If you are stuck in such a situation, here is what to do.

Mr. Sameer Verma, a resident of Nagpur, recently found himself in a perplexing situation with his insurance provider, Apex SecureLife Insurance. In January, he purchased a term insurance policy, initially choosing a 10-year limited premium payment option. Soon after, he decided a regular payment plan would be more suitable and submitted a request for the change. In February, he received an email from Apex SecureLife confirming the policy modification to a regular pay schedule, along with the adjusted premium details and a refund for the excess amount he had initially paid.

However, also in February, he received a phone call from an insurance representative informing him that the ‘critical illness waiver’ rider was being removed from his policy. Alarmed, Mr. Verma immediately requested an email confirmation for this significant change, but none was sent. After several follow-ups, it was not until May that he finally received a formal email officially stating the removal of the rider. This significant delay and the lack of prompt written communication about a crucial policy feature left him concerned about the validity of his policy and the insurer’s practices, prompting him to question his legal recourse.

Advice in such cases

Dealing with insurance companies can be daunting, especially when they alter policy terms without clear and timely communication. Such actions can be considered a deficiency in service.

• Document Everything: Keep a meticulous record of all communication. This includes the policy document, all emails, and detailed notes of any phone calls (date, time, name of the representative, and a summary of the conversation).
• Formal Grievance: The first step is to lodge a formal written complaint with the Grievance Redressal Officer (GRO) of the insurance company. Clearly state the issue, the timeline of events, and what you expect as a resolution.
• Escalate to IRDAI: If the insurer does not resolve your complaint to your satisfaction within 15 days, you can escalate the matter to the Insurance Regulatory and Development Authority of India (IRDAI) through their Integrated Grievance Management System (IGMS).
• Approach the Insurance Ombudsman: For a direct and cost-effective resolution, you can file a complaint with the Insurance Ombudsman in your jurisdiction. This is a quasi-judicial body specifically created to handle such disputes.
• 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 of 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.

Applicable Sections of Law

The legal framework in India provides robust protection for policyholders. The key statutes and regulations applicable in such a scenario include:

• The Insurance Act, 1938 and The Insurance Regulatory and Development Authority Act, 1999: These acts govern the functioning of insurance companies in India. IRDAI, established under its act, issues regulations to protect policyholders.
• IRDAI (Protection of Policyholders’ Interests) Regulations, 2017: These regulations mandate transparent and timely communication from insurers to policyholders regarding any changes to their policies. A failure to provide written confirmation for policy changes is a direct violation of these regulations.
• The Consumer Protection Act, 2019: The delay in communication and unilateral change without proper notification can be termed a “deficiency in service” under this Act. You can file a case in the appropriate Consumer Disputes Redressal Commission (District, State, or National, depending on the value of the claim) seeking relief.
• The Bharatiya Nyaya Sanhita, 2023 (BNS): While primarily a civil matter, if there is evidence of fraudulent intent from the outset, provisions related to cheating (Section 318 of BNS) could potentially be invoked, although this is rare in such service-related disputes.

If you are the complainant

If you decide to pursue a formal complaint or legal action, a structured approach is crucial.

• Organize Evidence: Arrange all your documents chronologically. Create a clear timeline of events, from purchasing the policy to the final communication about the rider’s removal.
• Draft a Clear Complaint: Your complaint, whether to the insurer, Ombudsman, or a consumer court, should be precise. Clearly state the facts, the regulations violated by the insurer, and the financial or other harm caused to you.
• Specify the Relief Sought: Be specific about what you want. This could be the reinstatement of the rider, compensation for mental anguish and harassment, or a refund of premiums.
• 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 of 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.

If you are the victim

As a policyholder who has been subjected to such practices, it’s important to know your rights and act assertively.

• Know Your Rights: Familiarize yourself with your rights under the IRDAI (Protection of Policyholders’ Interests) Regulations. Insurers are legally obligated to provide services fairly and transparently.
• Demand Written Communication: Never accept significant policy changes based on a phone call alone. Always insist on written confirmation via email or official letter. If they fail to provide it, document your request in writing.
• Act Promptly: Do not let time lapse. The law provides specific limitation periods for filing complaints, so it is important to act quickly once you realize there is an issue.
• 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 of 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.

How the police behave in such cases

It is important to understand that such disputes are primarily considered civil or contractual in nature, not criminal. Therefore, the police have a limited role.

• Jurisdictional Limitations: The police will likely inform you that this is a matter for a consumer court or the Insurance Ombudsman, as it pertains to a service agreement and not a cognizable criminal offense in most cases.
• Reluctance to File FIR: They are generally hesitant to register a First Information Report (FIR) for “cheating” under Section 318 of the BNS unless there is strong prima facie evidence of malicious and fraudulent intent from the very beginning of the contract. A simple case of poor service or delayed communication does not meet this threshold.
• Guidance to Proper Forum: A helpful police officer will guide you to the correct forum for redressal, such as the District Consumer Forum.

FAQs people normally have

• Can I sue my insurance company for poor service?
  Yes, you can file a complaint against the insurance company for “deficiency in service” at the appropriate Consumer Disputes Redressal Commission under the Consumer Protection Act, 2019.
• Is it better to go to the Insurance Ombudsman or the Consumer Court?
  The Insurance Ombudsman is a faster and free-of-cost mechanism. It’s often advisable to try this route first. If you are not satisfied with the Ombudsman’s decision, you can still approach the Consumer Court.
• Can an insurance company change my policy terms without my consent?
  No, an insurer cannot unilaterally change the fundamental terms and conditions of your policy mid-term without your explicit consent and proper notification as prescribed by IRDAI regulations.

What evidence is required?

Strong evidence is the backbone of any successful claim. You should gather:

• The original insurance policy document.
• All email communications with the insurer, especially the confirmation of policy change and the delayed email about the rider removal.
• Records of premium payments.
• A log of phone calls made, including dates, times, and the names of the representatives spoken to.
• A copy of the formal grievance letter sent to the company and any response received.

How long will the investigation take?

The timeline for resolution varies depending on the forum you choose:

• Insurer’s Grievance Cell: As per IRDAI norms, the insurer is required to resolve a complaint within 15 days.
• Insurance Ombudsman: The process typically takes 1 to 3 months to reach a decision.
• Consumer Court: This is a more formal legal process and can take anywhere from 6 months to several years, depending on the complexity of the case and the workload of the commission.

Advocate Sudhir Rao, Supreme Court of India