Mr. Pawan, aged 40 Years purchased an Insurance Policy for the Sum Assured of ₹1 Crore from XYZ Company Limited. The proposal date was 22.02.2024 and has paid one year premium of ₹30,733/-. In the proposal form, he nomin

CS Professional · Insurance - Law & Practice · PYQS · June 2025
Mr. Pawan, aged 40 Years purchased an Insurance Policy for the Sum Assured of ₹1 Crore from XYZ Company Limited. The proposal date was 22.02.2024 and has paid one year premium of ₹30,733/-. In the proposal form, he nominated his second wife Ms. Aparna and minor son Mr. Abhiroop who was born to his first wife as beneficiaries of 50% share of each for policy benefits. As his son is minor, his second wife Ms. Aparna is considered as legal trustee/guardian for the minor son. His first wife Ms. Karuna passed away on 1-2-2021 with post-partum problems leaving behind a son. Since his first wife passed away in 2021, he has been using anti-depressant medicines to come out from his bereavement and also married Ms. Aparna on 20-12-2023 to take care of his two-year-old son Mr. Abhiroop. The usage of depressant medicines is not mentioned in the proposal form as he thought that was not a material fact. His business also got affected with his mental depression and to raise money for his business continuation he assigned this ₹1 Crore insurance policy to his creditor on 25.06.2024 against the loan of ₹30 lakhs. Within 7 months of the proposal date, he died on 28.08.2024. The cause of death was reported in the discharge form of deceased life assured as sudden cardiac arrest in the sleep due to atherosclerosis (hardening of the arteries). As Ms. Aparna is not biological mother to Abhiroop and father passed away, parents of Ms. Karuna the biological mother of Mr. Abhiroop approached the insurance company for the policy benefits in the name of minor son Mr. Abhiroop under the trustee of biological grandparents. As it is an early claim, the investigation on death of the insured is initiated and the insurance company could not prove that it is a suicide though they come acrossed the rumors of suicide from neighborhood due to his depressive mentality. But on investigation, it is identified that life assured had suppressed or concealed the material fact of using anti-depressant medicines. Research showing that antidepressants might contribute to atherosclerosis by affecting factors like blood pressure, platelet aggregation, inflammation and endothelial function within the blood vessels which may lead to heart failure. Insurer put on hold the claim based on the following issues: Suppression of material facts or breach of the condition of 'utmost good faith' from the life assured. Early claim with a suspicion of suicide. Litigation on Trustee/Guardian for the minor son. Part of Insurance policy benefits is assigned to creditor. As this case is an early claim and due to complications in discharging the policy benefits, Insurance Company put on hold the benefits. What are the procedural compliance requirements under the IRDAI (Protection of Policy holder's interests) Regulations, 2017 to solve this case?

Answer & Explanation:

Procedural Compliance Requirements under the IRDAI (Protection of Policyholders' Interests) Regulations, 2017: The IRDAI (Insurance Regulatory and Development Authority of India) has established regulations to safeguard the interests of policyholders in the life insurance sector. Below are the key procedural compliance requirements outlined in the 2017 Regulations: 1. Timely Customer Requirements: Life insurance companies must raise any customer requirements within 15 days of receiving the intimation from the policyholder. This ensures prompt communication and facilitates a smoother claims process. 2. Investigation Timeline: The time limit for completing the investigation of a claim is set at 90 days. After the investigation is concluded, the insurer must decide on the claim within 30 days of receiving the investigation report. This regulation aims to ensure that claims are resolved efficiently and without unnecessary delays. 3. Interest on Delays: In the event of delays in the settlement of claims, the insurance company is required to pay interest at the rate of 2% above the bank rate from the date of receipt of the last necessary document. This provision acts as a deterrent against undue delays in claim settlement and emphasizes the importance of timely processing. 4. Claims for Deaths by Suicide: For claims related to deaths caused by suicide, the regulations stipulate that 80% of the premiums paid shall be payable to the beneficiaries. This provision recognizes the sensitive nature of such claims and aims to provide some financial relief to the beneficiaries without imposing excessive penalties on the policyholder.

Topics: Insurance Regulatory Framework

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