Key points
- Start with the insurer's grievance cell, then the Insurance Ombudsman (free, for claims up to 50 lakh rupees), or a consumer complaint within two years.
- Non-disclosure defeats a claim only if the fact was material and the proposal form asked about it; the insurer must prove both.
- Delay in intimation cannot be used to reject an otherwise genuine claim (Gurshinder Singh v. Shriram General Insurance, 2020).
The forums
Write to the insurer's grievance redressal officer and escalate on the IRDAI Bima Bharosa portal. If unresolved within 30 days, approach the Insurance Ombudsman for the region, whose award is binding on the insurer for claims up to 50 lakh rupees. Alternatively, file a consumer complaint; the ombudsman route does not bar it. Large commercial claims go to the civil court or arbitration if the policy provides.
Non-disclosure and pre-existing disease
Under Section 45 of the Insurance Act, a life policy cannot be questioned on any ground after three years from issue, and within three years only for fraud or material non-disclosure proven by the insurer. For health policies, IRDAI's rules bar rejection for pre-existing disease after the waiting period, and courts have held that a condition of which the insured was unaware is not a non-disclosure.
Exclusions
Exclusion clauses are read against the insurer and must have been communicated with the policy; an exclusion in a document never supplied to the insured cannot be relied on (Texco Marketing v. TATA AIG, 2022).
Motor and property
Breach of a policy condition that did not contribute to the loss, such as a minor delay in reporting theft, does not permit repudiation, though it may allow a non-standard settlement of 75% in some cases. Surveyor's reports are not binding on the insured.
Interest and compensation
Commissions award the claim amount with interest of 6 to 9% from the date of repudiation, and compensation for harassment in appropriate cases.
Frequently asked questions
What is the time limit to approach the Ombudsman?
Within one year of the insurer's final rejection or of the expiry of 30 days from your complaint to the insurer without a reply.
Can I claim from the insurer if the hospital was not in the network?
Yes, on a reimbursement basis. Cashless is a convenience, not a condition of coverage, unless the policy expressly restricts treatment to network hospitals.
Related practice area: Consumer Disputes
This article is for general information and does not constitute legal advice. Laws, rules and limitation periods change and depend on the facts; please take advice on your own situation before acting. Reading this article does not create a lawyer-client relationship with Akhtars Legalitarian.