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An ombudsman is an officer appointed by Government of India.any person having a grievance against an insurance company may,himself or by his legal heir,nominee,or assignee can lodge complaint to the insurance Ombudsman by online or in person.before setting up ombudsman There were growing disputes and complaints from the insured public/their legal heirs. With a view to address their grievances, the Government of India setup Insurance ombudsman rules ,The rules are meant to resolve disputes out of the court in a cost effective ,speedy, and efficient manner. The Institution of Insurance Ombudsman was formed with the very purpose of policyholder benefits. The ombudsman has power to entertain disputes w.r.t repudiation of claims, legal construction of policies, delay in claim settlement, premium payment disputes, non-issuance of insurance documents etc.At present there are 17 insurance ombudsman are working in India.
Benefits of Insurance ombudsman complaint
- Cost effective
- Complaint can resolve out of court
- Speedy disposal
Steps to file Complaint before ombudsman
Step 1 : The consumer has to send the written complaint to the grievance redressal officer of concerned company.
Step 2 : If Insurance Company has rejected complaint or not resolved it with your satisfaction or not responded to it at all for 30 days then you can file complaint before ombudsman and the value of claim including expenses claimed is not above Rs.30 lakhs.
The process of settlement
- Recommendation: The ombudsman will act as mediator and arrive at a fair recommendation on the facts of the case.if you accept this recommendation as a full and final settlement ,the ombudsman will inform the insurance company which should comply the orders of the insurance ombudsman within 15 days.
- Award ( Judgement or order ) : If a settlement does not work the ombudsman will pass an award within 3 months of receiving complaint and the order will be binding on the insurance company.
- After the award is passed : Once the award is passed the insurance company shall comply the order within 30 days of the receipt of award and intimate the compliance of the same to the insurance ombudsman.
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Frequently Asked Questions
Who can approach the Insurance Ombudsman ?
A person who has signed up for an insurance policy on personal lines and is aggrieved by the same by himself or by his legal heir,nominee,or assignee can approach the Ombudsman.
What do you mean by insurance on personal lines ?
It means a policy undertaken in the capacity of the concerned individual. Some examples of the same are life insurance, Mediclaim, personal property insurance, personal accident insurance, etc.
How to lodge a complaint before ombudsman ?
A complaint may be made in written form either in-person or through e-mail or post or online portal.
What is the time limit to approach the Insurance Ombudsman ?
An aggrieved person may approach the Insurance Ombudsman within one year of rejection of representation of complainant by the Insurer or the final reply of the Insurer to such representation, as the case may be.
What is the pecuniary limit of a dispute that the Ombudsman can entertain ?
The Insurance Ombudsman can only entertain a complaint including expenses claimed does not exceed Rs. 30,00,000.
What are the conditions for lodging of a complaint ?
- Complaint should be by an individual concerning insurance on personal lines as per terms of reference of the concerned Insurance Ombudsman
- Prior representation to the Insurance Company is mandatory. Either an unsatisfactory reply should be present, or the representation should not have been replied within one month.
- Complaint must be filed within one year of the events stated above
- Pecuniary limit for matter filed should not exceed Rs. 30 lakhs including expense.
- The dispute filed with the Forum should not have been filed priorly with another Court.
If insurance claim exceeds Rs.30 lakhs what can I do ?
If your claim excess Rs.30 lakhs including costs then you have to approach concerned jurisdiction Consumer forum or commission