Facing insurance issues? Here's how to file a complaint with the Ombudsman

Insurance grievances can be frustrating, especially when your claim is rejected, delayed, or unresolved. To help individual policyholders resolve such issues efficiently and cost-effectively, the Government of India introduced the insurance Ombudsman scheme. This impartial mechanism addresses complaints without the need to go to court.

Currently, there are 17 insurance Ombudsman offices across various locations in India. Any person with a grievance against an insurer can file a written complaint, either personally or through their legal heirs, nominee, or assignee, to the insurance Ombudsman. The complaint must be directed to the Ombudsman under whose jurisdiction the insurer’s branch office, the complainant’s residence, or their registered address falls.

Here’s a detailed guide to understanding the process and steps involved in availing the Ombudsman’s assistance.

Step-by-step guide to resolving insurance grievances

Step 1: Contact your insurance company

The first step is to raise your complaint directly with the Grievance Redressal Cell of your insurer:

1. File a written complaint: Provide details of your issue along with the required documents to the grievance officer of your insurance company.
2. Timeline: The insurer should acknowledge your complaint within 3 working days and resolve it within 2 weeks.
3. Resolution or escalation: If the insurer rejects your claim, provides an unsatisfactory resolution, or fails to respond within 30 days, you can escalate the issue further.
4. Your complaint pertains to any policy you have taken in your capacity as an individual, and the value of the claim including expenses claimed, should not be above ₹30 lakhs.

Step 2: Approach IRDAI’s grievance redressal cell

If you are dissatisfied with the insurer’s response, contact the Insurance Regulatory and Development Authority of India (IRDAI):

1. How to file a complaint: Use the Bima Bharosa System on IRDAI’s website, call 1800 4254 732 or 155255, or email complaints@irdai.gov.in.
2. What happens next: IRDAI forwards your complaint to the insurer and ensures they take the necessary steps to resolve it.
3. Token reference number: A reference number is issued for tracking your complaint.
4. No charges are required to be paid for lodging a complaint with the insurance Ombudsman.

Step 3: Reach out to the insurance Ombudsman

If your issue remains unresolved, the insurance Ombudsman can provide a fair and impartial verdict.

Conditions to approach the ombudsman:

1. You’ve already filed a complaint with the insurer and either: Your claim was rejected, or you did not receive a satisfactory resolution within 30 days.
2. The complaint involves a policy purchased as an individual.
3. The claim amount (including expenses) does not exceed ₹30 lakh.

Documents required:

1. Copy of representation submitted to insurance company/ insurance broker
2. KYC particulars: Aadhar card, Pan Card, Driving License, etc.
3. Photograph (in case of online registration of complaints)
4. Letter from insurance company/ insurance broker rejecting the representation/ repudiating the claim.
5. Copy of insurance policy
6. Any other document(s).

Settlement process:

1. Recommendation stage: The Ombudsman mediates to arrive at a fair recommendation. If you accept this as a full settlement, the insurer must comply within 15 days.
2. Award stage: If mediation fails, the Ombudsman issues a binding award within 3 months. The insurer must implement the decision within 30 days and inform the Ombudsman.
3. The insurance Ombudsman can entertain complaints where the quantum of loss payable under the insurance policy does not exceed rupees ₹50 Lakhs.

Step 4: Escalate to the consumer court

If you are unsatisfied with the Ombudsman’s verdict, you can file a case in the Consumer Court. Alternatively, you can approach the court directly after IRDAI’s resolution without involving the Ombudsman.

What complaints can be addressed to the insurance Ombudsman?

The insurance Ombudsman provides a platform for individual policyholders to resolve grievances against insurance companies efficiently and without court intervention. Here’s a detailed look at the types of complaints that can be submitted:

1. Delay in the settlement of claims beyond the time specified in the regulations framed under the IRDAI Act, 1999.
2. Partial or total repudiation of claims by the life insurer, general insurer, or health insurer.
3. Disputes regarding premium paid or payable as per the terms of the insurance policy.
4. Misrepresentation of policy terms and conditions at any time in the policy document or policy contract.
5. Legal construction of insurance policies, insofar as the dispute relates to claims.
6. Policy servicing-related grievances against insurers, their agents, or intermediaries.
7. Issuance of life insurance policies, general insurance policies (including health insurance), that are not in conformity with the proposal form submitted by the proposer.
8. Non-issuance of insurance policies after receipt of premium in life insurance and general insurance, including health insurance.
9. Any other matter resulting from the violation of the provisions of the Insurance Act, 1938, or the regulations, circulars, guidelines, or instructions issued by the IRDAI, or the terms and conditions of the policy contract, insofar as they relate to the issues mentioned in clauses (a) to (f).

Conclusion

The insurance Ombudsman plays a crucial role in ensuring fair treatment for policyholders. By addressing these types of complaints, it empowers individuals to safeguard their rights without the financial and emotional burden of court proceedings. Always ensure your grievance aligns with these categories and that you’ve followed the prescribed process before approaching the Ombudsman.

Rohit Gyanchandani is Managing Director at Nandi Nivesh Private Limited