Insurance Ombudsman

Ombudsman is derived from a Swedish word which means "Legal Representative". Therefore, an ombudsman is appointed to investigate the issues put forth by citizens aggrieved by any Government or non-Government organisation act.

By exercising its power vested under sec 114(1) of The Insurance Act of 1938, the Central Government established an insurance ombudsman by passing the Redressal of Public Grievances Rules in 1998. In 2017 Redressal of Public Grievances Rules was modified, and Insurance Ombudsman Rules were passed to resolve policyholders' complaints better.

An insurance ombudsman is one of the channels via which an aggrieved policyholder can complain to an insurance company, intermediary or insurance broker. As mentioned earlier, the insurance ombudsman is a scheme created by the Government of India, and its primary goal is to streamline and settle the grievances and complaints of policyholders with a cost-effective, efficient and fair approach.

Currently, there are 17 insurance ombudsman centres in India. The Council of Insurance Ombudsman (CIO) administers and controls the Office of Insurance Ombudsman in India, intending to provide speedy, efficient and cost-effective solutions.

Click here to know more about insurance ombudsman and details of insurance ombudsman contact number in your area.

Before you submit your grievance and escalate the issue to the insurance ombudsman, ensure you meet the following criteria:

1. You have made a complaint to the insurance company or the broker, which has not been resolved

2. The insurance provider or the broker has failed to reply to you within one month of your complaint;

You are dissatisfied with the response from the insurance company or the broker.

3. The complaint is made to the insurance ombudsman within 12 months from

(a) The date of rejection of the complaint by the insurance company or broker

OR

(b) The expiry of one month of filing the complaint (in case the said party fails to reply)

4. The compensation amount or the worth of our health insurance policy does not exceed ₹30 Lakhs.

The Insurance Ombudsman can address complaints regarding service deficiency against insurance companies, brokers and intermediaries. You can complain on the following grounds:

• Delay in settlement of claims beyond the time specified by the Insurance Regulatory and Development Authority of India Act, 1999

• Partial or total denial of claims by the life, general or health insurer

• Disputes over premiums paid or payable under an insurance policy

• Misrepresentation of policy terms and conditions in the policy document contract

• The legal construction of insurance policies in so far as the dispute relates to the claim;

• Servicing related grievances against insurers and their agents and intermediaries;

• Issuance of the policy which is not in conformity with the proposal form submitted by the proposer;

• Non-issuance of insurance policy after receipt of premium

• Any other issue arising from the violation of the provisions, regulations, guidelines, circulars, etc., of the Insurance Act of 1938. Also, any non-observance or non-adherence to the terms and conditions of the policy contract insofar as such matter relates to issues referred to in the above points.

If you are unsatisfied with the services provided by the insurance company, broker or intermediary, the insured can lodge a complaint with the Insurance Ombudsman in India. Below are the points you must keep in mind before complaining.

• The insured can lodge a complaint by themselves, through their legal heir, nominee or assignee.

• The complaint must be duly signed and in written form by post, fax, or email.

• Online complaints can be registered through the official website of the Council of Insurance Ombudsman. Alternatively, you can visit the insurance ombudsman office in your area to file a complaint.

Process for online registration of complaint

Step 1: Visit the Council of Insurance Ombudsman website

Step 2: Go to 'Complaint Online' section and select 'Register to Complaint'.

Step 3: Enter your mobile number to receive an OTP.

Step 4: Share details to proceed to register your complaint.

Process for offline registration of complaint

**Step 1: **Visit the Insurance Ombudsman office in your area.

**Step 2: **Follow the complaint form with all the policy details and the required documents.

Step 3: Send the hard copy to the Ombudsman office or by email or fax.

Step 4: If the complaint is lodged via post, you may be required to fill in forms P-II and P-III.

• Copy of representation submitted to the insurance company or the broker

• KYC documents like Aadhar card, Pan card, Driving licence, etc.

• Recent photograph (for online complaint registration)

• Letter from the insurance company or broker rejecting the claim.

• Copy of Insurance Policy

• Any other documents, if required.

The grievance settlement process through this channel can be classified into three stages:

- Stage 1: Recommendation

In this stage, the Ombudsman serves as a mediator to make a non-biased recommendation based on the facts provided. Once you accept the recommendation or the settlement, the Ombudsman will notify the insurance company or the broker, who must comply with the terms within 15 days.

- Stage 2: Award

If the settlement as per the recommendation fails, the Ombudsman passes an award in 3 months, binding on the insurance company.

- Stage 3: After the award is passed

The insurance company or the broker must comply with the award and notify the Ombudsman within 30 days of receiving the award

Purchasing a medical insurance plan requires you to take an informed decision based on various factors. Apart from comparing health insurance policies based on their features and pricing, it is also essential to consider factors like claim settlement ratio, grievance redressal policy and processes etc. This will ensure that your issue is addressed with utmost importance at the time of claim settlement or any other grievance. When addressing your grievances, you can seek the assistance of the Insurance Ombudsman for an effective and fair settlement of the issue.