Five consumer commission orders reported on September 29, handed down between September 21 and September 28 across four states, all apply the same principle in different forms: the burden of proving a repudiation sits on the insurer, not on the policyholder's family. A claim was rejected solely for want of original documents, and the Raipur bench called that deficiency in service and unfair trade practice. A life claim was repudiated on the strength of a congenital heart procedure performed in 2008, and the Sri Muktsar Sahib bench set the repudiation aside because LIC produced no medical record from before the policy was issued. A state health scheme claim for medicines taken after discharge was refused by the insurer and its administrator, and the Kannur bench held both liable. A travel insurance claim was rejected under an investigation-and-evaluation exclusion, and the Delhi bench held that a medical decision belongs to the treating physician. And in Amritsar, a bank was found deficient in service for not telling an account holder that a Rs 330 premium auto-debit had failed on a balance of Rs 223.42, after which the cover under a central life insurance scheme lapsed and the account holder's daughter died in a road accident.

Context: the orders, and the numbers in them

  • Raipur, Rs 12.75 lakh plus Rs 1 lakh and Rs 10,000. The family of a man treated for cardiac illness in 2015 under a health policy that had renewed continuously since 2010 was reimbursed nothing because the insurer said originals were not submitted despite reminders. The commission held that rejecting a claim solely on that ground is contrary to law when notarised or certified copies have been given and originals are offered for verification. It awarded the sum insured rather than the Rs 12.04 lakh claimed: Rs 5 lakh under the samayojan provision plus the Rs 1.50 lakh recharge benefit for 2015-16.
  • Sri Muktsar Sahib, Rs 5 lakh with 7 percent interest from January 29, 2024. LIC repudiated a death claim on the ground that the deceased had not disclosed an ASD/VSD closure and Post Fontan procedure done in 2008. The commission found the insurer's own papers inconsistent: one proposal form carried no signature or date, the "complete" form was dated May 22, 2022 although the policy had been issued on April 28, 2022, the repudiation letter relied on a form dated May 30, 2022 that was never produced, and LIC placed neither the policy nor its terms on record. Not one medical document predating the policy was filed. The award carries 7 percent annual interest from the repudiation date plus Rs 10,000, and the sum insured is reduced by any premium already refunded ex gratia.
  • Kannur, Rs 66,263 plus Rs 13,000 and Rs 7,000. A police employee enrolled under the state employees' medical insurance scheme admitted his mother after a stroke, was asked for a Rs 50,000 advance, and paid the Rs 74,263 the insurer and hospital did not cover. The bench held that the scheme entitles the beneficiary to the cost of drugs even after discharge, so the third-party administrator and the insurer were deficient and the hospital was not.
  • Delhi, Rs 9,06,625 plus Rs 25,000 and Rs 5,000. Two emergency-room visits in the United States, on January 28 and January 31, 2023, under a travel policy valid to March 31, 2023, came to $9,465.70. The insurer relied on the exclusion for investigation and evaluation. The bench did not accept it, noting that a traveller would not ordinarily be admitted merely for diagnostics when such facilities were available in India, and converted the bills at Rs 95.78 to the dollar on the date of the order.
  • Amritsar, Rs 1.5 lakh plus Rs 10,000. The bench held that a bank which operates an auto-debit facility, knows the balance was short and sees the debit reversed cannot fully absolve itself by saying the system failed; it had a duty to inform the account holder about the failed renewal transaction.

Implication: what these orders change in practice

  • Documents are a verification tool, not a veto. Four of the five cases turned on the insurer treating a document formality as decisive. Certified copies, with an offer to produce originals, move the burden back where the law puts it.
  • An old medical history is not evidence of concealment. The Punjab order is the useful precedent here because it names the evidentiary gaps: a procedure alleged for 2008 with no 2008 record, a condition inferred only from 2023 hospital papers, and a proposal form that post-dates the policy. An insurer relying on non-disclosure has to place pre-underwriting evidence on record.
  • Exclusions cannot re-decide medical questions. Both the Kannur and Delhi orders turn on whether treatment was medically necessary and whether the entitlement existed. A package rate applied by an administrator, or an exclusion invoked after the event, is not the same thing as a term of cover.
  • Compensation is bounded by the contract. In Raipur the claim was proved and the award was still cut to the sum insured. A win on liability is not the same as a win on quantum.
  • Distributors have duties too. The Amritsar order matters because a lapsed policy under a government scheme is usually treated as a lapsed policy, not as a bank failure. A Rs 106.58 shortfall cost a life cover benefit, and the bench treated the bank's silence as the actionable wrong.

Action

Keep the paper trail a claim file depends on: certified copies of every document, a dated acknowledgement of what you submitted, and the insurer's deficiency list in writing. If a claim is refused for want of originals, ask in writing for the specific documents, offer verification, and set a date. Escalate to the insurer's grievance redressal officer, then to IRDAI's Bima Bharosa portal, then to the insurance ombudsman, and keep the order dates, because each step has a clock. If the rejection is on non-disclosure, ask the insurer to produce the medical evidence it says it relied on and the date on which it obtained it; the Punjab order shows that a gap in that evidence is decisive. Watch for appellate orders on these decisions, and for any high court guidance that consolidates them.

Watch item: whether insurers respond to the pattern by tightening document checklists. That would make compliance worse for genuine claimants while leaving the underlying proof problem untouched.