विशेषज्ञ की सलाह चाहिए?हमारे गुरु मदद कर सकते हैं
Hari
Ramalingam Kalirajan11501 Answers |Ask - Follow
Mutual Funds, Financial Planning Expert - Answered on Nov 04, 2026
Asked on - Nov 04, 2026
I took Hospital Care Policy in June 2009 from ICICI Prudential Life Insurance Ltd. I am UpToDate in payment of premium and have not claimed any reimbursement.
Insurance company provided both Annual and Lifetime Limits of Claims of Rs. 20 lakhs covering Hospital expenses including Surgical and Convalescence Benefit. They maintained this stand for 17 years till June’26. However, they sent revised Policy Document in Sept’26 reducing Annual Limit to Rs. 4 lakhs, maintaining Lifetime limit the same. I requested to rectify the mistake. They, however, maintained that the Annual Limit stands revised quoting some clause of T&C. The T&C of the Policy is not in tandem with the main policy certificate. I requested for rectification through their Grievance Redressal Officer. They are not ready to correct their mistakes. This has reduced my claim limits during one Policy year.
I am Senior Citizen, 74+, based in Mumbai. I am advised for both Knee Replacement Surgery in a reputed Hospital costing more than Rs. 10 lakhs. I sought clarification on my entitlement of the Claim before getting admitted in the Hospital. They quote some clauses of the T&C offering me a maximum of Rs. 1 lakh towards Surgical benefit etc. on a sum insured of Rs. 20 lakhs. They are misreading / misinterpreting Clauses of their own T&C. I requested for personal hearing, no response from them.
I have complained to IRDAI Grievance Cell. They have directed the insurance company to resolve the issue immediately. Still no response from ICICI Prulife Insurance.
Request your advice please.
Hari Narayan Belawat,
Ans: Your concern is valid, particularly because the policy has been continued for 17 years with regular premium payments. Being a senior citizen, you should not have to face uncertainty about your medical coverage at the time of a major surgery.
There are two important issues here:
– The insurer has reduced the Annual Claim Limit from Rs. 20 lakhs to Rs. 4 lakhs.
– There is a dispute regarding the interpretation of the original policy certificate and the terms and conditions.
The key question is whether the insurer has the contractual right to reduce your benefits during an ongoing policy, especially when the earlier policy documents stated otherwise.
Do not accept the revised benefit limits merely because the insurance company has quoted a clause. Ask them to establish clearly how that clause applies to your original policy.
» Immediate Actions Recommended
I suggest the following steps:
– Obtain the original policy document issued in 2009, including the complete terms and conditions.
– Compare it with the revised policy document issued in September 2026.
– Ask the insurer to provide a written explanation identifying the exact clause that permits the reduction of the Annual Limit.
– Ask them to explain why the original policy certificate and the revised terms differ.
– Request a written clarification on the exact benefits payable for knee replacement surgery, including surgical and convalescence benefits.
– Preserve all premium receipts and correspondence. Continue paying premiums to avoid any disruption in policy continuity.
» Escalate to the Insurance Ombudsman
Since you have already approached IRDAI and the insurer has not resolved the matter, I suggest approaching the Insurance Ombudsman in Mumbai.
The Insurance Ombudsman provides an independent grievance redressal mechanism.
You can seek the following relief:
– Restoration of the original Annual Limit of Rs. 20 lakhs, subject to the original policy terms.
– A declaration regarding the correct interpretation of the policy benefits.
– Written confirmation of your knee replacement surgery entitlement.
– Appropriate relief for any deficiency in service by the insurance company.
You generally need to approach the Ombudsman within one year of receiving the insurer's rejection or unsatisfactory decision. Please do not delay this escalation.
» Regarding Your Knee Replacement Surgery
This is particularly important because your medical requirement should not suffer due to an ongoing insurance dispute.
– Ask the hospital insurance desk to submit a pre-authorisation request, if this facility is available under your policy.
– Obtain the insurer's written response before admission, wherever medically feasible.
– Do not rely only on verbal assurances from the insurance company.
– If surgery is medically urgent, discuss the timing with your treating orthopaedic surgeon. Do not postpone necessary treatment solely because of this dispute.
– Keep all hospital estimates, medical advice and insurance correspondence safely.
Also, do not surrender or discontinue this 17-year-old policy while the dispute is pending.
» Our Assessment
Your strongest point appears to be the difference between the original policy certificate and the revised
However, the actual entitlement will depend on the contractual terms, benefit definitions and any valid amendments applicable to your policy.
The insurer should not simply quote isolated clauses without explaining their applicability to your original policy.
Given your age and the significant medical expenses involved, I would recommend getting an insurance lawyer to examine both policy documents and represent your case before the Ombudsman, if required.
You have maintained the policy for 17 years. It is important to protect your contractual rights and obtain clarity before incurring substantial medical expenses.
Best Regards,
K. Ramalingam, MBA, CFP,
AMFI-Registered MFD – ARN 4188
www.holisticinvestment.in
https://www.linkedin.com/in/ramalingamcfp/
(more)
There are two important issues here:
– The insurer has reduced the Annual Claim Limit from Rs. 20 lakhs to Rs. 4 lakhs.
– There is a dispute regarding the interpretation of the original policy certificate and the terms and conditions.
The key question is whether the insurer has the contractual right to reduce your benefits during an ongoing policy, especially when the earlier policy documents stated otherwise.
Do not accept the revised benefit limits merely because the insurance company has quoted a clause. Ask them to establish clearly how that clause applies to your original policy.
» Immediate Actions Recommended
I suggest the following steps:
– Obtain the original policy document issued in 2009, including the complete terms and conditions.
– Compare it with the revised policy document issued in September 2026.
– Ask the insurer to provide a written explanation identifying the exact clause that permits the reduction of the Annual Limit.
– Ask them to explain why the original policy certificate and the revised terms differ.
– Request a written clarification on the exact benefits payable for knee replacement surgery, including surgical and convalescence benefits.
– Preserve all premium receipts and correspondence. Continue paying premiums to avoid any disruption in policy continuity.
» Escalate to the Insurance Ombudsman
Since you have already approached IRDAI and the insurer has not resolved the matter, I suggest approaching the Insurance Ombudsman in Mumbai.
The Insurance Ombudsman provides an independent grievance redressal mechanism.
You can seek the following relief:
– Restoration of the original Annual Limit of Rs. 20 lakhs, subject to the original policy terms.
– A declaration regarding the correct interpretation of the policy benefits.
– Written confirmation of your knee replacement surgery entitlement.
– Appropriate relief for any deficiency in service by the insurance company.
You generally need to approach the Ombudsman within one year of receiving the insurer's rejection or unsatisfactory decision. Please do not delay this escalation.
» Regarding Your Knee Replacement Surgery
This is particularly important because your medical requirement should not suffer due to an ongoing insurance dispute.
– Ask the hospital insurance desk to submit a pre-authorisation request, if this facility is available under your policy.
– Obtain the insurer's written response before admission, wherever medically feasible.
– Do not rely only on verbal assurances from the insurance company.
– If surgery is medically urgent, discuss the timing with your treating orthopaedic surgeon. Do not postpone necessary treatment solely because of this dispute.
– Keep all hospital estimates, medical advice and insurance correspondence safely.
Also, do not surrender or discontinue this 17-year-old policy while the dispute is pending.
» Our Assessment
Your strongest point appears to be the difference between the original policy certificate and the revised
However, the actual entitlement will depend on the contractual terms, benefit definitions and any valid amendments applicable to your policy.
The insurer should not simply quote isolated clauses without explaining their applicability to your original policy.
Given your age and the significant medical expenses involved, I would recommend getting an insurance lawyer to examine both policy documents and represent your case before the Ombudsman, if required.
You have maintained the policy for 17 years. It is important to protect your contractual rights and obtain clarity before incurring substantial medical expenses.
Best Regards,
K. Ramalingam, MBA, CFP,
AMFI-Registered MFD – ARN 4188
www.holisticinvestment.in
https://www.linkedin.com/in/ramalingamcfp/