Know Your Rights: How to file complaints with Insurance Ombudsman

The office of the Insurance Ombudsman is an alternate grievance redressal platform which has been set up by the Government of India with an aim to resolve grievances of aggrieved policyholders of all personal lines of insurance, group insurance policies, policies issued to sole proprietorship and micro enterprises, against insurance companies, their agents and intermediaries in a cost-effective and impartial manner.

The offices of the Insurance Ombudsman are under the administrative control of the Council for Insurance Ombudsmen (CIO).

When to approach Ombudsman with complaints

You first approached your insurance company with the complaint and they rejected it

Complaint has not been resolved it to your satisfaction or not responded to it at all for 30 days

Your complaint pertains to any policy you have taken in your capacity as an individual

The value of the claim including expenses claimed is not above Rs 30 lakh

Complaints to the Ombudsman can be about

Delay in settlement of claims, beyond the time specified in the regulations framed under the IRDAI Act, 1999.

Any partial or total repudiation of claims by the life insurer, general insurer or the health insurer

Any dispute about premium paid or payable in terms of insurance policy

Misrepresentation of policy terms and conditions at any time in the policy document or policy contract.

Legal construction of insurance policies inso far as the dispute relates to the claim

Policy servicing related grievances against insurers and their agents and intermediaries

Issuance of life insurance policy, general insurance policy including health insurance policy which is not in conformity with the proposal form submitted by the proposer

Non-issuance of insurance policy after receipt of premium in life insurance and general insurance including health insurance

Any other matter resulting from the violation of provisions of the Insurance Act, 1938, or the regulations, circulars, guidelines or instructions issued by the IRDAI from time to time or the terms and conditions of the policy contract, so far as they relate to issues mentioned at clauses (a)to (f).

Settlement process Recommendation

The Ombudsman will act as mediator and arrive at a fair recommendation based on the facts of the dispute. If you accept this as a full and final settlement, the Ombudsman will inform the company which should comply with the terms in 15 days.

Award

If a settlement by recommendationdoesnot work,the Ombudsman will pass an award within three months of receiving all the requirements from the complainant and which will be binding on the insurance company. Once the Award is passed the Insurer shall comply with the award within 30 days of the receipt of award and intimate the compliance of the same to the Ombudsman.

Where to file online complaints

https://www.cioins.co.in/

(The writer is a Vile Parle-based social activist)

Published on: Monday, January 30, 2023, 08:09 AM IST