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WHOM TO COMPLAIN FOR MY INSURANCE POLICY? THE ANSWER IS OMBUDSMAN

Ombudsman

In order to have a cost effective and efficient courts system, the government of India introduced the Insurance Ombudsman Scheme. This Ombudsman scheme was designed to help the consumers to settle their issues and complaints against the insurance companies in an impartial way.

Ombudsman is a like a judge to the court. He is the Judge for the cases comes to his office for various issued related to the claim settlement.

In India there are 12 Insurance Ombudsman in different locations (list attached below). You can approach any one of these offices nearby the location of the insurance company that you have a complaint against.

When to approach Ombudsman?

You should approach your insurance company with the complaint. You can approach the ombudsman in the following situations.

  • The Insurance company has not resolved it
  • The issue is not resolved to your satisfaction.
  • The case is not responded within 30 days after the complaint is given.

And you have to note the below two points also.

  • You should have taken the policy in capacity of an Individual
  • The value of the claim including expenses claimed is not above Rs 20 lakh

What can I complain about?

  1. Non-issue of policy document after receiving the policy premium from you. Example: you can complain if the company is making delays in dispatching the policy document without any valid reasons.

 

  1. Any dispute about the premium paid or payable in future in the terms of the policy. Example: You can complaint if there is a mismatch between the terms and conditions of the policy sold to you and the content in the policy document

 

  1. Any dispute on the legal construction relating to the claims of the policies

 

  1. If the insurance company has repudiated (Rejected) your claim in partial or full. Example: If the company has given you a sum assured of Rs 100000 but had paid only Rs 80000 as claim you can approach ombudsman.

 

  1. Delay in settlement of claims by the insurance company without any valid reasons.

 

The settlement process

Once you had approached the ombudsman, you will get an impartial result on your complaint. The solution will be given as a recommendation by the ombudsman to the insurer and the policy holder.


Recommendation:

The Ombudsman will act as an counsellor and mediator and

  • He will arrive at a very fair recommendation based on the facts of the dispute
  • If you accept his recommendation as the full and final settlement, the Ombudsman will inform the company regarding the same. The company should comply with the terms within 15 days.

Award:

  • If a settlement by recommendation does not work, the Ombudsman will:
  • Pass an award within 3 months of receiving the complaint and which will be
    • A speaking award with the detailed reasoning
    • Binding on the insurance company but
    • Not binding on the policyholder
  • The Ombudsman can also award an ex-gratia payment

Once the Award is passed 

  • You have to accept the award in writing and the insurance company has to be informed of it within 30 days and
  • The Insurance Company has to comply with the award in 15 days after that.

And this is not an end of the road for you. If the recommendations or award is not satisfactory, you can still approach the court to resolve your issues.

For list of Ombudsman offices in India click here.

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