Case Studies on Insurance Ombudsman Claims

Insurance Ombudsman Claims/Awards:Case studies on Motor OD

IO centre Facts/Insurance Co’s stand on Repudiation

Issues involved Insurance Ombudsmans’ Reasoning /Decision

AHD11/003/264

A/C :S Y Patel

Quantum dispute: Motor OD claimSurveyor assessed :Net of salvage/ deductibles 2.15 lacs.

Surveyor assessed Net loss payable 2.15 lacs., butDischarge voucher sent for 1.95 lacs

Accident was not in dispute.No reasons could be adduced why the amt was reduced. Therefore IO directed to pay the amt 2.15 lacs with simple interest

AHD11/002 /302

A/C :M P Rawal

Pvt car purchased, RTOtransfer confirmedAccident took place 20 days after said transfer

Policy was not transferred within period of 14 days IMT-GR 17: Hence Repudiation

Repudiation Decision upheld , no relief to complainant

AHD11/004 /243

A/C :P GKalantri

Repudiation : in absence of documents like FIR confirming accident

Statement of Insured, on accident relied & survey conducted

No evidence to deny the date of loss, as observed from Survey report. Directed as claim payable

AHD11/002 /263

A/C :Yogesh Patel

Quantum dispute: Motor OD claim : Partial Loss

Repair basic settlement offered

Assessed loss after depreciation, fell below 75% of IDVNot treated as constructive total loss CTL

Should have assessed without applying depreciation & treated as constructive total loss CTLRepair basic settlement offeredDecision by Insurer upheld

AHD11/003 /158

A/C : K A Saha

Repudiation on the ground: Insured has not taken steps to safeguard the vehicle

Allegedly Stolen while kept in a Pay & park plot for 8 days. Delayed FIR

Delayed FIR might have led to failure of police investigation.Decision by Insurer upheld

KochiIO/KCH/

GI/28/A/C : K

Karunakaran

Repudiation on the ground:Violation of permit. Overloading one person beyond the permit.

Surveyor assessed the loss about Rs one lac. Accident caused by a paid driver whose FIR/ Final report insisted

No evidence to show that overloading one person beyond the permit, contributed to cause of accident .

Surveyors assessed loss payable.

Bhopal/506/009 A/C

Gurmeet singh

Quantum dispute: Motor OD claim : Partial LossSettled for 61,000/- in absence of Bills/cash memos for the difference.

Surveyor assessed Net loss payable 72,000/- Bills/cash memos for the difference could not be produced.

Surveyors assessed amount payable subject production of evidence of expenses incurred for all such items.

Decision by Insurer upheldAHD

11/002 /258A/C :S K

Maru

Repudiation Motor OD claim: Policy transferred 90 days after tfr of ownership & 10 days after accident.

Insured under the policy was seller of the vehicle.Complainant was alsoseller of the vehicle

Violation of GR-17 of IMTRepudiation Decision upheld

AHD14/003 /007

A/C :S N Arora

Repudiation : Car fallen into ditch. Driver escaped unhurt Curve protected by fencing. Vehicle toppled without damage to parapet.

All unusual occurrences need using due process of law by calling witnesses.

Forum is neither empowered nor equipped with the required process. Complainant advised to take up the matter with appropriate forum.

AHD14/002 /339A/C : V V

Verma

Repudiation :No claim due to non-compliance of requirement in the procedure to produce name of driver up to satisfaction

Name of driver/ Name of complainant. Affidavit sworn. Complainant was also admitted due to orthopedic fracture.

Complaint could prove that he was indeed driving the vehicle, as his hospitalization papers producedDirected to pay Surveyors assessed full claim

AHD11/002 /360

A/C :R B Saha

Repudiation : Agreed to settle on non standard 75% basis.

Insured vehicle did not have a valid certificate of periodic inspection. as per SG rules mandatory to have

In order to avoid harsh consequences normally Insurers offer non standard basic settlement of the assessed amount.

seating ,exceeding 6 persons Decision upheld.AHD

11/003 /304 V K Nanolia

Repudiation Motor OD claim: Valid /effective DL not possessed by the driver. Licensed to drive LMV

Vehicle involved was Contract carriage Maxi cab which is a transport vehicle

Adequate precaution was not taken to engage a driver with Valid /effective DL. Repudiation Decision upheld.

AHD11/005 /257V Prassana

Repudiation Motor OD claim: Vehicle was stolen.Claim admitted. Quantum dispute.

Executed discharge voucher in full/final settlement. Cheque payable subject to letter of subrogation /undertaking.

Unqualified discharge voucher in full/final settlement was executedThe case can not be reopened

AHD11/002 /360A A Imam

Repudiation Motor OD claim: Claim settled on total loss basis. After having accepted grievances raised

Towing charges negligible. Separate amount for accessories claimed

Ceiling specified in the policy. At this stage separate claim not permissible.

AHD11/014 /0081

K S Saha

Motor OD claim: Admitted for 12281/-as per survey assessment. Not accepted by complainant

Engine stopped working water logged. Major amount found not admissible, in view of cause of damage.

Vehicle inspected by expert technician. Damage attributed to attempt to run the engine, while in contact with water.Decision upheld

AHD11/004 /111

J V Hirappa

Repudiation Motor OD claim: Theft of vehicle while parked in open place without lock

Violation of condition : Reasonable care to safeguard. FIR confirms the fact, critical document.

Since policy condition :reasonable safeguard not complied with.Decision of repudiation upheld

AHD11/004 /367

T P Patel

Repudiation Motor OD claim: Engine being run without sufficient oil leading to block.

Surveyor noted that there was no external damage to engine, gear box, bumper, chamber etc. Damage due to lack of lubrication, beyond the scope of cover.

Damage due to accident only coveredEstablished process of claim scrutiny followed. Another panel surveyor affirmed the position.Decision of repudiation upheld.

Insurance Ombudsman Claims/Awards:Case studies on Misc Policies



AHD11/002/0018

Girish Jethwa

Engg Policy :Repudiation on the ground of exclusions in such policy.

Probe is an exchangeable tool, but not specifically named to fit the description in exclusion clause.

Scope of coverage does not specifically state exclusionsDirected as claim payable, in absence of clear terms.

Chennai/11/2/1044 A/C D S

Prabhakar

Householders Policy , with baggage cover:Repudiation due to special exclusion clause.

Scope of cover : Cellphone , articles on journey worn or carried about are excluded items from baggage

Interpretation : Item does not fall under category of articles carried in baggage. Decision by Insurer upheld

AHD11/002/002

N K Ramanathan

Householders Policy Repudiation due to exclusion clause.

Washing machine damaged. Drum jammed. Survey observed Damage due to normal wear & tear.

General exception excludes normal wear & tear.Decision by Insurer upheld

AHD11/002/072V M Patel

Householders Policy Repudiation due to Scope of cover / property description clause.

Damage to swimming pool due to flood. Operative clause: Bldg/ Contents of class a construction

Property described in schedule. Reference to building is transparent.Swimming pool is not a part of Bldg insured.Decision by Insurer upheld

Insurance Ombudsman Claims/Awards:Case studies on Fire claims



BBSR14/002/0057 Ranjit singh

Quantum dispute: fire at Godown/shops claimSurveyor assessed loss 431000 as per a/c books etc

Fire brigade certificate loss 95 000/-Same amount offered for settlement

Survey report amount sustainable Directed claim payable as per Survey report & not Fire brigade certificate having no access to a/cs.

HYD G003/2006/0

7 A/C K N Rao

Poultry sheds damaged by cyclone .Shed damaged beyond repair claimed fresh thatchs at roof .

Cause of loss not disputedNot properly constructed as per Survey report.Recommended 20-25% for repair.

To repair the loss extra material required more then 50% , practically.Partly allowed.75% of estimated amount of claim, fresh thatchs at roof payable.

Guwhati 14/004/0112

A/C M Sharma

Quantum dispute: fire at Shop . Under Insurance. application of average clause. Survey report stock prior to fire, ascertained as 14 lacs but SI was for 8 lacs.

Survey report Rs 66000 /-without average clause.Net Loss payable after application of average clause & policy excess deductibles 24,000/-

Ordered for settlement , net loss payable, as per survey plus lump sum ex gratia as interest & compensation, for long delay in settlement.

AHD11/005/270

U V Chauhan

Std Fire & Spl perils policy. House damaged.Repudiation due to exclusion clause.

Damage due to heavy rain Due to water leakage / seepage by rain water in first floor & stair room.

Peril causing damage is an excluded peril, as per coverage.Decision by Insurer upheld.

Insurance Ombudsman Claims/Awards:Case studies on Burglary claims



BBSR11/02/0056 A/C

T K Mondal

Shop Stock BurglaryAmount claimed as per stock statement produced

Assessment on the basic of quantity claimed, but offered as per Income Tax documents/ Returns

Order Reasonable : settlement on the basis of Income Tax documents/ Returns

Chandigarh 25/OIC/11/0

7 J Singh

Shop Stock BurglaryLow boundary wall , no watch & ward but main gated locked broken

Violent, visible , forcible entry pre condition for admissibility of claim

Loss genuine as per InvestigationOrdered the claim payable

KochiGI/11/2006-

7A/c Anantharam

an

Shop Stock BurglaryStock statement/ documents not produced

Repudiation : Stock records/ documents not producedNot payable on the basic of quantity claimed

Cost of stock :difference before & after the loss, quantified by Surveyor & CA awarded as payable

Insurance Ombudsman Claims/Awards:Case studies on PA/JPA claims



AHD15/005/170 H C Soni

TTD benefit Repudiation : Difference in medical opinion

9 weeks by treating Dr & 6 weeks by referee. Both has expertise in the field

TTD benefit payable.Golden mean rule benefit for 6 weeks granted

HYD G-14/2006-7G lakshmi

JPA : Deceased brutally killed by extremists, along with others suspecting as

Police final report issued. Bodies badly brunt to ashes.Non –settlement in absence

Insurer did not dispute death & satisfied on its genuineness.Directed as claim payable for full SI

police informers. of PMR etc along with interestAHD

11/002/279B N Babia

TTD benefit settled.Repudiation of subsequent PPD claimed.

Policy condition : More then one sub clause , for same period is excluded.

Decision by Insurer, to settle on TTD only upheld.

AHD11/005/030K K Bhatia

PA claim TTD benefit not settled.Insured injured severally by vehicular accident

Complainant was treated by Specialists Recommended at least 104 weeks TTD/ Very difficult to access the TTD

Looking into injuries & opinion of medical referrers benefit awarded for 104 weeks not exceeding the SI.

Case studies on MediclaimsInsurance Ombudsman Claims/Awards:



ChennaiIO/CHN/G-40/2010-11 S Chandran

Mediclaim :OPD treatmentRepudiation on the ground of exclusions in such policyNo hospitalization

OPD treatment , not hospitalized for 24 Hrs On such condition post-hosp expenses up to 60 days payable.

No hospitalization Policy condition for minimum 24 Hrs as in patient requiredRepudiation upheld

Chennai 11/02/1281 M S Velu

Mediclaim : break in policy for 7 months. Complainant failed to submit copy of discharge summary

Any policy commencing after break in policy, considered as fresh policy. Pre existing disease are exclusions in such policy.

Insurer submitted prior medical reports advise for further treatment on the ailmentRepudiation upheld

Chandigarh101/uii/14/07

Surinder Singh

Mediclaim ; Enteric fever, hospitalized.Justification sought by TPA for longer duration

Hospitalized for 11days.Adm/Discharge summary clear on the issue.Harassed on flimsy grounds

A qualified Dr recommend admission for as specified period. Period is immaterial & not questionable.Ordered claim be settled

Chandigarh81/uii/

14/07 V K Nayyer

Mediclaim & OMP for 3 months, for this period Mediclaim policy not renewed. Extension for renewal purpose.

Mediclaim policy not renewed & subsequently taken treated as fresh policy.Both Policy should be taken from same insurer

Distn between Mediclaim & OMP unsustainable. Policy taken from other insurer are valid for the purpose of continuityOrdered that claim be settled

Chandigarh81/uii/14/07

Sunita Rao

Pre-operative x-ray not submitted. TPA insisted forPost operative film showing plating done on the fracture

Treating Dr./Hospital confirmed ‘mandible fracture & plating was done’. Holding up the pending claim unjustified

On the basis of facts & circumstances, no doubt on the treatment established it was a case of fracture as a result of accident Ordered that claim be settled

Chandigarh128/nic/

14/07 HC Nair

Insured felt pain in chest collapsed in office Hospitalized, for 3 days. ECG done & advised admission.

Investigation carried out, no serious abnormality detectedNo positive existence of any ailment, though initially appeared to be heart ailment

Repudiated as per policy clause exclusion 4.10Investigation shows normal results.Repudiation upheld.

Chandigarh119/nic/14/07 S Mitra

Repudiation as per Panel Dr opinion , known case of Atrial Fibrillation & hypertension. No need for Hospitalization, no emergency.

Hospitalized, for I day, as advised admission, by treating Dr. Basic question was Hospitalization required /not

Hospitalization was not warranted. As per discharge summary readjustment , of continuing mediclaim only & could have evaluated by ECG only Complaint dismissed

ChennaiIO/CHN/G-1058/2006-7 G S Vennkat

raman

Repudiation : Pre existing disease are exclusions in policy. Disease/ ailment which could not develop in short span of time

Histopathology report revealed that insured had papillary carcinoma, infiltrating perithioridal soft tissues,

There should be a manifestation by way of set of symptoms /signs prior to proposal acceptance. Insurer failed to establish the same .Directed to settle the claim.

ChennaiIO/CHN/G-1037/2006-7 Muralidhar

Mediclaim policy Repudiation : TPA pointed that it was for management of an ailment which was related to Pre-existing exclusions. They may be one of the contributing factors among others

Patient was Diabetic Hypertentive for past 20 years. Pre-existing.Insured met with an accident & had a blood clot.Hospitalized, 5 days. They may be one of contributing factors among others

Diabetic Hypertention are not the sole cause of for heart problem , controlled by regular medication .. Heart disease as Proximate cause could not be conclusively established by the insurers. Directed to settle the claim

Hyd –G-030/2006-07

D K Jain

Individual Mediclaim policy Repudiation : treatment fall under exclusion 4(5)

Zyoptix surgery of both the eyes. Operation was neededInsured’s contention: No abnormal increase in refractive error

Insurer obtained an independent opinion from expert Surgery undergone falls under cosmetic/aesthetic treatment. In view of the evidence Decision upheld.

Kochi GI/28/206-07 Jayalakhmi

Individual Mediclaim Repudiation : break for 2 days in renewal. Amt of renewal premium entrusted to agent, insured reportedly unaware of the break

Insurer had not taken a fresh proposal formPolicy treated a fresh one Repudiation on Pre-existing

All Insurers have discretion to condone 7 days delay in renewal. Insurer should have obtained a fresh proposal form. Technically break is a fact , but Insurer is also at lapse.50% of the claim allowed

Kochi GI/27/206-07Anju Manoj

Individual Mediclaim Repudiation : Treatment for chicken pox. No facility in hospital for treatment in isolation of such patients

Repudiation : domiciliary treatment, did not satisfy the requirement laid down in the policy.

Close examination of record : Treatment genuine. Dr clarified only domiciliary treatment possible, for want of isolation facility in hospital.IO Directed to honor the claim.

Kochi GI/24/206-07

V Rajan

Mediclaim policy not renewed in chain.Repudiation: Due to break in renewal & the policy treated as fresh one.

Thyoriod operation & the case history cited the problem as existing for a period of 3 years.

The records of the case proved that the disease was pre existing to the present policy. Insurer justifiable in repudiation as per policy condition. Decision upheld, Complaint dismissed

Kochi GI/22/206-07

Rashita p

Repudiation. Pre existing disease. Insurer based their decision on the opinion of a panel Dr., that the problem could have pre existed for175 days.

Insured contended to be unaware of the problem as of Cervical Spondylosis till the consultation & advise for hospitalization.

In any case in absence of proper diagnosis , insured could not be said to be aware of it . Directed to settle the claim, subject to proper verification of bills/ compulsory deductibles

Kochi GI/21/206-07

K S Pillai

Repudiation. Insurer based their decision on TPAs stand that tests conducted only for diagnosis of Angioplasty done three years back.

Angioplasty done three years back. Admitted againOn evolution of records, tests were found to be of continuous treatment of Angioplasty done earlier.

Contention of Insurer found erroneous, taking overall view of the caseDirected to settle the claim, subject to compulsory deductibles.

Mumbai GI-036 /2005-06

P Chibbar

Overseas Mediclam Disclosed diabetics & BP submitted ECG . Developed fever, while at Newziland admitted & claim repudiated on pre-existing exclusion

Admission note confirmed that some patient had Transient ischemic attack. Some old ischemic changes consistent with age.

Pre disposing factors are intervened in a complicated manner & existing illness played a major part. For a possible genesis of the disease, which could be diagonised by test followed by a package of treatments.50% of the admissible claim allowed

Insurance Ombudsman Claims/Awards:Case studies on Group Mediclaims



Chandigarh/GIC/292/

Gr Mediclaim :surgery for Kidny stone removal

Not only a disease should be Pre –existing, but also

Imp ingredient of policy condition: Existence of disease should be in the

NIA-14/06Repudiation on the ground of exclusions :Pre –existing disease

should be in the knowledge of insured. Clarification by treating Dr, in discharge summary past history ‘ nil’

knowledge of insured.Disease not being in the knowledge of complainant, directed as claim payable

Documents

Case Studies on Insurance Ombudsman Claims