Insurance policy holders often find their grievances or issues, getting a cold or unsatisfactory response from the insurer. Whether it is with reference to a mis- sold policy by a pushy agent, or a rejection in claims, many policy holders are unhappy with the support provided by the insurer. The grievances either remain unresolved or, the policy holder is left to compromise. In case of such concerns, policy holders could approach an intermediary government body known as "Ombudsman" to resolve the issue.
The Insurance Ombudsman is an authoritative body set up by the government to address policy holder's grievances that may arise in an insurance transaction. Set up in different centres across the country, the main objectives of the Ombudsman are to:
- Receive and consider complaints of policy holders against an insurer
- Aims to find a suitable resolution of the issue.
- Impartial decisions and upholding right insurance practices in the sector.
Grievances Addressed By Ombudsman
There are 12 ombudsmen in the country that would look into grievances relating to claim rejections or non-satisfactory response from the insurance company. The nature of grievances addressed is:
- Partial or total rejection of claims by the insurance companies
- Dispute with regards to premium payable on policy
- Dispute on the legal construction of the policy wordings in case such dispute relates to claims
- Delay in settlement of claims
- Non-issuance of any insurance document
Approaching Ombudsman- How to go about it
Having understood what the Ombudsman is for, let us see the procedure required to be followed to get your complaint across.
The power vested on the Ombudsman is restricted to insurance contracts up to a value of Rs. 20 lakhs. Only if your policy contract is lower than this amount must you approach Ombudsman. Complaints should be in writing. No formal application or prescribed format exists. So a simple letter addressed Chief Vigilance Officer should do. The letter should be marked to the jurisdiction under which the office of the insurer falls. Attach copies of policy documents, any communication with the insurer along with the letter.
What you need to bear in mind
- Before making a complaint to Ombudsman, you should have approached your insurer with the concern. Only if the issue was rejected or, a reply was not received from the insurer within a period of one month from raising the same or, if the response was unsatisfactory, must you go to Ombudsman.
- The complaint to Ombudsman should be made within one year of the insurers reply.
- The issue or complaint must not already be pending before any other court, arbitrator or consumer forum.
Response and Final Decision
It is the duty of the insurance Ombudsman to settle any complaint received, on an impartial basis. The final decision would be on the basis of what he thinks is fair and fit. Ombudsman will examine the grievance and call for a hearing of both parties. Within 30 days, he will send his recommendation on the matter to both parties. If the complainant accepts the settlement, then he has to provide a written consent within 15 days. Otherwise, insurance Ombudsman declares his decision within three months. If further dis-satisfaction persists, the policy holder would have to approach a court of law/consumer forum.
On the part of the insurance company, he must oblige with the decision passed by the insurance Ombudsman, within a span of three months.
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