Two insurers rejected her father’s death claims. She took them on and won ₹26L.

“Half of my father’s body was already paralysed [when we bought the policy]. We had disclosed this, his hypertension, and other diseases when buying the personal accident policy. The insurer rejected the claim, saying his death was due to a seizure and not an accident. This wasn’t written in any of the medical documents,” Ambesh said.

Chand had suffered a paralysis attack in June 2021, months before he died, and got better in the following weeks. “He had started going to work as well. On 9 August 2021, he slipped on the stairs. We took him to a CGHS (Central Government Health Scheme)-empanelled hospital in Delhi. There was a lot of internal bleeding and it became a case of brain haemorrhage. The surgery began the same day and lasted 24 hours,” Ambesh said.

Hospital trouble

Hospital expenses were not an issue as he was covered under CGHS. But, being a CGHS patient came with its own set of challenges. The hospital discharged him forcefully, said Ambesh. “They told us they couldn’t keep a CGHS-empanelled patient for a long time. They put pressure on us for a forced release. We had to arrange for everything from an oxygen cylinder to a concentrator and a suction machine at home. Within an hour of reaching home, he felt uneasy so we took him to a hospital nearby,” she added.

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The family’s troubles multiplied from here. Two hospitals refused to admit him and a third kept him for only a day. “Eventually a private hospital admitted him. He was there until he passed away more than a month later,” Ambesh said. “Thankfully we got the cashless facility and ₹16 lakh was paid by the government,” she added.

Insurance trouble

Amid all this, the family still needed to pay their EMIs for the flat. Ambesh emailed the insurance company several times to get the claim under the group accident policy, but it was rejected. “Somebody suggested that I threaten to take them to consumer court. This too did not work. I eventually got to know about a company that helps policyholders get their claims. They told me about the insurance ombudsman,” she said.

Ambesh filed a complaint, shared all the documents and finally got a hearing date with the ombudsman. “It was an online meeting. What surprised me most was that it lasted less than five minutes. The insurance company, which made me run from pillar to post for one-and-a-half years, did not say a word in front of the ombudsman chief, as though they were only waiting for me to escalate the matter. Thankfully I got the claims amount of ₹22 lakh and paid the remaining loan,” she said.

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Next up was an insurance policy that her father had bought from a public-sector bank with which he’d had an account. “I got hold of the insurance document and the bank statement showed that the bank would deduct ₹200 every year for the insurance policy. When I approached the bank, the staff told me they deduct it just like that, and nobody gets it,” she said.

Ambesh did not give up. She approached the insurance company directly. It, too, rejected the claim, saying the fall was not accidental but happened due to complications arising out of his medical condition. “I had expected this. I showed them the ombudsman award in my favour, but they still did not settle the claim. I again reached out to the ombudsman,” she said. The ombudsman eventually ruled in her favour and Ambesh received the ₹4 lakh payout.

A potential solution

Note that an aggrieved policyholder must first write to the grievance redressal officer (GRO) of the insurance company before she can approach the insurance ombudsman. GROs are supposed to take an impartial view of the complaint, but industry stakeholders said this does not happen for obvious reasons. This leads to cases piling up at ombudsman offices, especially in metro cities.

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The Council for Insurance Ombudsmen (which manages the offices of the insurance ombudsman) spent ₹61 crore to resolve 49,705 claims rejections in FY24, or about ₹12,000 per complaint. The council receives funds from insurance companies based on their turnover. 

Consumer policy expert Bejon Misra, who was a member of the insurance ombudsman advisory committee, suggested that insurance companies facing a large number of complaints be required to pay more. “This would encourage insurers to resolve complaints and reduce the number of cases filed with the ombudsman,” he said.