Insurance is a basic necessity in our lives today, be it health/medical insurance, life insurance, vehicle insurance and so on. However, in times of need, the rejection of any insurance claim can be a really traumatic affair and problematic for individuals. Here’s looking at some of the reasons behind claims being turned down and the fixes that can be employed. The IRDA (Insurance Regulatory and Development Authority) of India has already notified that the rejection of a claim by an insurance company will be on the basis of absolutely logical and valid reasons. Rejection of claims for technical grounds mechanically will lead to policyholders losing their trust in insurers, leading to huge litigation.
Key factors behind insurance claim being turned down
- Inadequate Data in the proposal form: This may be a reason for rejection of the insurance claim. The proposal form should be absolutely accurate, honest and contain all required information since this will be used by insurance companies for assessment of risks and premium calculation.
- Suppressing Information: Many people often do not disclose all material facts and this violates the basic principle behind insurance, thereby leading to claim rejections. A material fact is any aspect that may impact the premium rate. These facts include aspects like lifestyle habits, pre-existing diseases/ailments, family disease history, policies, smoking habits, age and so on.
- Pre-existing ailments: Disclosing any pre-existing disease is one of the grounds for rejection. However, insurance companies have their own obligation to see whether the customer can be insured or not before providing the policy. The claim of the insured cannot be rejected/turned down arbitrarily unless the pre-existing ailment was concealed by the person insured. Not disclosing the operation/hospitalization for any such disease near the mediclaim policy date is the only rejection basis for claims of the insured. Legally, in the Tarlok Chand Khanna vs United India Insurance Co. Ltd., case, the statement by the National Consumer Dispute Redressal Form clearly outlined that the onus lay on the insurance company to prove that the customer was suffering from any such pre-existing ailment.
- Policy Lapses: In the Life Insurance Corporation of India & Anr. V. Dharam Vir Anand case, the Court had observed that a grace period of 30 days will be there for paying half-yearly/yearly/quarterly premiums and a grace period of 15 days will be given for monthly premium payments. In case of death within this period and prior to the premium payment, the policy will remain valid and the sum assured will be paid post deduction of the premium amount and other unpaid premiums prior to the next renewal date of the policy. In case premiums are unpaid prior to the grace period expiring, the policy will be lapsing accordingly. Non-payment leads to policies lapsing and this is another reason behind claims not being entertained at all.
- Delays with regard to claim filing: This is another key reason behind claims being rejected. In a case back in October 2017, it was stated by the Supreme Court that in case of a genuine insurance claim, it cannot be turned down on delay-based grounds. In case of any theft of the vehicle, the owner has to inform the insurer within a period of 8 days post date of theft. However, delays due to unavoidable circumstances cannot be reasons for insurance claims being rejected.
Solutions upon insurance claim rejection:
- Grievance Redressal System of your insurance company: Most insurance companies have grievance redressal frameworks which you can take recourse to in case the claim has been rejected.
- IRDA: IRDA has its Grievance Redressal Cell as part of the Consumer Affairs Department which takes up all complaints from customers. However, prior to approaching this Cell, you should register the grievance with the Redressal Cell of your insurance company. This step comes into play in case you do not get any responses from the insurer over a sustained time period.
- Insurance Ombudsman: You can inform the Ombudsman in writing about your grievance. The addresses of Ombudsman Centres pertaining to several jurisdictions are available. Compensation can be awarded by the insurance ombudsman up to a sum of Rs. 30 lakhs.
- Consumer Protection Act of 1986: The Consumer Court is the last step if the above mentioned remedies do not work at all.
Always read the insurance contract terms and conditions with care prior to signing on the dotted line. You should always personally enter details in the Insurance Proposal Form without entrusting it to the insurance agent. Also make sure that you disclose all material facts under the terms of the insurance policy in question.