The Insurance Ombudsman provides policyholders with a relatively simple, cost-effective and impartial mechanism for resolving insurance grievances without immediately approaching a court or consumer forum. Complaints may relate to personal insurance, group insurance, and eligible policies issued to sole proprietorships and micro enterprises. However, following the correct procedure and presenting the complaint clearly can significantly improve the effectiveness of the process.
DOs
1. First Complain to the Insurance Company
Before approaching the Insurance Ombudsman, submit a written complaint to the insurer or insurance broker concerned. Clearly mention the policy number, claim number, nature of grievance and the relief sought.
You can approach the Ombudsman if the insurer or broker rejects the complaint, provides a response that is unsatisfactory, or fails to reply within 30 days.
2. Check Whether Your Complaint Falls Within the Ombudsman’s Jurisdiction
The Ombudsman can consider complaints involving matters such as claim repudiation, partial settlement, delay in settlement, disputes concerning premiums, policy terms, policy servicing, non-issuance of a policy after receipt of premium and non-compliance with applicable policyholder-protection requirements.
The mechanism covers personal lines of insurance, group policies and eligible policies of sole proprietorships and micro enterprises.
3. Observe the Monetary Limit
Check the financial jurisdiction before filing. The current maximum compensation that an Insurance Ombudsman may award is Rs. 50 lakh, including relevant expenses, following the 2023 amendment to the Insurance Ombudsman Rules.
4. File the Complaint Within the Prescribed Time
Normally, the complaint should be filed within one year from the insurer’s rejection or unsatisfactory decision. Where the insurer or broker has failed to respond, the period is calculated after expiry of one month from the representation made to it.
The Ombudsman has power to condone delay in appropriate cases after following the prescribed procedure, but a complainant should not rely on this exception. Filing promptly is always preferable.
5. Submit Complete Documentation
Attach documents necessary to understand the dispute. Depending upon the case, these may include:
- complete policy document and schedule;
- proposal form, where available;
- claim form and supporting claim documents;
- insurer’s repudiation or partial-settlement letter;
- grievance submitted to the insurer;
- insurer’s response;
- correspondence with the insurer, broker or TPA;
- medical records for health or life claims;
- bills, survey reports or loss documents; and
- other evidence supporting the amount claimed.
For certain health insurance disputes involving pre-existing diseases or waiting periods, earlier policy records may also be relevant.
6. Present the Facts Chronologically
Prepare a simple timeline covering policy purchase, occurrence of loss, claim submission, requests for documents, insurer’s decision, grievance raised and subsequent response.
A structured complaint is easier to understand than a lengthy narrative containing unrelated allegations.
7. Clearly State the Relief Sought
Specify exactly what you want the Ombudsman to consider. This may be payment of a rejected claim, balance amount following partial settlement, correction of a policy-related issue or another appropriate remedy within the Ombudsman’s jurisdiction.
9. Approach the Correct Ombudsman Office
A complaint can be lodged with the Ombudsman having territorial jurisdiction based on the relevant insurer or broker office or the complainant’s residential address/place of residence. Complaints can also be filed electronically through the Council for Insurance Ombudsmen’s online platform.
DON’Ts
1. Don’t Approach the Ombudsman Before Giving the Insurer an Opportunity to Respond
Going directly to the Ombudsman without first raising the grievance with the insurer or broker can make the complaint premature.
2. Don’t File the Same Dispute Before Multiple Forums
A complaint is not maintainable before the Insurance Ombudsman where proceedings concerning the same subject matter are pending before or have already been disposed of by a court, consumer forum or arbitrator. Decide the appropriate grievance-redressal route before initiating parallel proceedings.
3. Don’t Submit an Emotional Complaint Without Evidence
Statements such as “the insurer treated me unfairly” are insufficient by themselves. Explain which decision is disputed, why it is disputed and what documentary evidence supports your position.
4. Don’t Hide Material Facts
Disclose relevant information even where it may appear unfavourable. Suppression of previous illnesses, earlier correspondence, claim history or important policy information can undermine the credibility of the complaint.
5. Don’t Send Only the Repudiation Letter
The Ombudsman needs the context surrounding the dispute. The policy wording, claim documents and relevant correspondence can be essential in determining whether the insurer correctly applied the contractual terms.
6. Don’t Ignore Policy Conditions
Before challenging repudiation, read the exact exclusion, warranty or condition relied upon by the insurer. Your complaint should explain why that provision does not apply, has been incorrectly interpreted or does not justify the decision taken.
7. Don’t Exaggerate the Amount of Loss
Claim only amounts that can be reasonably supported. Under the Rules, compensation cannot exceed the direct loss suffered by the complainant, and the Ombudsman’s award is subject to the prescribed monetary ceiling.
8. Don’t Delay After Receiving the Insurer’s Final Decision
Important documents may become difficult to obtain with time, and limitation issues can arise. Preserve all correspondence and initiate the Ombudsman process promptly.
Key Takeaway
The Insurance Ombudsman mechanism is designed to make insurance dispute resolution accessible and relatively straightforward. A complainant does not strengthen a case by making it longer or more aggressive. The strongest complaint is usually one that is timely, fact-based, properly documented and clearly connected to the policy terms and the relief requested.
Before filing, remember four basic steps:
Complain to the insurer first. Preserve the evidence. Observe the time and monetary limits. Explain precisely why the insurer’s decision should be reconsidered.
