The Punjab and Haryana High Court has affirmed that persistent symptoms such as pain and swelling, without a confirmed medical diagnosis, cannot be treated as a pre-existing disease under a health insurance policy. This ruling reinforces the principle that liability under insurance contracts hinges on clinical diagnosis, not subjective or prolonged discomfort, and sets a critical precedent for claim adjudication in health insurance disputes.
Background & Facts
The Dispute
The petitioner, M/s Star Health Allied Insurance Co Ltd, issued a health insurance policy to respondent Lakshmi Kant Data on 05.09.2023 with a sum assured of Rs. 5,00,000. The policy was a renewal of an earlier policy issued on 05.09.2022. The insured, the petitioner’s wife, was hospitalized from 05.05.2024 to 11.05.2024 and diagnosed with chronic osteomyelitis of the right distal radius shaft. She sought cashless treatment, which was denied by the insurer on grounds of a pre-existing condition. The insured subsequently claimed reimbursement of Rs. 1,02,914, which the insurer rejected.
Key Facts
- The insured had consulted the Post Graduate Institute (PGI), Chandigarh, on 23.03.2024 for right forearm pain and swelling persisting for two years
- The discharge summary from the hospitalization dated 11.05.2024 recorded that the patient developed spontaneous, insidious-onset, gradually progressive pain over the lower forearm about two months prior
- The treating doctor noted that the actual diagnosis of chronic osteomyelitis was established only after the policy commencement
- The insured submitted all prior medical records, diagnostic reports, and consultation details to the insurer
- The insurer rejected the claim solely on the basis of the two-year history of pain and swelling
- The claim amount sought was Rs. 1,02,914; the Ombudsman found Rs. 81,468 admissible after deducting Rs. 21,446 for non-payable items
Procedural History
- 05.05.2024: Hospitalization of insured for chronic osteomyelitis
- 11.05.2024: Discharge summary issued by hospital
- June 2024: Insurer rejected claim citing pre-existing condition
- July 2024: Complaint filed before Insurance Ombudsman, Chandigarh
- 17.02.2026: Insurance Ombudsman issued award partially allowing claim for Rs. 81,468
- 23.03.2026: Writ petition filed before Punjab and Haryana High Court under Articles 226/227 seeking quashing of the award
Relief Sought
The petitioner sought setting aside of the Insurance Ombudsman’s award dated 17.02.2026 and a direction to deny the claim entirely on grounds of pre-existing condition.
The Legal Issue
The central question was whether the presence of prolonged symptoms such as pain and swelling for two years prior to policy issuance constitutes a pre-existing disease under a health insurance policy, or whether a confirmed medical diagnosis is required to trigger the exclusion clause.
Arguments Presented
For the Petitioner
The insurer contended that the insured had been suffering from chronic osteomyelitis for two years prior to policy issuance, as evidenced by the two-year history of pain and swelling disclosed at PGI on 23.03.2024. It argued that the Ombudsman erred in distinguishing between symptoms and diagnosis, and that the policy’s pre-existing condition exclusion was clearly triggered. Reliance was placed on standard policy wordings and industry practice.
For the Respondent
The insured argued that pain and swelling are clinical symptoms, not a medical diagnosis, and that the actual disease - chronic osteomyelitis - was only confirmed after the policy commenced. He emphasized full disclosure of all medical records and acted in good faith. The Ombudsman correctly held that the condition was not pre-existing under the policy terms.
The Court's Analysis
The Court examined the findings of the Insurance Ombudsman and the legal boundaries of writ jurisdiction under Article 226. It emphasized that the High Court does not function as an appellate forum and cannot reappreciate evidence or substitute its own factual conclusions.
"The writ of certiorari can be issued if an error of law is apparent on the face of the record; ... an error of fact, however grave it may appear to be, cannot be corrected by a writ."
The Court noted that the Ombudsman had correctly distinguished between symptoms and diagnosis. The fact that the insured reported pain and swelling for two years did not equate to a pre-existing disease, as no clinical diagnosis of osteomyelitis had been established prior to the policy date. The diagnosis was confirmed only during hospitalization in May 2024, after the policy was in force.
The Court further held that the Ombudsman’s conclusion - that the insured acted with transparency and good faith by disclosing all prior consultations - was supported by the record. The insurer’s rejection was based on an erroneous conflation of symptoms with disease, which the Ombudsman rightly rejected.
The Court also reaffirmed that the jurisdiction under Article 226 is supervisory, not appellate. Absent any illegality, procedural impropriety, or error of law apparent on the face of the record, the Court cannot interfere with factual findings of a specialized tribunal like the Insurance Ombudsman.
The Verdict
The petition was dismissed. The High Court upheld the Insurance Ombudsman’s award dated 17.02.2026, directing the petitioner to pay Rs. 81,468 to the insured. No further directions were issued, and all pending applications were disposed of.
What This Means For Similar Cases
Symptoms Alone Do Not Trigger Pre-Existing Condition Exclusions
- Practitioners must now argue that insurers cannot deny claims based solely on patient-reported symptoms without a prior clinical diagnosis
- Policy wordings must be interpreted in light of medical reality: pain, swelling, or discomfort are not synonymous with disease
- Insurers must obtain and evaluate diagnostic reports, not rely on patient history alone to invoke exclusions
Full Disclosure Shields Insured from Bad Faith Allegations
- Submission of all prior medical records, even if incomplete, demonstrates good faith and negates allegations of concealment
- Insurers cannot later claim non-disclosure if all documents were provided at the time of claim
- This precedent strengthens the position of insureds in disputes over policy exclusions
Ombudsman Findings Are Presumed Valid Unless Legally Flawed
- Writ petitions against Insurance Ombudsman awards face a high threshold: only errors of law apparent on the record are reviewable
- Courts will not reweigh evidence or second-guess factual conclusions on symptoms, diagnosis, or causation
- Practitioners should focus appeals on procedural irregularities or misinterpretation of policy terms, not factual disputes
