Can the Insurance Ombudsman examine the merits of a rejected insurance claim?

Ombudsman CAN go into the facts or the merits of your repudiation.

here is the short case summary:
The dispute arose from a health insurance policy issued by Niva Bupa. For the first two years, I was entitled to and successfully claimed the annual health check-up benefit.

At the time of renewal, Niva Bupa unilaterally changed the policy terms. I was not aware of these changes because the insurer never specifically informed me about the modifications before renewal. Under insurance regulations and principles of fair disclosure, an insurer is expected to clearly communicate any material changes in policy terms before renewal. Unlike a new policy, there is no free-look period available for a renewed policy, making prior disclosure even more important.

Relying on the understanding that the renewed policy continued on the same terms as the earlier policy, I submitted my annual health check-up claim. Only after the claim was rejected did I discover that the policy terms had been altered.

I pursued the matter through the insurer’s Grievance Redressal Officer (GRO) and subsequently through Bima Bharosa, but neither forum provided any effective relief.

I then approached the Insurance Ombudsman. During the proceedings, the Ombudsman directed the insurer to honour the disputed claim and continue the policy on the previous policy terms. However, this settlement was recorded and an award was passed without my consent, despite my complaint seeking much broader relief for the insurer’s breach of policy terms. The award states that I accepted the settlement, which is factually incorrect. I have therefore sought, under the RTI Act, the video recording or any documentary evidence showing where I allegedly accepted the offer.

Further, this was a three-year policy. Legally, an insurance policy is a single, integrated contract. If the Ombudsman directed that the previous policy terms should continue to apply, that direction should apply to the entire three-year policy and not merely to a single year’s health check-up claim.

Despite the Ombudsman’s award, Niva Bupa again rejected my health check-up claim in the following policy year. I have therefore approached the Insurance Ombudsman once again, alleging non-compliance with the Ombudsman’s award, in addition to pursuing RTI proceedings regarding the incorrect recording of my alleged acceptance of the earlier settlement.

Related: how India's insurance system fails the insured, the full case.