#insurance claim denial

The M.P. State Consumer Commission ruled that insurers cannot deny claims for intravitreal injections like Lucentis solely because they are administered as outpatient procedures, if certified by a medical professional as medically necessary. This sets a critical precedent for policyholders undergoing chronic eye treatments, ensuring coverage aligns with clinical reality rather than arbitrary hospitalization clauses.

The NCDRC has ruled that under Section 45 of the Insurance Act, an insurer cannot deny a life insurance claim after three years from the date of policy issuance, regardless of alleged misrepresentation or suppression of material facts. This reinforces the statutory protection for policyholders and ensures finality in claims, benefiting millions of Indian life insurance beneficiaries.

The NCDRC ruled that an insurer’s refusal to settle a motor insurance claim without challenging the repair estimate or submitting opposing evidence amounts to deficiency in service under the Consumer Protection Act. This sets a clear precedent: insurers must actively justify denials, not remain passive, protecting policyholders from arbitrary claim rejections.

Delhi State Consumer Disputes Redressal Commission rules that a company insuring a commercial vehicle for livelihood purposes falls under the definition of 'consumer' under the Consumer Protection Act 2019. The Commission rejected insurer's attempt to deny claims based on mere suspicion of forged bills, reinforcing that valid claims cannot be dismissed without concrete evidence.