Insurance Business IRDA

How you can file a case with Insurance Ombudsman in India?

The Insurance Regulatory and Authority of India have set up a procedure for insurance companies to handle customer grievances. If you have any queries or you want to file a complaint, then the insurance company should be the first place you want to visit, but if you aren’t satisfied with the response, you can approach the insurance ombudsman.  

Who is an Insurance Ombudsman?

The Indian Government launched the Insurance Ombudsman scheme to help the policy holders to get their complaints addressed and resolved off the court efficiently and in an unbiased manner.

Presently there are 17 Insurance Ombudsman Centres in India. The contact details of them can be fetched from the IRDAI’s official website. The complaint can be filed to the insurance ombudsman under whose jurisdiction the branch of the insurance company or its office is located or where the complainant resides.

The main objective of the ombudsman is to resolve all complaints encountered in settlement of these claims.

Who and when can one approach the Insurance Ombudsman?

Firstly, any individual policyholder may approach Insurance ombudsman for redressal of their grievance.

Secondly, there are certain types of complaints for which a policyholder can approach the Insurance Ombudsman. Following are the complaints for which a policyholder can approach:

• In case of any delay in the claim settlement, beyond the time limit, stated according to the regulations under IRDAI Act, 1999^[1];
• Disputes pertaining to premiums payable or paid for life or general insurance policy;
• In case of any partial or total rejection of claims by the life insurer or general insurer;
• Complaints related to the services of policy by an insurance company, an agent or by an intermediary;
• In case of non-issuance of the insurance policy after receipt of premium by the insurance company. This can be related to the life insurance, health insurance or any other general insurance products;
• In case of issuance of insurance policy that is not in compliance with the submitted proposal form. It can be related to the life insurance, health insurance or any other general insurance products;
• Any disputes pertaining to the legal construction of insurance policies in so far as such dispute pertains to claim;
• Any complaints related to violation of provisions of the Insurance Act, 1938 or the guidelines, regulations and circulars issued by the regulatory body.

Step by Step Procedure for filing complaint with Insurance Ombudsman in India

Complaint can be filed extremely easily and seamlessly. The following steps should be followed:

• In case one fails to obtain a satisfactory response from the insurance company on their grievances or in case you have not received a response on time, i.e., within a month from the complaint, proceed to file a complaint with the Ombudsman.
• Contact the Insurance Ombudsman office that comes under the purview of your jurisdiction. For instance, you reside in Bangalore, and the insurance company’s office is located in Mumbai, then you can approach the Ombudsman in Bangalore centre for filing the complaint.
• A complaint may be filed by sending a letter (hard copy) to the Ombudsman or via fax or mail. However, in case you mail your complaints, you must also send the hard copy letter later.
• Your letter should include all the necessary details like policy number and complaint details. Enclose the relevant documents as demanded by the Ombudsman and post them to the centre. The documentation requirement may vary depending on the nature or type of the complaint filed.
• If you visit the Ombudsman centre, you can fill Form P-II and P-III. If you have sent the documents by post, the Ombudsman will reach out to you asking to fill these forms.
• Once the complaint is submitted, and documents are also submitted, a date will be fixed by the Ombudsman for hearing.

Settlement process followed by the Ombudsman

The ombudsman plays the role of a mediator between the policyholder and the insurance company. The ombudsman depends upon the facts to arrive at a fair recommendation. If you are satisfied with the recommendations and accept it as a final settlement, the ombudsman will intimate the insurance company by sending an acceptance letter. It should be complied by within 15 days.

However, if you are not satisfied with the recommendations, the ombudsman shall pass an award within 3 months, which would be binding on the insurer. The insurance company is required to comply with the award within 30 days.

Conclusion

An insurance ombudsman plays the role of a mediator between the policyholder and the insurance company. Its role and responsibility are critical with respect to maintaining a healthy relationship with the policyholder and the insurance company. If you face any issue relating to insurance, you must first reach out to your insurance company and then to the ombudsman.

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