When can You Approach The Insurance Ombudsman in India?

In the Insurance industry like any other industry, there are customers and investors who are not satisfied with the policy of the companies offering the policies. The Insurance Ombudsman is a scheme of the government to address those complaints of the policyholders for effective and efficient settlement of the problems out of the courtroom and in an impartial manner.

At present, there are 17 Insurance ombudsmen in the country in different regions and one can approach the specific ombudsman of their specific location under which the insurance company is situated against which the policyholder has the complaint.

Who is an Ombudsman in Insurance?

The institution of Ombudsman Insurance was established in November 1998 under the supervision of the Government of India, the first task of this institution was to maintain systematic speed and transparency in the grievance claim process for the insurance policyholders. By this time, many new rules regarding insurance had been coming in India, and the general public was also facing many problems regarding insurance to reduce them all, the Ombudsman was formed. The objective of this Ombudsman body is to know and mitigate all the difficulties in the settlement of these claims. The first and foremost objective of the constitution of the Ombudsman in Insurance is to provide efficient, effective, and fair redressal of grievances of the policyholders.

Insurance Ombudsman can be Approached if:-

• Your complaint has not been resolved by the insurance company or you are not satisfied with the solution they have provided or the insurance company has not responded to your complaint within thirty days of the submission of the complaint

• The complaint is related to any of the policies you have purchased on your own as an individual and

• The claim value including the amount you have claimed as expenses are not more than 20 lacs.

Insurance Ombudsman can be Approached for the following Disputes

• Insurance company in total or partial denial of the claims made by the insured person or his family members=
• Any issue related to premium which is payable or paid for the insurance policy
• Claims can be for legal issues related to the policy
• If the claims are not settled within a specified time frame by the insurance company
• If the insurance company doesn’t hand over the insurance documents to you after you pay the first premium.

Step to Approach the Insurance Ombudsman

• Recommendation- The Insurance Ombudsman like a mediator and counselor will help both the parties to reach an impartial and fair decision and recommendation after verifying the facts of the complaint. If the policyholder accepts the decision as to the final one then the Insurance Ombudsman would ask the insurance company to act upon the decision within 15 days.

• Award: If the policyholder doesn’t accept the recommendation, the Insurance Ombudsman within 3 months of the complaint would deliver an award which can be a speaking award with detailed facts and reasoning. Ex-gratia payment can also be awarded by the Ombudsman. Once the policyholder receives the award, he or she needs to inform the insurance company of the same and the company needs to follow the same. The policyholder also needs to accept the award in writing.

Procedure Related to Approaching Insurance Ombudsman

• Time limit: Within one year of the claim rejection by the insurance company whether completely or partially, the policyholder needs to approach the Ombudsman.

• Where to approach: The policyholder must check under which Ombudsman’s jurisdiction the insurance company falls. He needs to approach the same Ombudsman. Generally, the jurisdiction is placed according to the region or location of the insurance company.

• Dispute amount limit: The amount of the claim or the dispute must not be exceeding the maximum limit of 20 lacs. It also should include the claim expenses along with the value of the claim.

• Fees: Insurance Ombudsman is a government initiative that doesn’t charge any money from the policyholders. If anyone asks for money for settling your claim, know that is probably a fraud.

• Who can approach: The policyholder or the family member of the deceased policyholder can approach the Ombudsman for any complaint. No lawyers or agents are allowed to file any complaint on behalf of the policyholder. The policyholder has to be present during the process.

• Place: One can file the complaint via E-mail, fax, or post along with mandatory documents attested and attached. It is safe to E-mail the documents so that it remains safe and also reached the Ombudsman table quickly.

• Results: Ombudsman tries to solve every case with impartial decision making and also fair judgment is their basic policy but if the policyholder doesn’t win then he has the right to approach the consumer forum or consumer court for further investigation and judgment.

• When you Cannot Approach Ombudsman: If the complaint has already been filed in the consumer court or forum and the proceeding of the same has begun, the policyholder cannot approach the Insurance Ombudsman with the same complaint.

What is the settlement process followed by Insurance Ombudsman in India?

The claim settlement process by Ombudsman is very simple and easy, Ombudsman acts as a mediator for settlement between you and your insurance and helps both the parties to arrive at an appropriate remedy or settlement. Look, going to Ombudsman means that you have not got justice from your policy, and Ombudsman does not work for anyone party and in this case Ombudsman provides a better suggestion to both of you in case of this disordered insurance policy.

However, if the agreement does not work due to any reason, the Ombudsman will pass a decision within three months, which will be binding on the insurer. The insurance company must comply with the award within 30 days, and this is how the Ombudsman demonstrates its strength.

Conclusion

Insurance products are beneficial but there are many legalities and terms and conditions which are attached to them. Hardly, any policyholder reads the full document and the terms and conditions before investing nor any insurance agents will tell the facts of the insurance policy in detail. The issues arise from not having proper and adequate information about the policy you have purchased. The insurance Ombudsman is very helpful and supportive for the policyholders and tries every bit to secure the investor’s money.