Bengaluru Resident Takes On Health Insurer And Wins: What To Do If Your Insurer Fails To Respond To Your Claim?

Those who have ever faced the situation of a delayed reimbursement on their health insurance claim would understand what a harrowing experience it can be if your insurer doesn’t respond to it.

Recently, a resident of Bengaluru faced such an ordeal when his medical reimbursement claim was not processed by his health insurance firm. Umesh C (36), filed a reimbursement claim of Rs 71,000 wherein his insurer not only denied his claim but also did not refund the premium of Rs 15,972 after his policy was rejected for renewal.

Distressed, Umesh took the legal recourse to get justice. Following months of persistence, legal notices, and escalation, his efforts finally paid off when the city’s consumer court ruled in his favour, ordering his insurer to pay the dues with interest and compensation.

What was the issue?

Umesh purchased a family insurance policy from Redkenko Health Tech Pvt Ltd which promised him coverage of 10 days of hospitalisation and 50 per cent of OPD costs. Yet, his claim for hospitalisation on April 16 and 17, 2024 got flatly rejected without justification, according to a report by the Times of India.

Adding to his troubles, Umesh had also paid a premium of Rs Rs 15,972 for a ‘forever family plan’ that guaranteed full coverage of medical consultations, medicines, and hospital expenses up to Rs 20 lakh. However, at the time of policy renewal, the company refused to do the same citing ‘health score issues’.

How Did Umesh Laid Claim On His Rights?

Initially, Umesh reached out to his insurer via email to get information on his claim rejection and premium refund delay. The firm acknowledged his request for a refund, but no money ever arrived in his account.

With no other option, Umesh escalated his grievance to multiple authorities such as the National Consumer Forum, Insurance Regulatory and Development Authority (Irdai), the RBI ombudsman, and even the JC Nagar police.

He also visited the insurance company’s Bengaluru office, only to find it shut down. Determined to hold them accountable, Umesh sent a legal notice on June 10, 2024, to the insurer’s headquarters in Mumbai and the Bengaluru branch, to which he did not get any response.

As a final recourse, Umesh turned his appeal to the city’s II Additional District Consumer Disputes Redressal Commission to file a formal complaint. The Commission sent legal notices to the insurer which never responded with any defence. After examining all the evidence such as Umesh’s hospital bills, transaction records, and the policy document, the Commission upheld the insurer’s failure and found it guilty of misleading advertising and deficiency in service.

The Commission further ordered the insurer to pay him a total of Rs 86,972 (Rs 71,000 + Rs 15,972 premium refund) with 6 per cent interest from the date of the complaint until full payment. Taking note of the mental distress and legal expenses incurred by Umesh, the authority also awarded him Rs 10,000 as compensation.

If you ever find yourself in such a situation, Here’s How You Can File A Complaint;

1) Contact Your Insurer: The first step is to file a formal complaint with your insurance company and get a written acknowledgment behind the claim rejection or any premium refund delays.

2) Raise Grievance With RO: Every insurance company has a designated Grievance Redressal Officer (GRO). You can reach out to them and file your dispute.

3) Complaint With Irdai: If the insurer does not resolve your issue within two weeks, you can file a complaint with the insurance regulator via the following ways;

- You can either lodge your complaint with Bima Bharosa System (https://bimabharosa.irdai.gov.in/)

- Email your grievance at complaints@irdai.gov.in

- Or call these numbers 155255 or 1800 4254 732 to register your complaint.

However, if all else fails, you can always take legal action against your insurer by approaching the insurance ombudsman or consumer court to seek justice.