Insurance Ombudsman: 13 Guidelines Insured Should Know

Insurance companies use various tricks to woo customers to buy policy in order to make profit. However after buying the policy, when it comes to servicing the customers the reality is different. For e.g. when a claim is made, insurer will try every possible trick to reject a claim or during renewal, the premium would be raised with no valid justification or other gimmicky features added to the policy.

In such cases, either the insured person has to accept and move ahead with the decision of the insurer or take efforts in battling typically with the company’s support functions or sometimes with the company’s different teams. However even after doing so, the outcome is not always in the favor of the policy holder.

So the final option for the insured person is to file complaint with the Insurance Ombudsman (grievance cell) of Insurance Regulatory and Development Authority of India (IRDAI), the autonomously run controlling body of all the insurance companies in India (life and general). Or lodge a legal case against the insurer. But going through a legal route is recommended only when ombudsman’s final verdict is not favorable. And also going through legal way will cost you money and the verdicts are often delayed.

For the benefit of the insurance policy holder, IRDA has set key guidelines while lodging complaint at the ombudsman. And every policy holder should be aware of these basic guidelines which will help them when lodging a complaint at ombudsman against the insurance company.

  1. There is no charge or any kind of fees for lodging a complaint. So anyone asking money in return of filing the complaint is definite case of fraud.
  2. On the behalf of the insured person, legal heir, nominee, or assignee can also file the complaint.
  3. If you are covered under group mediclaim policy (i.e. health insurance offered by the company to its employees) then on your behalf your employer can lodge a complaint at insurance ombudsman.
  4. Complaint should be made within one year from the date of receipt of the order sent by the insurer. If there is a delay then, only in certain cases with valid reasons, the ombudsman will take the case in their hands. In this situation, objection of the insurer is also taken into consideration.
  5. If the complainant is not satisfied with the decision given by the insurance company, then insured person can lodge a complaint at insurance ombudsman within one year of the receipt of the reply.
  6. If there is no revert by the insurer in a month of sending the complaint, then complainant can approach the ombudsman.
  7. There is no need of lawyer for filing complaint at the insurance ombudsman.
  8. Complainant can also file a legal complaint against the insurance company, if he/she is unsatisfied with the final verdict of the ombudsman.
  9. If the legal complaint is already made either in a court/arbitrator or consumer forum then you cannot file the same complaint at the ombudsman.
  10. After filing the complaint and submission of all relevant documents, ombudsman takes 3 month time to give final judgement (called as award).
  11. Complaint should be filed in written. Your complaint letter should contain following details of the complainant:
  • Signature
  • Name
  • Address
  • Name and address/branch of the insurance company
  • Facts or any other proof specifying the details of the complaint
  • Any other supported documents
  • Loss caused to the insured person

Check out tricks used by fraudsters claiming from IRDA.

12. You can file following complaints at IRDA for the following:

  • Delay in claim or no settlement
  • Disputes in premium charged
  • Premium paid but policy is not issued or renewed
  • There is a change made by the insurance company in the proposal form submitted by the insured.
  • Falsifying the terms and conditions of the insurance policy at the time of buying the polic

13. If the final judgement goes in the favor of the insured, then ombudsman can award compensation to the  policyholder in one of the two ways:

  • Compensation will be paid which cannot exceed more than Rs. 30 Lacs. Or
  • Will give monetary compensation which would be the loss suffered by the complainant because of the action taken by the insurer.

 

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