How to ensure fair grievance redressal for health insurance claims? Know here
1 day, 21 hours ago

How to ensure fair grievance redressal for health insurance claims? Know here

India TV News  

Being denied a health insurance claim due to lack of documentation can be frustrating, but recent guidelines from the Insurance Regulatory and Development Authority of India aim to address the issue. Simplified documentation Insurers must provide a standardised review of documentation requirements at the time the policy is issued. Written explanation of rejections If the claim is denied, insurers must provide a detailed written explanation explaining the reasons. Assistance with mail Insurance companies must help claimants identify missing documents and resolve discrepancies in order to process claims.

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History of this topic

The US’ angst over health insurance: Lessons for India
1 week, 4 days ago

The US’ angst over health insurance: Lessons for India

Live Mint  

The recent murder of the head of a prominent health insurer in the US, allegedly fuelled by resentment toward the industry's practices, has cast a harsh spotlight on claims policies that have left many policyholders dissatisfied. In 2021-22, health insurance surpassed motor insurance to become the largest segment by premiums among Indian non-life insurers. For instance, Star Health, the second-largest …

Insurance ombudsman doesn't allow third party help: A dilemma for policyholders
3 weeks, 1 day ago

Insurance ombudsman doesn't allow third party help: A dilemma for policyholders

Live Mint  

When businessman Mukesh Garg’s two insurance claims were rejected, he represented himself before the insurance ombudsman, a statutory body that helps in out-of-court settlement of insurance cases, but sought help from a third party for the required paperwork. Consumer policy expert Bejon Misra, who was a member of the insurance ombudsman advisory committee, highlighted the lack of a level playing …

Insurance Claims Cannot Be Denied For Pre-Existing Ailments Without Prior Medical Tests: Delhi State Commission
3 weeks, 4 days ago

Insurance Claims Cannot Be Denied For Pre-Existing Ailments Without Prior Medical Tests: Delhi State Commission

Live Law  

The Delhi State Commission has held that denial of insurance claim on the ground of pre-existing ailments is unjustified where no medical tests were conducted before issuing the policy. Observations: The bench relied on the judgment in Pradeep Kumar Garg vs National Insurance Co. ltd. FA 482/2005 and observed that until a person is hospitalised for a disease closer to …

Denial Of Insurance Claim Is Justified In Case Of Breach Of Insurance Contract By The Insured Person: Delhi State Commission
1 month, 1 week ago

Denial Of Insurance Claim Is Justified In Case Of Breach Of Insurance Contract By The Insured Person: Delhi State Commission

Live Law  

Delhi State Consumer Disputes Redressal Commission ruled that denial of insurance claim by “United India Assurance Co. ltd.” is valid where the insured person violates the terms of insurance policy. A coram of President Sangita Dhingra Sehgal and Judicial member Pinki held that non-submission of requisite and essential documents,as per the terms of policy, by the Complainant for due assessment …

Ernakulam District Commission - Internal Dispute Mechanism Under MEDISEP Scheme Doesn't Bar Aggrieved Persons From Approaching Commission
1 month, 3 weeks ago

Ernakulam District Commission - Internal Dispute Mechanism Under MEDISEP Scheme Doesn't Bar Aggrieved Persons From Approaching Commission

Live Law  

The District Consumer Disputes Redressal Commission, Ernakulam bench consisting of D.B. held that the existence of an internal grievance redressal mechanism under the Medical Insurance Scheme for State Employees and Pensioners does not exclude the Consumer Commission from entertaining the complaint. Background Facts Oriental Insurance argued that the complainant has not exhausted the grievance redressal mechanism provided under the Medical …

Himachal Pradesh State Commission Holds United India Insurance Co. Liable For Wrongful Repudiation Of Valid Claim
3 months, 1 week ago

Himachal Pradesh State Commission Holds United India Insurance Co. Liable For Wrongful Repudiation Of Valid Claim

Live Law  

The State Consumer Disputes Redressal Commission, Himachal Pradesh bench of Justice Inder Singh Mehta held 'United India Insurance Company Limited' liable for wrongful repudiation of a medical claim based on erroneous interpretation of the policy's clauses. Observations of the State Commission: The State Commission observed the condition stated by the Insurance Company for repudiating the claim, was not applicable to …

East Godavari District Commission Holds Aditya Birla Health Insurance Co. Liable For Wrongful Repudiation Of Valid Claim
5 months, 1 week ago

East Godavari District Commission Holds Aditya Birla Health Insurance Co. Liable For Wrongful Repudiation Of Valid Claim

Live Law  

The District Consumer Disputes Redressal Commission, East Godavari bench of Sri D. Kodanda Rama Murthy, Sri S. Suresh Kumar and Smt. Lakshmi held Aditya Birla Health Insurance Company Ltd. liable for wrongful repudiation of a valid health insurance claim based on pre-existing diseases. Brief Facts: The Complainant obtained a health insurance policy from Aditya Birla Health Insurance Co. Ltd. for …

Ernakulam District Commission Holds Future Generali India Insurance Co. Liable For Wrongful Repudiation Of Genuine Medical Claim
5 months, 2 weeks ago

Ernakulam District Commission Holds Future Generali India Insurance Co. Liable For Wrongful Repudiation Of Genuine Medical Claim

Live Law  

The District Consumer Disputes Redressal Commission, Ernakulam bench of Shri D.B. held Future Generali India Insurance Company Ltd. liable for deficiency in service. Brief Facts: The Complainant took a Corona Rakshak Policy from Future Generali India Insurance Company Limited. Therefore, the District Commission held that the Insurance Company wrongfully repudiated the Complainant's claim. Case Title: Ajaychand V. vs Future Generali …

Courts Must Favour Complainant In Case Of Presence Of Two Interpretations Of Same Clause: Ernakulam District Commission
6 months, 1 week ago

Courts Must Favour Complainant In Case Of Presence Of Two Interpretations Of Same Clause: Ernakulam District Commission

Live Law  

The Ernakulam District Commission, presided by Shri. Sreevidhia T.N., held Star Health & Allied Insurance liable for deficiency in service and unfair trade practice. The insurer maintained there was no deficiency in service or unfair trade practice, contested the ₹1,20,000 hospitalization expenses, and argued any liability should be limited to ₹95,286, excluding non-medical expenses. Observations by the District Commission The …

No Proof Of Pre-Existing Disease, Kangra District Commission Holds Star Health And Allied Insurance Co Liable For Wrongful Repudiation
6 months, 3 weeks ago

No Proof Of Pre-Existing Disease, Kangra District Commission Holds Star Health And Allied Insurance Co Liable For Wrongful Repudiation

Live Law  

The District Consumer Disputes Redressal Commission, Kangra bench of Hemanshu Mishra, Arti Sood and Narayan Thakur held Star Health and Allied Insurance Co. Ltd liable for deficiency in services due to its unjustified rejection of a genuine claim. The bench held that the Insurance Company repudiated the claim without conducting a proper investigation or obtaining affidavits from treating doctors regarding …

Mere Deduction Of Premium Does Not Create Binding Insurance Contract, Uttarakhand State Commission Dismisses Appeal Against New India Assurance Co.
6 months, 4 weeks ago

Mere Deduction Of Premium Does Not Create Binding Insurance Contract, Uttarakhand State Commission Dismisses Appeal Against New India Assurance Co.

Live Law  

The State Consumer Disputes Redressal Commission, Uttarakhand bench of Kumkum Rani and Mr B.S. The bench dismissed an appeal filed against the New India Assurance Co. by holding that there existed no renewed insurance contract at the time of the loss and the Insurance Company refunded the premium which was automatically deducted by the bank. Feeling aggrieved, the Complainant filed …

Rejection Of The Health Insurance Claim Cannot Be Based Solely On Assumption Of Pre-Existing Condition: Delhi State Commission
8 months, 1 week ago

Rejection Of The Health Insurance Claim Cannot Be Based Solely On Assumption Of Pre-Existing Condition: Delhi State Commission

Live Law  

Delhi State Consumer Disputes Redressal Commission, headed by Justice Sangita Dhingra Sehgal alongside members Ms. Pinaki and Mr. J.P. Agrawal, held HDFC Insurance liable for deficiency in service over the rejection of a health insurance claim solely on the presence of non-communication of pre-existing conditions. Brief Facts of the Case The complainant's husband applied for an HDFC Life Group Credit …

Ernakulam District Commission Holds Oriental Insurance Liable For Deficiency In Service Due To Non-Disclosure Of Policy Terms During The Signing Of The Contract
9 months, 1 week ago

Ernakulam District Commission Holds Oriental Insurance Liable For Deficiency In Service Due To Non-Disclosure Of Policy Terms During The Signing Of The Contract

Live Law  

The Ernakulam District Consumer Disputes Redressal Commission, headed by D.B. Upon visiting the insurer's office and providing details of pre-existing conditions, the complainant requested to port their existing policy, which the insurer agreed to do. Observations by the Commission The Commission observed that the insurer had failed to provide the complainant with the necessary terms and conditions of the policy …

Kerala consumer rights panel holds insurance company, bank accountable for medical claim denial
10 months, 3 weeks ago

Kerala consumer rights panel holds insurance company, bank accountable for medical claim denial

The Hindu  

In a major verdict, the Ernakulam Consumer Disputes Redressal Commission in Kerala has held a general insurance company and a bank that facilitated insurance coverage accountable for denial of medical insurance claim to a customer and directed them to pay a compensation of ₹2.23 lakh. Binu and members V. Ramachandran and Sreevidhia T.N., issued the verdict on a petition filed …

Do Not Deny Insurance Claim For Brief Home Visit During Hospitalization, Ludhiana Commission Holds Aditya Birla Health Insurance Co. Liable
1 year, 3 months ago

Do Not Deny Insurance Claim For Brief Home Visit During Hospitalization, Ludhiana Commission Holds Aditya Birla Health Insurance Co. Liable

Live Law  

The District Consumer Disputes Redressal Commission, Ludhiana bench comprising Sh. Sanjeev Batra and Ms. Monika Bhagat held Aditya Birla Health Insurance Company liable for rejecting the claim of the hospitalized Complainant on the basis that the Complainant visited his home for certain hours while he was hospitalized. However, the insurance company rejected his claim, asserting that the Complainant had occasionally …

Chandigarh: Insurer penalised for rejecting mishap victim’s mediclaim
1 year, 4 months ago

Chandigarh: Insurer penalised for rejecting mishap victim’s mediclaim

Hindustan Times  

A Zirakpur woman, who had approached the District Consumer Disputes Redressal Commission, Chandigarh, over rejection of mediclaim by the insurer following an accident, has been awarded the complete claim, along with compensation for mental harassment. The consumer commission directed Religare Health Insurance Company Limited to pay the claim amount along with compensation. The commission directed Religare Health Insurance Company Limited …

92-yr-old Chandigarh man wins legal fight against wrongly rejected mediclaim
1 year, 8 months ago

92-yr-old Chandigarh man wins legal fight against wrongly rejected mediclaim

Hindustan Times  

Wrongly rejecting a 92-year-old man’s medical claim has cost an insurance firm dear. The 92-year-old alleged that despite the fact that the claim was fully covered as per the terms and conditions of the policy, the company wrongly repudiated it, which amounted to deficiency in service and unfair trade practice. Holding New India Assurance Co. Limited, Chandigarh, guilty of unfair …

Insurance Claim: Three methods to help you resolve insurance-related issues faster; check details
2 years, 1 month ago

Insurance Claim: Three methods to help you resolve insurance-related issues faster; check details

Firstpost  

Insurance coverages are common among individuals who want to ensure financial security for emergency situations. Policyholder objections are regularly sent to the insurance company, but sometimes the customers don’t receive any desired response from the company officials. Here are some additional methods to resolve insurance policy-related issues: Contact the Grievance Redressal Officer: Every insurance company assigns a Grievance Redressal Officer …

Insurance Ombudsman Performs Quasi-Judicial Functions While Deciding Complaints; Award Can Be Challenged Under Article 227: Bombay High Court
2 years, 4 months ago

Insurance Ombudsman Performs Quasi-Judicial Functions While Deciding Complaints; Award Can Be Challenged Under Article 227: Bombay High Court

Live Law  

Observing that the Insurance Ombudsman is like a tribunal while deciding a complaint, the Bombay High Court on Thursday held that an insurance company can challenge Insurance Ombudsman's award before the High Court under Article 227 of the Constitution. The court was dealing with petition under Article 227 filed by an insurance company challenging Insurance Ombudsman decision granting relief to …

Insurance firm directed to settle claims of patient
2 years, 7 months ago

Insurance firm directed to settle claims of patient

Deccan Chronicle  

Hyderabad: The District Consumer Disputes Redressal Commission-I directed the State Bank of India General Insurance to pay Rs 1,47,343 along with an interest at nine per cent for failing to settle the claims of a person who was insured with them and had undergone treatment. They filed a petition before the commission against Paramount Health Services and Insurance TPA services, …

Insurer can't refuse claim by citing existing medical condition once policy issued: Supreme Court
3 years ago

Insurer can't refuse claim by citing existing medical condition once policy issued: Supreme Court

India TV News  

An insurer cannot repudiate a claim by citing an existing medical condition that was disclosed by the insured in the proposal form, once the policy has been issued, the Supreme Court has said. "Once the policy has been issued after assessing the medical condition of the insured, the insurer cannot repudiate the claim by citing an existing medical condition, which …

Insurance firms to comply with mental health Act: HC
3 years, 8 months ago

Insurance firms to comply with mental health Act: HC

The Hindu  

The Delhi High Court on Monday said that insurance companies are liable to give effect to the Mental Healthcare Act 2017 in their policies from the time it came into force in 2018. The High Court’s directions came on a woman’s plea whose claim for reimbursement of costs for treatment of schizophrenia were rejected by the National Insurance Company Ltd …

Delhi High Court Seeks Response From IRDAI On Plea Alleging Failure To Protect Interests Of Policy Holders
3 years, 9 months ago

Delhi High Court Seeks Response From IRDAI On Plea Alleging Failure To Protect Interests Of Policy Holders

Live Law  

The Delhi High Court has sought response from the Insurance Regulatory Development Authority of India on a petition alleging inaction on its part for protecting the interest of various policy holders. Under Section 14 of the IRDAI Act, 1999, the authority is entrusted to protect the interests of policy holders in matters concerning assigning of policy, settlement of insurance claims, …

Ombudsmen are underutilized in insurance sector
4 years ago

Ombudsmen are underutilized in insurance sector

Live Mint  

The ombudsman is a good but under-utilized and misunderstood grievance redressal option for insurance. The ombudsman accepts complaints pertaining to individual or group insurance and can award up to ₹30 lakh. Only in two of 17 ombudsman offices was the number of decisions favouring insurers higher than those favouring policyholders. Although the complaints are unevenly distributed across the 17 ombudsman …

Cannot Burden Insurer To Follow Up An Inadequate Disclosure Of Material Facts By The Insured: SC [Read Judgment]
5 years, 6 months ago

Cannot Burden Insurer To Follow Up An Inadequate Disclosure Of Material Facts By The Insured: SC [Read Judgment]

Live Law  

The Supreme Court has observed that it is duty of the insured while making the proposal to make a clear and specific disclosure of material facts and that the insurer cannot be burdened to follow up an inadequate disclosure.As per the relevant policy in this case, the details of claims lodged during the preceding three years. The Supreme Court has …

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