T07 · 21 documents tagged to this reason
“Condition specifically excluded under the policy”
Exclusion fights split into two very different kinds. Where the exclusion requires the insurer to make a medical judgment call — cosmetic vs. necessary, experimental vs. established — it must prove that call, and often can't. Where the exclusion is plain on the policy's face — maternity, obesity, first-year fibroids — fighting the label rarely works; the fight has to be about wording and connectors instead.
How insurers word it
- Condition specifically excluded under clause …
- Cosmetic / aesthetic procedure, not medically necessary
- Excluded as maternity-related expense
- Experimental or unproven treatment
Arguments that have beaten this
C-T07-1
Medical necessity beats a "cosmetic" label
Surgery performed as medically necessary treatment — life-saving, or for a diagnosed disease — is not "cosmetic" just because the insurer's desk reviewer calls it that. The insurer must show the procedure's purpose was genuinely aesthetic.
Source
OA-002: bariatric surgery for metabolic syndrome — no obesity exclusion existed in that policy, and surgery to save life was not excluded; ₹3.6 lakh awarded.
Where this argument fails
The policy carries an explicit exclusion squarely covering the treatment — an obesity-treatment clause, a maternity clause. Where the exclusion is plainly on the policy's face, this argument does not hold; the verdict there is Weak.
C-T07-2
"Experimental" needs proof, not a label
The insurer must prove a treatment is not established medical practice; an in-house doctor's unsupported opinion is not enough — especially where the industry has paid for the same treatment before.
Source
OA-013: the insurer conceded it had no proof and no applicable exclusion clause; ₹1.75 lakh awarded.
Where this argument fails
The treatment is genuinely outside established medical practice, with no supporting literature or precedent.
C-T07-3
Read the exclusion's exact connector word
"Treatment of X" catches only direct treatment of X. "Resulting from" or "traceable to X" reaches complications too. The single word joining the exclusion to your treatment can decide the case both ways — read it before arguing either side.
Source
Blind-eval case Hyderabad G-246: a knee treatment for an obese patient fell outside an obesity-treatment exclusion because the clause said "treatment of" obesity, not treatment of an obese person — allowed, with 9% interest. Contrast Kolkata 474: a heart attack held to "result from" excluded diabetes/hypertension under wider wording — dismissed. Also OA-061 (incisional hernia traceable to a prior surgery).
Where this argument fails
The exclusion's wording plainly reaches your exact treatment or its direct complication, with no narrower connector to argue.
We publish the losing side too. An appeal built on an argument that does not fit your facts wastes the one year you have.
The insurer's doctor called my surgery "cosmetic" but my own doctor says it was necessary. Who wins?
The burden is on the insurer to prove the aesthetic purpose, not on you to disprove it. In one corpus case, bariatric surgery for a genuine metabolic condition was paid in full because the insurer couldn't show it was cosmetic and no obesity exclusion applied. But check your policy wording first — where an obesity or cosmetic exclusion squarely applies, this argument weakens considerably.
My heart attack was rejected as "resulting from" my diabetes, which is excluded. Is that fair?
Check the exact connector word in your exclusion clause. "Resulting from" or "traceable to" a condition is written broadly enough to reach complications, and this kind of rejection has been upheld on that wording. A narrower clause — "treatment of" the excluded condition itself — would not reach a complication in the same way. The word matters more than the label.
Is this the reason on your letter?
Ladai will read your specific letter and policy and tell you which of these arguments actually reaches your facts — and how strong that makes your case.
Get your verdict on this