An insurance company cannot enforce restrictive terms and conditions, such as co-pay clauses, under a group insurance policy if those terms were not explicitly communicated or furnished to the individual insured, as the insurer bears the burden of ensuring policy awareness.

O R D E R

Challenging the impugned award dated 25.02.2026 passed by the

1^st respondent, the petitioner Insurance Company has filed the present writ petition.

2. It is the case of the petitioner that the 2^nd respondent / insured was covered under Star Group Health Insurance Policy for the sum insured of Rs.5,00,000/- vide Policy No.P/121318/01/2025/000019 for the period from 30.04.2024 to 29.04.2025. The proposer of the said policy is Tamil Nadu Government Doctors Association for the benefit of its members to a limit of Rs.5,00,000/- per person. The 2^nd respondent's mother, namely D.Shanthi, aged 71 years old was admitted on 24.12.2024 and discharged on 26.12.2024 for diagnosis of CA right breast, for which the 2^nd respondent claimed a sum of Rs.1,40,755/- towards cashless treatment, but the petitioner had settled Rs.40,378 and 25% is the co-pay contribution. The 2^nd respondent, having not satisfied with the amount settled, made a complaint to the 1^st respondent, who in-turn directed the 2^nd respondent to pay Rs.60,220/- with applicable interest vide impugned order dated 25.02.2026, against which, the present writ petition has been filed.

3. The learned counsel appearing for the petitioner submits that the first respondent ought not to have directed the petitioner to settle the claim made by the second respondent without considering the policy conditions. Further, he submits that the terms of the policy were duly served to the members of the group. Without considering the serving of terms and conditions, the first respondent directed the insurer to pay a sum of Rs.60,220/- with applicable interest as per the IRDAI Guidelines. Therefore, the impugned order is liable to be set aside.

4. Heard the learned counsel appearing for the petitioner. Since no adverse order is going to be passed against the respondents, notice to the respondents is dispensed with.

5. This Court has gone through the impugned award and finds that the Insurance Policy is a group Insurance policy and the terms and conditions of the policy and the exclusions have to be furnished to the insured, whereas, in the present case, the insured did not have the benefit of going through the terms and conditions of the policy and therefore, the contentions of the Insurance Company that the policy condition restricts to 15% and disallowance on the said head which is in dispute, cannot be countenanced. Without furnishing the terms and conditions of the policy, invoking the terms and conditions at the time of processing the claim is not tenable. The Insurance Company cannot claim any immunity on the ground that the insurance policy is a group insurance policy and it is the duty of the insured to be aware of the terms and conditions of the policy. The conclusion arrived at by the first respondent Ombudsman based on the facts and circumstances of the case seems to be justifiable. Therefore, the writ petition cannot be entertained.

6. Accordingly, this Writ Petition stands dismissed. There shall be no order as to costs. Connected miscellaneous petitions are closed.