Munish Sharma raises a serious complaint against ICICI Lombard for rejecting his daughter’s genuine accident-related dental treatment claim, despite IRDAI guidelines protecting policyholders. The case highlights poor claim handling and violation of consumer rights.
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Complaint Summary : ICICI Lombard Accident Claim Denied – Munish Sharma’s Complaint Against Unfair Rejection
| Customer Name | Munish Sharma |
|---|---|
| Complainant Relation | Father (for daughter’s accident claim) |
| Company/Brand | ICICI Lombard |
| Policy Number | 4177I/ICICI/329382118/01/000 |
| Complaint Type | Health Insurance Claim Rejection |
| Incident | Accident with dental injury (broken teeth) |
| Treatment Timeline | Accident hospitalization approved; dental treatment advised after 15 days |
| Issue | Claim denied for dental procedure despite medical recommendation |
| Status | Pending – Claim Rejected |
| Original Post URL | LinkedIn Source |
Detailed Write-Up
The Core Complaint
Munish Sharma has raised a formal complaint against ICICI Lombard General Insurance regarding the rejection of a genuine accident-related claim. His daughter met with an accident for which cashless hospitalization was initially approved. However, her dental injury (broken teeth) required a stabilization procedure, which was scheduled 15 days later as per the treating doctor’s advice.
Shockingly, when the family submitted the dental claim, ICICI Lombard refused both cashless approval and reimbursement, citing technical grounds.
Why This Denial is Unjustified
- The dental procedure was a direct continuation of the accident.
- The deferral of treatment was a medical decision, not a consumer choice.
- As per IRDAI guidelines, insurers cannot reject accident claims on frivolous technical grounds.
- The denial defeats the purpose of accident insurance coverage, which is meant to protect consumers from unexpected financial burdens.
Consumer Rights at Stake
- Right to Fair Treatment – Every genuine policyholder’s claim should be assessed transparently.
- Right to IRDAI Protection – IRDAI clearly mandates that insurers cannot arbitrarily deny valid accident claims.
- Right to Escalation – Consumers can escalate unresolved disputes to the IRDAI Grievance Cell and the Insurance Ombudsman.
Possible Escalation Steps
Munish Sharma has demanded urgent intervention and warned that if the issue is not resolved within IRDAI’s stipulated timelines, he will escalate it to:
- IRDAI Grievance Redressal Cell
- Insurance Ombudsman
This case highlights the urgent need for accountability in health insurance claim handling.
FAQs – ICICI Lombard Accident Claim Rejection
Q1. What is Munish Sharma’s complaint against ICICI Lombard?
His daughter’s accident-related dental treatment claim was rejected despite it being a direct consequence of a covered accident.
Q2. Was the initial accident hospitalization approved?
Yes, ICICI Lombard approved the cashless hospitalization for immediate accident-related treatment.
Q3. Why was the dental claim rejected?
ICICI Lombard cited technical grounds, despite the procedure being a continuation of the same accident.
Q4. Why does Munish Sharma consider this rejection unfair?
Because the treatment was medically deferred by the doctor, and IRDAI guidelines prohibit denial of genuine accident claims.
Q5. Which IRDAI rules apply here?
IRDAI mandates that insurers must honor all valid accident claims and cannot reject them on frivolous or irrelevant grounds.
Q6. What escalation options are available?
- File a complaint with ICICI Lombard’s Grievance Redressal.
- Approach the IRDAI Grievance Cell.
- Escalate to the Insurance Ombudsman.
Q7. What is the role of the Insurance Ombudsman?
The Ombudsman provides an independent platform for resolving disputes between policyholders and insurers.
Q8. Can dental injuries from accidents be covered under health insurance?
Yes, when directly resulting from an accident, dental treatments are generally covered under accident policies.
Q9. How long should ICICI Lombard take to resolve a complaint?
As per IRDAI, insurers must provide a written resolution within 30 days.
Q10. What happens if ICICI Lombard still denies the claim?
Munish Sharma can pursue relief through legal and regulatory channels, including the Ombudsman.
Q11. What evidence supports the claim?
Medical documents clearly show the treatment was scheduled 15 days later as per the treating doctor’s advice.
Q12. How does this case affect ICICI Lombard’s credibility?
Such complaints damage trust and raise concerns about claim settlement practices.
Q13. What should policyholders do when their claims are unfairly rejected?
Maintain records, escalate to IRDAI, and seek legal remedies if needed.
Q14. Does IRDAI actively monitor rejected claims?
Yes, IRDAI requires insurers to report complaint and claim rejection data.
Q15. What consumer protections are available under Indian law?
Policyholders are protected by Consumer Protection Act, 2019 and IRDAI regulations.
Q16. Can rejected claims be reversed?
Yes, with proper escalation and supporting documentation, insurers may be forced to approve the claim.
Q17. Why is this case important for other policyholders?
It exposes unfair practices that could affect anyone holding an accident insurance policy.
Q18. Can Choice4Voice.com help escalate such insurance disputes?
Yes, Choice4Voice.com publishes genuine consumer complaints to pressure companies and regulators for resolution.
Q19. What steps should ICICI Lombard take immediately?
- Approve the claim in compliance with IRDAI rules.
- Improve transparency in claim handling.
- Strengthen customer support for sensitive accident cases.
Q20. What is Munish Sharma’s final demand?
He demands immediate approval and reimbursement of his daughter’s dental treatment expenses.
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