One of my clients recently had a case which I am explaining below and if you are stuck in such similar situation, here is what to do.

Note: Due to attorney-client privilege, I cannot disclose complete case details or identify the actual parties involved. However, I am sharing the essential facts and legal approach so that if you find yourself in a similar situation, you can understand the available solutions and legal remedies.

Mr.X, aged 61 years, held a health insurance policy with Y.company Insurance under their X.brand scheme. In DD/MM/YYYY, Mr.X was hospitalized in City A due to severe liver complications requiring emergency endoscopy and life-saving procedures. The family filed claims totaling ₹76,954 on DD/MM/YYYY. Despite initial assurances from the insurance company representatives, both claims were rejected citing policy exclusions that were never clearly disclosed during policy purchase. The family had to bear ₹2.5 lakhs out of pocket for the emergency treatment. When escalated to the Insurance Ombudsman, the company’s bad faith became evident through contradictory documentation and delayed responses, prompting legal action for insurance fraud and consumer rights violation.

Advice in Such Cases

Consult with Lawyer: The very basic and important step to start is talk to Lawyer / advocate. You should not hesitate in paying his consultation fee i.e. might be in range of Rs. 10,000 to 50,000 depends case to case. He is helping you in this situation to come out. He is expert in the domain and can help you explain the procedure which you might have never explored. A good lawyer can get the issues resolved much faster than you think.

• Document all communications with the insurance company including phone recordings if possible
• File a complaint with the Insurance Ombudsman within specified time limits
• Approach Consumer Forum for deficiency in service and unfair trade practices
• Consider criminal complaint if fraudulent misrepresentation is established

Applicable Sections of Law

Under Bharatiya Nyaya Sanhita (BNS), Section 318 deals with cheating and dishonestly inducing delivery of property. Section 319 covers punishment for cheating. The Consumer Protection Act 2019 provides remedies for deficiency in service. Under BNSS, Section 154 governs filing of FIR for cognizable offenses. Insurance fraud cases often involve multiple legal frameworks including insurance regulations, consumer protection laws, and criminal provisions for fraudulent practices by insurance companies.

If You Are the Complainant

• Gather all policy documents, premium payment receipts, and claim-related correspondence
• File complaint with Insurance Ombudsman within one year of final rejection
• Document financial hardship caused by claim rejection and out-of-pocket expenses
• Submit complaint to Consumer Forum highlighting deficiency in service
• Consider criminal complaint if misrepresentation or fraud is evident in policy terms

If You Are the Victim

• Preserve all medical records and emergency treatment documentation immediately
• Record all telephonic conversations with insurance company representatives
• Calculate total financial loss including treatment costs and mental harassment
• File police complaint if fraudulent concealment of policy terms is established
• Seek compensation for mental agony and harassment through Consumer Forum

How the Police Behave in Such Cases

Police typically treat insurance disputes as civil matters initially. However, when criminal elements like fraud, cheating, or criminal breach of trust are established, they register FIR under BNS. Officers may require substantial documentation proving fraudulent intent by the insurance company. Investigation involves examining policy documents, claim processing records, and company communications for evidence of deliberate misrepresentation or unfair claim rejection practices.

FAQs People Normally Have

Can I file criminal case against insurance company? Yes, if fraudulent misrepresentation or cheating is established under BNS Section 318-319.

What is the time limit for Ombudsman complaint? One year from the date of final rejection by the insurance company.

Can I claim compensation beyond policy amount? Yes, Consumer Forum can award compensation for mental harassment and deficiency in service.

Will police investigate insurance fraud immediately? Only if prima facie criminal elements are established with proper documentation.

What Evidence Is Required?

• Original insurance policy document with terms and conditions
• Premium payment receipts and policy renewal documentation
• Complete medical records including emergency treatment details
• All correspondence with insurance company including emails and letters
• Audio recordings of telephonic conversations with company representatives
• Financial documents showing out-of-pocket expenses incurred
• Expert medical opinion supporting necessity of emergency treatment

How Long Will the Investigation Take?

Insurance Ombudsman typically resolves complaints within 30-45 days. Consumer Forum proceedings may take 6-18 months depending on complexity. Criminal investigation, if initiated, can extend 2-3 years including trial. Civil recovery suits in regular courts may take 3-5 years. Timeline varies significantly based on evidence quality, legal representation, and court workload in respective jurisdictions.

Advocate Sudhir Rao, Supreme Court of India