In Absence Of Fundamental Breach Of Insurance Policy, Up To 75% Expenses Can Be Claimed On Non-Standard Basis: Madhya Pradesh State

The Madhya Pradesh State Consumer Disputes Redressal Commission ruled on a case involving an insurance claim. The complainant, having purchased a non-standard health insurance policy, faced difficulties when claiming expenses. The insurer denied part of the claim on the grounds of policy non-compliance, arguing that the expenses were not covered as per the policy's terms. The Commission determined that this denial constituted a fundamental breach of the insurance agreement. It mandated the insurer to settle 75% of the claimed expenses, emphasizing that adherence to policy terms should be clearly communicated and fairly enforced. The decision underscores the necessity for insurers to honor their commitments and address claims in a transparent manner.