance Ombudsman. By the impugned order, the Ombudsman (R1) was
persuaded to partly allow the complaint and direct the Petitioner to pay an
amount of Rs.80,000/- towards the full and final settlement of his claim.
6. Ms. Vemula, learned Counsel for the Petitioner, submitted that, the fact
that the Respondent No.2 availed treatment at an excluded hospital / service
provider was incontrovertible. Yet, the Ombudsman (R1) directed the Insurer
to satisfy the claim, albeit truncated one. As the treatment was availed in an
excluded hospital, the Ombudsman (R1) could not have passed an award in
teeth of the contractual rights and obligations of the parties.
7. Indeed, the Ombudsman (R1) has noted that the Respondent No.2 had
underwent a surgery in an excluded hospital. Yet, in view of the fact that the
Respondent No.2 suffered an unbearable pain on Sunday, the policy was in
operation for more than three years, the claim in question was Respondent
No.2’s first claim and there was no dispute about the treatment actually
availed by Respondent No.2 in the said hospital, the Ombudsman (R1) was
persuaded to allow the complaint in part and direct the Petitioner to pay an
amount of Rs.80,000/- towards the full and final settlement of the claim of the
SSP 2/3
9 wp 4885 of 2026.doc
Respondent No.2.
8. This Court in exercise of its supervisory jurisdiction does not find any
legal infirmity in the impugned award. Incontrovertibly, the inception of the
policy was on 11 August 2021. Respondent No.2 – complainant had
furnished adequate justification for availing the treatment at an excluded
hospital on account of an emergent situation. Thus, having regard to the fact
that the claim of the Respondent No.2 that he had availed treatment at the
said hospital appeared to be genuine, and the quantum of claim allowed by
the Ombudsman (R1), no interference is warranted with the impugned award.
9. The Writ Petition, thus, stands dismissed.
( N.J.JAMADAR, J. )
SSP 3/3
Signed by: S.S.Phadke
Designation: PS To Honourable Judge
Date: 27/08/2026 15:13:24
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