Case Studies On Insurance Ombudsman Claims

Insurance Ombudsman Claims/Awards:
Case studies on Motor OD

IO centre Facts/Insurance Cos stand
on Repudiation
Issues involved Insurance Ombudsmans Reasoning
/Decision
AHD
11/003/264
A/C :
S Y Patel
Quantum dispute: Motor
OD claim
Surveyor assessed :Net of
salvage/ deductibles 2.15
lacs.
Surveyor assessed Net loss
payable 2.15 lacs., but
Discharge 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
AHD
11/002 /302
A/C :
M P Rawal
Pvt car purchased, RTO
transfer confirmed
Accident 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
AHD
11/004 /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
AHD
11/002 /263
A/C :
Yogesh Patel
OD claim : Partial Loss

Repair basic settlement
offered
Assessed loss after
depreciation, fell below
75% of IDV
Not treated as constructive
total loss CTL
Should have assessed without
applying depreciation & treated as
constructive total loss CTL
Repair basic settlement offered
Decision by Insurer upheld
AHD
11/003 /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.
Kochi
IO/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
OD claim : Partial Loss
Settled 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.

AHD
11/002 /258
A/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 IMT
Repudiation Decision upheld
AHD
14/003 /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.
AHD
14/002 /339
A/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 produced
Directed to pay Surveyors assessed
full claim
AHD
11/002 /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
seating ,exceeding 6 persons
In order to avoid harsh consequences
normally Insurers offer non standard
basic settlement of the assessed
amount.
Decision upheld.
AHD
11/003 /304
V K Nanolia
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.
AHD
11/005 /257
V Prassana
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 executed
The case can not be reopened
AHD
11/002 /360
A A Imam
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.
AHD
11/014 /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
AHD
11/004 /111
J V Hirappa

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
AHD
11/004 /367
T P Patel
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 covered
Established process of claim scrutiny
followed. Another panel surveyor
affirmed the position.
Decision of repudiation upheld.

Case studies on Misc Policies

on Repudiation
/Decision
AHD
11/002/0018
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 exclusions
Directed 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.
AHD
11/002/002
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.
AHD
11/002/072
V 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.

Case studies on Fire claims
on Repudiation
/Decision
BBSR
14/002/0057
Ranjit singh
Quantum dispute: fire at
Godown/shops claim
Surveyor 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 disputed
Not 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.
AHD
11/005/270
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.

Case studies on Burglary claims
on Repudiation
/Decision
BBSR11/02/
0056 A/C
T K Mondal
Shop Stock Burglary
Amount 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 Burglary
Low boundary wall , no
watch & ward but main
gated locked broken
Violent, visible , forcible
entry pre condition for
admissibility of claim
Loss genuine as per Investigation
Ordered the claim payable
KochiGI/11/
2006-7A/c
Anantharam
an
Shop Stock Burglary
Stock statement/ documents
not produced
Repudiation : Stock records/
documents not produced
Not payable on the basic of
quantity claimed
Cost of stock :difference before &
after the loss, quantified by Surveyor
& CA awarded as payable

Case studies on PA/JPA claims
on Repudiation
/Decision
AHD
15/005/170
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-
14/2006-7
G lakshmi
JPA : Deceased brutally
killed by extremists, along
with others suspecting as
police informers.
Police final report issued.
Bodies badly brunt to ashes.
Non settlement in absence
of PMR etc
Insurer did not dispute death &
satisfied on its genuineness.
Directed as claim payable for full SI
along with interest
AHD
11/002/279
B 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.
AHD
11/005/030
K 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 Mediclaims
IO centre
Facts/Insurance Cos
stand on Repudiation
Issues involved Insurance Ombudsmans
Reasoning /Decision
Chennai
IO/CHN/G-
40/2010-11
S Chandran
Mediclaim :OPD treatment
Repudiation on the ground
of exclusions in such policy
No 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 required
Repudiation 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 ailment
Repudiation upheld
Chandigarh
101/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
Chandigarh
81/uii/14/0
7 V K
Nayyer
Mediclaim & OMP for 3
months, for this period
Mediclaim policy not
renewed. Extension for
renewal purpose.
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 continuity
Ordered that claim be settled
Chandigarh
81/uii/14/0
7 Sunita
Rao
Pre-operative x-ray not
submitted. TPA insisted for
Post 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
Chandigarh
128/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 detected
No positive existence of any
ailment, though initially
appeared to be heart ailment
Repudiated as per policy clause
exclusion 4.10
Investigation shows normal results.
Repudiation upheld.
Chandigarh
119/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
Chennai
IO/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.
Chennai
IO/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
Patient was Diabetic
Hypertentive for past 20
years. Pre-existing.
Insured met with an
accident & had a blood clot.
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
exclusions. They may be
one of the contributing
factors among others
Hospitalized, 5 days. They
may be one of contributing
factors among others
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 needed
Insureds 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
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 form
Policy 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/27/206-07
Anju Manoj
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
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 again
On 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
case
Directed 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
Case studies on Group Mediclaims
IO centre
Facts/Insurance Cos
stand on Repudiation
Issues involved Insurance Ombudsmans
Reasoning /Decision
Chandigarh/
GIC/292/NI
A-14/06
Gr Mediclaim :surgery for
Kidny stone removal

Repudiation on the ground
of exclusions :
Pre existing disease
Not only a disease should
be Pre existing, but also
should be in the knowledge
of insured. Clarification by
treating Dr, in discharge
summary past history nil
Imp ingredient of policy condition:
Existence of disease should be in the
knowledge of insured.
Disease not being in the knowledge
of complainant, directed as claim
payable

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Case studies on Motor OD

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