The document discusses an insurance claim dispute case. A policyholder filed a claim for his son's kidney stone treatment, but the insurance company rejected it, arguing the condition was pre-existing. The consumer disputes forum found that while the claim was not payable due to the pre-existing exclusion, the insurance company was deficient for not properly communicating this to the complainant. The forum directed the insurance company to pay Rs. 5,000 to the complainant for deficiency in service.

1. PRESENTED BY:
Kapil Dev Sharma
Kunal Dhawan
Naved Sami
Pooja Babber
Vishal Sharma

2.  Essential Elements of Insurance
 Concept of Claim
 Amount payable
 Types of Claims
 Processing of Insurance Claim
 Guidelines
 Disputes in Insurance Claim
 Rejection of Claim
 Summary

3.  Concept of Insurable Interest
 Doctrine of Good Faith
 Proximate Cause

4.  Claim is a right of insured to receive the amount secured
under the policy of insurance contract promised by
Insurer
 Insurance Claim is the request of the insured policy
holder/beneficiary from the insurer/insurance issuing
company for financial reimbursement whenever he/she
suffers a loss of the insured property/life/health/etc
 Insurer- settle the claim after satisfying himself that all
the conditions and requirements for settlement of claim
have been compiled with

5.  Should be done in accordance with the specifications
of the insurance policy/contract
 The amount insured or face value of policy
 Bonus if declared by company
 Share of profit in case of participation policy
 Surrender value if policy lapsed

7.  Payable as per the terms of contract- at the end of the term
 Insurers inform the policyholder well in advance about the
maturity date
 Insurers send the form of discharge which is duly signed, and
returned with-
a) Original Policy document
b) proof of age- to prove the identity
c) Document of assignment- if executed on a separate
stamped paper
 Gross amount includes basic sum assured, bonus etc
 Deductions include loan amount, unpaid premium etc.
 Circumstances like settling the claim on the basis of
indemnity bond require more caution (in case original policy
is not found)

8.  Intimation of death by a proper person and proof of
death
A. Premature/early claim: insured dies within 3 years of
taking out of policy
a) statement from the last medical attendant giving details
of last illness and treatment
b) Statement from the hospital
c) Statement from the employer
B. Other claim : insured dies after 3 years of taking out of
policy
a) Policy number and Name of life assured
b) Date and Cause of death
c) Claimants relationship
d) Death certificate
e) Deeds of assignment

9. C. In case of unnatural death: accident, suicide, or
unknown cause etc
a. Police inquest report
b. Panchanama
c. Post mortem report
d. Chemical examination report
D. Under the Indian Evidence Act, a person is presumed to
be dead if he is disappeared for 7 years
 Upon the death of the life insured the amount is payable
to the nominee given in the proposal form

10.  Some policies entitled for the survival benefit before
the expiry of the full term of the policy
 Settlement is easier than maturity claim
 Insurer sends advance intimation and the discharge
voucher which is returned with necessary documents
a) Proof of identity
b) Original policy
c) Document of assignment

11. 1) The policy holder or the beneficiary calls up the insurer
claiming the insurance asking about all the minute details
of the process of claiming the same along with the
documents required
2) The insurance company asks for the details of the loss and
the relevant documents in support of the Claim
3) A notice has to be issued by the policy holder for claiming
the same with utmost urgency mentioning all the possible
details (namely, name of the policy holder, names of the
persons associated with the accident, witness particulars,
their addresses, etc).

12. 4) The insurance company would make all the possible
queries and inspections by the company representatives or
consultants
5) They have the right to inspect all the relevant properties
related with the loss along with police verifications and
determination of the policy holder's liability structure
6) The processing period is mentioned in the contract
document, which is the approximate time required for
verification of the genuineness of the Insurance Claim
7) On agreement of claim amount between the insured and
the insurer, the claim is settled
Claim form

13. As per IRDA,
 Insurance company is required to settle a claim within 30
days of receipt of all requirements
 If the claim warrants further verification, the company
should complete its procedures within 6 months from
receipt of written intimation of the claim
 If the company settles the claim beyond 6 months period,
then interest is payable by the company on the claim
amount
 The interest is payable only where the claimant has
submitted all the requirements. Further, rate and period of
interest are decided as per IRDA guidelines

14.
Every insurer, in the case of an insurer specified in sub clause (‑ a)
(ii) or sub clause (‑ b) of clause (9) of section 2 in respect of all
business transacted by him, and in the case of any other insurer in
respect of the insurance business transacted by him in India, shall
maintain:
(a) a register or record of policies, in which shall be entered, in
respect of every policy issued by the insurer, the name and
address of the policy­­holder, the date when the policy was
effected and a record of any transfer, assignment or nomination
of which the insurer has notice, and
(b) a register or record of claims, in which shall be entered every
claim made together with the date of the claim, the name and
address of the claimant and the date on which the claim was
discharged, or, in the case of a claim which is rejected, the date
of rejection and the grounds there for.

15.  Identifying the person to whom the payment is to be made
 Whether the payment is within the terms of policy
 Whether the amount claimed is reasonable
 Proof of Death
 Identification of assignee, nominee or the legal heir to whom the
payment is to be made

16. The main reasons for claim not being passed in full
are :
 Insured has pre­existing disease and it was already
mentioned in policy document as an exclusion.
 The specific disease is not covered under the policy
 Disease is a pre­existing disease and it was not revealed
by the insured at the time of issue of policy.
 The main reasons for claim being passed in part are :
 Some of the tests conducted/treatment were not relevant to the
disease for which patient was admitted.
 Some costs like consumables are not payable by the insurance
company

17.  Claims may arise because of –
a) Survival up to end of the policy term­ maturity claim
b) Survival up to a specified period during the term –
survival benefits claim
c) Death of the life assured during the term – death
claims
 Insurance claim management is a core issue for the
protection of insurance policyholders

18.  Completed proposal form plays an important role as
it affects the claims under policy
 It has been observed that all the Insurance Claims
are not genuine and are fraudulent in nature. So,
every Insurance Claim is needed to be processed by
the insurer before approval in order to avoid
insurance fraud
 Need for enhanced efficiency, transparency and
disclosure of information to policyholders during the
claim management process

20. Mr. Devinderpal Singh, a resident of Jamalpur, had taken a Mediclaim
policy from the company for his 10-year-old son Raja. He was insured for
Rs 20,000 for the period from October 13, 1998 to October 12, 1999. The
complainant stated before the forum that in the first week of November,
1998, his son, felt severe pain in his abdomen. After the medical
examination, a stone was found in his kidney. Thereafter, Raja was taken to
the Sidhu Hospital for the treatment and there he underwent treatment in
November 1998.
The complainant stated that he had spent huge amount on his treatment
but could not preserve all the bills and submitted the bills for Rs 18,500.
The company pleaded that the said policy was obtained after concealment
of the precious disease as the disease was pre-existing at the time of taking
the policy as such the claim was not payable.

21. The company further stated that Dr Tarsem Lal Gupta who was
referred the case for the medical opinion, said Raja was suffering
from pre-existing disease at the time of taking the insurance policy
and as the claim fell within the exclusion clause No. 401 of the
policy. The company maintained that the claim was rightly
repudiated
The forum observed, "It appears as if the father of Raja had
knowledge of the disease and as such he took the policy to meet the
expenses of the treatment. The forum stated that the disease was
pre-existing and was not covered under the policy. The
forum further added that the company had intimated the
complainant that the claim lodged was considered as 'no claim' as
per the rules of the policy. The forum held that there was a clear
deficiency on the part of the company for not intimating the
complainant
The District Consumer Disputes and Redressal Forum in Ludhiana
directed National Insurance Company to pay Rs 5,000 to Mr.
Devinderpal Singh on account of deficiency in service, even though
claim was not payable.