If you are an Individual you can file a complaint against Insurance Company in case they reject the claim or made partial payment to Insurance Ombudsman
The Insurance Ombudsman scheme was created by the Government of India for individual policyholders to have their complaints settled out of the courts system in a cost-effective, efficient and impartial way.
There are at present 17 Insurance Ombudsman in different locations and any person who has a grievance against an insurer, may himself or through his legal heirs, nominee or assignee, make a complaint in writing to the Insurance ombudsman within whose territorial jurisdiction the branch or office of the insurer complained against or the residential address or place of residence of the complainant is located.
You can approach the Ombudsman with complaint if:
- You have first approached your insurance company with the complaint and
- They have rejected it
- Not resolved it to your satisfaction or
- Not responded to it at all for 30 days
- Your complaint pertains to any policy you have taken in your capacity as an individual and
- The value of the claim including expenses claimed is not above Rs 30 lakhs.
Your complaint to the Ombudsman can be about:
- a)Delay in settlement of claims, beyond the time specified in the regulations, framed under the IRDAI Act, 1999.
- b)Any partial or total repudiation of claims by the Life insurer, General insurer or the Health insurer.
- c)Any dispute about premium paid or payable in terms of insurance policy
- d)Misrepresentation of policy terms and conditions at any time in the policy document or policy contract.
- e)Legal construction of insurance policies in so far as the dispute relates to claim.
- f)Policy servicing related grievances against insurers and their agents and intermediaries.
- g)Issuance of life insurance policy, general insurance policy including health insurance policy which is not in conformity with the proposal form submitted by the proposer.
- h)Non issuance of insurance policy after receipt of premium in life insurance and general insurance including health insurance and
- i)Any other matter resulting from the violation of provisions of the Insurance Act, 1938 or the regulations, circulars, guidelines or instructions issued by the IRDAI from time to time or the terms and conditions of the policy contract, in so far as they relate to issues mentioned at clauses (a) to (f)
The settlement process
Recommendation:
The Ombudsman will act as mediator and
- Arrive at a fair recommendation based on the facts of the dispute
- If you accept this as a full and final settlement, the Ombudsman will inform the company which should comply with the terms in 15 days
Award:
- If a settlement by recommendation does not work, the Ombudsman will:
- Pass an award within 3 months of receiving all the requirements from the complainant and which will be binding on the insurance company
Once the Award is passed
- The Insurer shall comply with the award within 30 days of the receipt of award and intimate the compliance of the same to the Ombudsman.
