Introduction- The Ombudsman is a person appointed by the insurance council. The serving term of the Insurance Ombudsman is three years and there are 17 Ombudsman across India.
Who can approach an Insurance Ombudsman?
Any person who has a grievance against an insurer, may himself or through his legal heirs, nominee or assignee, complain to the Insurance Ombudsman within whose territorial jurisdiction the branch or office of the insurer complained against, or the place of residence of the complainant is located.
Types of complaint accepted by the Insurance Ombudsman
- Delay in claim settlement, beyond the time limit i.e. 30 days, stated as per the regulations under IRDAI Act, 1999
- Disputes relating to premiums payable or paid
- Any partial or total rejection of claims by a life insurer or general insurer
- Complaints relating to the services of policy by the insurance company, an agent or by an intermediary
- Non-issuance of insurance policy after receipt of premium by the insurer. This can be related to life insurance, health insurance or any general insurance products
Issuing an insurance policy that doesn’t comply with the submitted proposal form is not acceptable.
- Any disputes relating to the legal construction of insurance policies in so far as such dispute relates to claim
- Any complaints relating to a violation of provisions of the Insurance Act, 1938 or the guidelines, regulations and circulars issued by the regulatory body IRDAI.
Procedure for filing a complaint
- If you have not received a satisfactory response from your insurance company on your grievances nor received a timely response, within a month from the complaint, proceed to file a complaint with the Insurance Ombudsman.
- Make sure to file the complaint within a year from the date of rejection by the insurer. Additionally, there should be no pending proceedings in any other court, Consumer Forum, or arbitrator on the same subject matter.
- Contact the Insurance Ombudsman office in your jurisdiction. For example, you are staying in Bengaluru and your insurance company’s office is in Delhi, you can approach the Insurance Ombudsman in Bengaluru or Delhi.
- You can file a complaint by sending a letter (hard copy) to the Insurance Ombudsman or by fax or email. It’s important to note that if you email your complaints, you must also send a hard copy of the letter later. The Ombudsman now allows online submissions of complaints as well.
- Your letter must include all the necessary details such as policy number and complaint details. Enclose relevant documents as required by the Insurance Ombudsman and post it to the centre. The requirement of documents may vary depending on the nature or type of complaint.
- Once the complaint is registered, his office writes back to the complainant giving a complaint number and form P-II & P-III. These are simple forms that take down the details in a particular format. The complainant must submit the forms along with the required documents as requested in Form P-II & P-III. These documents can be sent via courier or post, and visiting the ombudsman’s office is not necessary.
- The Insurance Ombudsman will schedule a hearing date after receiving the complaint and relevant documents.
How does Insurance Ombudsman work? What is the settlement process?
When you place a complaint with the Insurance Ombudsman as a policyholder, he will:
- Act as a mediator in resolving a complaint. In cases where a complaint is resolved through mediation, the Ombudsman issues a recommendation deemed fair within one month of receiving mutual written consent for mediation. Copies of the recommendation are sent to both the complainant and the insurer.
- If the complainant accepts the recommendations as the final settlement, the Insurance Ombudsman will notify the insurance company by sending a letter of acceptance. The insurer must comply within 15 days.
- If the complaint isn’t resolved through mediation, the Ombudsman issues an award based on the evidence within three months. The award will be in writing and states the reasons upon which the award is based. This award is binding on the insurer.
- Once the Insurance Ombudsman passes the award, the insurance company must comply with it within 30 days of receiving the award.
- The insurer needs to inform the Insurance Ombudsman about the compliance of the award.
