Insurance Ombudsman

Understanding the Role of the Insurance Ombudsman

The Insurance Regulatory and Development Authority of India (IRDAI) established the Insurance Ombudsman. The Insurance Ombudsman provides a faster and cheaper platform to resolve disputes between insurance companies and policyholders. The insurance ombudsman empowers policyholders to seek redressal of grievances related to:

• Claim settlements and rejections.
• Policy issuance and renewal issues.
• Misleading or false information provided by the insurance company.
• Delays in processing claims or payments.
• Unfair terms and conditions within the policy.
• Misleading advertising and marketing of insurance products.

Key Features of the Insurance Ombudsman

Below, we have mentioned the key features of the Insurance Ombudsman:

• Accessibility: The Ombudsman is available to all policyholders, irrespective of their claim amount or location. Complaints can also be filed online, through post, or in person at designated offices.
• Cost-effectiveness: Filing a complaint with the Ombudsman is free, making it a viable option for policyholders who need more financial resources to seek legal recourse.
• Time-bound Process: The Insurance Ombudsman mandates a time-bound resolution process, with most cases being disposed of within 3 months. This ensures quick resolution for policyholders who often face financial difficulty due to insurance issues.
• Informal and Fair: The Insurance Ombudsman is informal and avoids the complexities of legal proceedings. Both sides can present their case, ensuring a fair and transparent process.

Powers of Insurance Ombudsman

The Insurance Ombudsman has two main functions: conciliation and award-making. The organization takes care of customers’ complaints about any issue against the services provided by any insurance company. These issues include:

• Any partial or complete rejection of claims 
• Disputes involving paid or due premiums
• Disputes regarding the policy wording
• Delays in claims resolution
• Despite receiving the premium payment, the insurance paperwork relating to the policy has yet to be issued.

List of Insurance Ombudsman Offices in India

Below-mentioned is the list of Insurance Ombudsman available in India:

When to Approach the Insurance Ombudsman?

Suppose you are facing an issue with your insurance provider regarding your claim rejection or claim delay. In that case, you can escalate it to the Insurance ombudsman in the below-mentioned circumstances:

• If your complaint was initially lodged with your insurance provider, but it was either rejected, unanswered for 30 days or not adequately resolved.
• Your complaint pertains to your life insurance coverage.
• The value of your life insurance claim should be under INR 30 lakhs.

To file a complaint with the Insurance Ombudsman, you must submit a written complaint in a prescribed complaint form. You can submit the complaint in person or through a letter, fax, or email. However, if you choose to submit the complaint via email, attaching a hard copy of the complaint is mandatory. It's important to note that you must file the insurance claim within one year of the insurer's rejection. Furthermore, the ombudsman will not handle a court case or consumer forum already dealing with the same complaint.

Process For Lodging A Complaint With Insurance Ombudsman

Below, we have mentioned the process to file a complaint with the insurance ombudsman:

• Connect with the nearest Insurance Ombudsman office. 
• Send a hard copy of the complaint to the Insurance Ombudsman to file your complaint using the procedure for complaints. Moreover, You can also send your grievance via fax or email.
• The complaint must contain all appropriate information, such as details on the policy issue, the paid and unpaid premiums, the complaint in detail, the actions the insurance company took, etc. To the Insurance Ombudsman office in your area.
• After registering your complaint to the insurance ombudsman, you must fill out P-II and P-III forms. 
• Then, you need to mail these documents along with your complaint to the Insurance Ombudsman.
• Once the Ombudsman will get all the documents, they will announce a hearing date.

Types Of Complaints That The Insurance Ombudsman Will Accept

The Insurance Ombudsman can handle a wide range of complaints related to life insurance policies with a claim value of up to INR 30 lakhs. Here's a breakdown of the types of complaints typically accepted:

• Claim rejection: If your insurance company has rejected your claim, you can seek the Ombudsman's intervention.
• Partial claim settlement: Even if your claim is partially settled, but you believe the amount is inadequate, the Ombudsman can help.
• Delays in claim settlement: If your claim settlement is unreasonably delayed, you can file a complaint.
• Unfair claim terms or conditions: If you believe the claim terms or conditions are unfair or ambiguous, the Ombudsman can review them. 
• Mis-selling of policies: If you were misled or misinformed about a policy before purchasing it, the Ombudsman can investigate.
• Non-disclosure of policy terms: If the insurer fails to disclose important information about the policy, you can file a complaint.
• Unfair policy terms and conditions: If you believe certain policy terms are unfair or unreasonable, the Ombudsman can assess them.
• Premium disputes: If there are disagreements regarding premium payments or charges, the Ombudsman can mediate.
• Poor customer service: If you've experienced rude or unresponsive customer service from the insurer, you can file a complaint.
• Misrepresentation of information: If the insurer provides false or misleading information about the policy or claim process, it can be addressed by the Ombudsman.
• Delay in policy issuance or renewal: Failure in issuing or renewing your policy can be investigated by the Ombudsman.

Settlement Process With Insurance Ombudsman

The settlement process with the Insurance Ombudsman typically unfolds in the following steps:

• Get a complaint form from the Ombudsman's website or office and fill it out correctly.
• Attach the required documents like policy documents, claim rejection letters, correspondence with the insurer, etc.
• Submit the complaint by mail, fax, or email (with a paper copy attached).
• The Ombudsman's office will acknowledge receipt of your complaint and assign it to a designated officer.
• This Ombudsman officer will investigate the whole case.
• The Ombudsman officer will review both sides of the case, including your complaint, the insurance company's response, and any supporting documents.
• Both parties are typically bound to comply with the Ombudsman's recommendation unless there are valid reasons for objection.
• If mediation fails, the Ombudsman may decide to dismiss the complaint, refer it to another forum (court, consumer forum), or issue binding instructions to the insurance company.
• The case will be closed once the complaint is resolved and both parties are satisfied.

Conclusion

The Insurance Ombudsman is important in empowering policyholders and ensuring a fair and balanced insurance market. By understanding its functions, limitations, and potential for improvement, we can strengthen this important protection for policyholders, ensuring they get the protection and justice they deserve in the complex world of insurance.