Travel insurer ‘rejects’ claim after man dies in US accident, father wins Rs 40 lakh payout

“The repudiation of the claim by the opposite party (Care Health Insurance Limited) is illegal and not in accordance with law. Consequently, the complainant is entitled to be indemnified under the policy… The (insurer) kept on raising the queries on false and flimsy grounds although all the documents were already submitted,” the commission said on July 6.

The dispute arose after Dev Singh, who had travelled to the US under a travel insurance policy issued by Care Health Insurance, died in a road accident in Los Angeles on November 4, 2021. His father, Rajeev Singh, the nominee under the policy, later lodged a claim for the insured amount. The insurer sought additional documents through several communications before ultimately repudiating the claim on June 16, 2022, leading to the consumer complaint.

Insurance purchase, death, claim

According to the complaint, Dev Singh purchased an “Explore Gold-WW” travel insurance policy from Care Health Insurance on August 30, 2021, after paying a premium of Rs 9,633. The policy remained valid until February 25, 2022, and provided accidental loss coverage of US$50,000.

While staying in Los Angeles, California, Dev met with a fatal road accident on November 4, 2021. Following his death, Rajeev informed the insurer and initiated the claim process by submitting the documents sought for processing the insurance claim. Rajeev claimed he promptly responded to every communication issued by the insurer and repeatedly furnished documents, including the autopsy report, hospital records and other documents sought during the claim process.

According to the complaint, despite receiving those documents, the insurer continued to raise new queries and repeatedly sought records that had already been submitted. The claim was eventually repudiated on June 16, 2022, on the ground of “deficiency not replied”. After a legal notice failed to resolve the dispute, the complainant approached the consumer commission seeking reimbursement under the policy along with compensation for harassment and litigation expenses.

Care Health Insurance opposed the complaint, contending that the complainant had not furnished all documents required to process the claim. The insurer submitted that several communications had been issued seeking compliance with the policy requirements and argued that the claim was repudiated because the alleged issues remained unresolved despite requests.

Insurer’s stance unjustified: Forum

After examining the documents placed on record, the commission found that the complainant had replied to every communication sent by the insurer. It noted that hospital documents had already been submitted in PDF format on February 14, 2022. Despite this, the insurer continued asking for the same before rejecting the claim.

The commission concluded that the insurer had failed to justify rejecting the claim and held that the complainant was entitled to the policy benefit. Allowing the complaint, the commission directed Care Health Insurance to pay around Rs 40.76 lakh, representing the insured amount payable under the policy.

It also awarded interest at 7 per cent per annum from the date of filing of the complaint until payment. In addition, the insurer was directed to pay Rs 50,000 towards harassment, mental agony, loss of time and litigation expenses. The commission directed the insurer to comply with the order within 30 days.

Takeaway

The order highlights that an insurer cannot reject a genuine insurance claim by repeatedly demanding documents that have already been submitted. For consumer-related grievances, individuals may contact the consumer helpline in their respective states (Delhi: 1800-11-4000) or call the National Consumer Helpline at 1915 for assistance.