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Insurance Ombudsman: How To File A Complaint

Do you have a complaint against your insurance company?

If yes, one of the options available — to seek remedy — is the Insurance Ombudsman scheme.

Detailed below are the 20 salient aspects of the same, that you should be aware of.

One. Insurance Ombudsman is a scheme by the Govt. of India to address and resolve the complaints of insurance policyholders — in a cost-effective, efficient and impartial manner without needlessly taking the matters to the court of law.

Two. It is for the individual policyholders only. So, you can raise a complaint with the Insurance Ombudsman only if it pertains to a policy taken in an individual capacity.

Three. Both Public and Private insurers are covered under the scheme.

Four. All kinds of insurance policies viz. life cover, mediclaim, vehicle, personal accident, household property etc. fall under the purview of the scheme.

Five. The claim value, including any expenses, should not exceed Rs.20 lakhs.

Six. You should have first raised your complaint with the insurance company. If they fail to resolve the matter; or don't respond for 30 days; or you are not satisfied with the solution proposed, you can approach the office of Insurance Ombudsman.

Seven. The complaint with the Insurance Ombudsman must be raised within one year of rejection or final reply by the insurance company.

Eight. There are 17 such offices, in different locations across the country. You have to write to the one that has jurisdiction over the location of your insurance company. For the Group Insurance policies, the jurisdiction over the location of your residence is considered. [See Addresses of Insurance Ombudsman.]

complaint-to-insurance-ombudsman
When and how to approach the Insurance Ombudsman with your complaint.

Nine. Your complaint should be about 
(a) partial or total rejection of your claim, 
(b) delay in claim settlement, 
(c) dispute regarding the premium, 
(d) non-issuance of policy document after the premium has been paid or 
(e) any legal issue pertaining to your claim.

Ten. If you have already raised the matter in a Court or Consumer Forum, you cannot approach the Insurance Ombudsman.

Eleven. You don't need to hire a lawyer in such matters.

Twelve. The complaint to Insurance Ombudsman has to be in writing. It should be duly supported by all the relevant papers and documents.

Thirteen. There are no fees or charges applicable.

Fourteen. Wherever necessary, the Ombudsman may conduct a hearing of both the Parties involved in the dispute.

Fifteen. Initially, the Insurance Ombudsman will try to resolve the complaint through mediation and pass a fair Recommendation, within ONE month of lodging the complaint.

Sixteen. If you are Ok with the Recommendation, you have to confirm the same in writing within 15 days. Accordingly, the Ombudsman will inform the insurance company, who will then have 15 days to comply with the same.

Seventeen. If mediation doesn't work, the Ombudsman will pass a fair Award, within a period of THREE months.

Eighteen. You have to confirm your acceptance of the Award in writing within 30 days. The insurance company then has to comply with the Award within 15 days. The Award is binding on the insurance company.

Nineteen. However, the same is not binding on the policyholder. If you are not satisfied with the Ombudsman's Award (or Recommendation), you can take the usual recourse to law.

Twenty. There is a provision of awarding even ex-gratia payment under the scheme.

This, in a nutshell, is how your complaint against the insurance company is handled under the Insurance Ombudsman Scheme.

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