“You have every right to know—what you bought, what it covers, and what it doesn't.”

 

In an industry built on trust, transparency is not a luxury. It is your right. But too often, policyholders are left confused andanxious—especially when claims are delayed, rejected, or disputed—because they didn't know the right information at the right time. 



Let's walk you through your legal rights, practical steps, and how to avoid insurance claim-related issues like a pro. 



   1. Why Insurers Owe You Clarity 



Whether it's a life policy, health cover, or general insurance, insurers are legally bound to provide: 



       ● All terms & conditions in simple language. 



       ● Clear disclosure of inclusions and exclusions. 



       ● Transparent premium breakdowns. 



       ● Claim process instructions and timelines. 



       ● Reasons, in writing, for any claim rejection. 



These aren't favours—they're your rights, rooted in IRDAI regulations and consumer protection laws. 



2.  When the Silence Gets Loud: Real-Life Scenarios 

Let's say your claim is "under review" for weeks. Or you receive a one-line claim rejection with no explanation. 



Both are violations of fair practice guidelines. 



Delays beyond 30 days after document submission (without a valid reason) are considered non-compliance under IRDAI norms. 



Still, thousands face claim settlement delays, lack of response, or confusing jargon, especially during emergencies. Let us better understand this through the case of Johny Milton v. Universal Sompo General Insurance Co. Ltd.  



     ● The Case: 



Johny Milton had taken a family health insurance policy from Universal Sompo General Insurance through Indian Overseas Bank (IOB), known as the IOB Health Care Plus Policy. This policy covered several members of his family, including his mother. 



In March 2021, his mother underwent treatment for an eye condition called Myopic Choroidal Neovascular Membrane, and as part of her treatment, doctors administered an Accentrix injection. This procedure was done in a day care setting — meaning she didn't stay overnight at the hospital, but the treatment was medical and necessary. 



Johny submitted a claim. However, the insurance company rejected the claim, stating that it was an outpatient (OPD) procedure, which they claimed was not covered under the policy. 



     ● The Arguments-  



● Complainant's Side: 



          ○ The injection was administered in a hospital setting and qualifies as a day care procedure. 



          ○ IRDAI guidelines (2019) explicitly mention intra vitreal injections as admissible under day care. 



          ○ The same procedure was approved for claim reimbursement by the insurer in a later instance (August 2021), proving                inconsistency. 





● Insurer's Side: 



         ● The treatment is classified as outpatient, not under the policy's listed day care procedures. 

         

         ● Rejection was based on policy terms—no deficiency in service. 



The District Consumer Commission ruled in favor of the complainant, holding the insurer guilty of deficiency in service and unfair trade practice. The court found the rejection arbitrary and inconsistent, especially since the same procedure was reimbursed later. 



        ● The insurer was ordered to pay: 

                 

                         ○ ₹27,720 (claim amount) 



                         ○ ₹20,000 (compensation) 



                         ○ ₹10,000 (litigation cost) 



                         ○ 9% interest if unpaid within 30 days 



This case highlights: 



           ● The importance of knowing your policy rights and IRDAI rules 



           ● That rejection doesn't always mean you're wrong — even courts can confirm the insurer's fault 



           ● Why inconsistencies in claim handling should always be questioned 



For policyholders, this is a strong reminder to challenge unfair denials and seek legal recourse when necessary. 



3. What You Should Ask for—and How 



Here's your go-to checklist of information you're entitled to demand from your insurer: 



Information You Can Ask  Why It Matters 
Complete policy brochure and terms To understand what is actually covered 
Break-up of premium components  To check if you're being charged fairly 
Copy of signed proposal form  To identify mis-selling of insurance policies 
Timeline for claim settlement  To hold them accountable to IRDAI timelines 
Written justification for claim rejection To challenge or appeal with evidence 
Details of claim rejection-related issues  To file a formal complaint if needed 

❖ Pro Tip: Always communicate via email. It leaves a digital trail. 



4. What If They Still Don't Respond? 



If your insurer is non-cooperative or evasive, you can: 



            ● File a Complaint about the Insurance Company on the IRDAI Grievance Portal. 



            ● Escalate to the Insurance Ombudsman in your region. 



            ● Seek the services of expert legal support, aka Subject Matter Experts. 



In many mis-sold insurance policies, the issue begins at the very first step, where incorrect or incomplete information was shared or the policyholder was coerced during the policy sale. 



5. Why Experts Matter in Complex Cases 



Reading fine print is one thing. Interpreting it in a legal context is another. 



If you're stuck with a claim rejection, facing delays in the claim process, or suspect mis-selling of your insurance policy, it's time to seek help. 



Experienced legal professionals understand the tactics insurers use—vague clauses, grey areas, or denial based on outdated disclosures—and know how to counter them. 





Conclusion 



You Deserve Answers and Support. It's not unreasonable to expect clarity. It's your right. 



The next time an insurer keeps you in the dark, remember: You're not powerless. And you don't have to go through this alone. 



Whether it's a claim rejection, delay in claim process, or a complaint about your insurance company, the right experts can help you demand what's rightfully yours—information, resolution, and peace of mind.