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 approached me when XYZ Insurance Company rejected his accidental death claim following his mother’s tragic demise in a road accident on DD/MM/YYYY in City A. Despite having a comprehensive health insurance policy with accidental death coverage, the insurance company was denying the claim citing various technical reasons. Mr. X had submitted all required documents including post-mortem reports, police panchanama, inquest reports, and death certificate. The insurance company’s claim settlement team was deliberately delaying the process and raising unnecessary queries. After months of correspondence, they finally rejected the claim stating insufficient evidence, despite having all legally mandated documentation. Mr. X was devastated and sought legal intervention to recover the rightful insurance amount and punitive damages.

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.

• Maintain all correspondence with the insurance company in writing
• Document every phone call and meeting with insurance officials
• File complaint with Insurance Ombudsman before pursuing legal action
• Preserve all original policy documents and claim-related paperwork

Applicable Sections of Law

Under Bharatiya Nyaya Sanhita (BNS), insurance fraud and wrongful denial can attract Section 318 (cheating) and Section 340 (wrongful confinement of property). The Bharatiya Nagarik Suraksha Sanhita (BNSS) Section 173 governs the investigation process if criminal action is required. Consumer Protection Act, 2019 provides additional remedies for deficiency in service. Insurance Act, 1938 and IRDAI regulations mandate fair claim settlement practices. Contract law principles apply for breach of insurance contract terms.

If You Are the Complainant

• File complaint with Insurance Ombudsman within one year of rejection
• Approach Consumer Forum under Consumer Protection Act for service deficiency
• Send legal notice to insurance company demanding claim settlement
• File civil suit for recovery of insurance amount with interest and damages
• Report to IRDAI if company violates settlement timelines or practices unfair denial

If You Are the Victim

• Gather all medical records, post-mortem reports, and police investigation documents
• Obtain certified copies of all government documents related to the accident
• Collect witness statements and CCTV footage if available
• Review policy terms carefully to understand exact coverage and exclusions
• Seek second medical opinion if insurance company disputes cause of death

How the Police Behave in Such Cases

Police generally cooperate in providing necessary documentation for insurance claims. They issue panchanama, inquest reports, and final investigation reports upon request. However, police may be reluctant to modify their initial findings if insurance companies dispute accident classification. Some officers might suggest approaching insurance ombudsman first before filing criminal complaint for cheating.

FAQs People Normally Have

Can I approach courts directly? Yes, but it’s advisable to first exhaust ombudsman and consumer forum remedies as they’re faster and cost-effective.

What if policy has lapsed? Check grace period provisions and revival options before claim rejection.

Can insurance company investigate independently? Yes, they can conduct their own investigation but cannot deny valid claims based on unreasonable grounds.

Is there time limit for filing complaints? Insurance Ombudsman complaints must be filed within one year of rejection.

What Evidence Is Required?

• Original insurance policy documents and premium payment receipts
• Death certificate issued by competent authority
• Post-mortem report detailing cause of death
• Police panchanama and final investigation report
• Medical records and treatment documents if applicable
• Witness statements and accident scene photographs
• Legal heir certificate and succession documentation

How Long Will the Investigation Take?

Insurance companies must settle claims within 30 days of receiving complete documents. Consumer forum cases typically take 3-6 months. Insurance Ombudsman provides decisions within 30 days of hearing. Civil court proceedings may extend 1-3 years depending on case complexity and court workload.

Advocate Sudhir Rao, Supreme Court of India