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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
  • Issuance of an insurance policy which is not in compliance with the proposal form submitted.
  • 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 with the Insurance Ombudsman

  1. 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. It is important to note that the complaint should be made not later than a year from the date of rejection of the complaint by the insurer and there should not be any other proceedings pending in any other court, Consumer Forum or arbitrator pending on the same subject matter.
  2. 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.
  3. A complaint can be filed by by sending a letter (hard copy) to the Insurance Ombudsman or by fax or email. It is important to note that, if you email your complaints, you are also required to send the hard copy of letter later. The Ombudsman now allows online submissions of complaints as well.
  4. 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.
  5. Once the complaint is registered, the ombudsman 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 is then required to submit the forms along with the documents as asked for in the Form P-II & P-III. These documents can be sent via courier or post and you need not visit the ombudsman’s office.
  6. After submission of complaint and documents, a date will be fixed by the Insurance Ombudsman for hearing.

 

How does Insurance Ombudsman work? What is the settlement process?

When you place a complaint with the Insurance Ombudsman as a policyholder, the Ombudsman will:

  1. Act as a mediator in resolving a complaint. Where a complaint is settled through mediation, the Ombudsman makes a recommendation which he thinks fair, within one month of the receipt of mutual written consent for such mediation and copies of the recommendation are sent to the complainant and the insurer.
  2. If the recommendations are accepted by the complainant as the final settlement, Insurance Ombudsman will inform the insurance company by sending a letter of acceptance, with which they must comply within 15 days.
  3. Where the complaint is not settled by mediation as mentioned above, the Ombudsman passes an award, based on the pleadings and evidence brought on record, within a period of 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.
  4. Once the award is passed by the Insurance Ombudsman, the insurance company must comply with it within 30 days from the receipt of the award
  5. Compliance of the award by the insurer needs to be informed to the Insurance Ombudsman.