Procedure of lodging complaint with the Insurance Ombudsman

Dear Friends,

You are aware that Insurance is a contract of upmost good faith. Both insured and insurance companies have to play their part properly and according to the policy document and agreed terms and conditions mentioned therein.

But in some cases disputes arises on the basis of non compliance of terms and conditions of the policy or wrong interpretation of those by the insurer or the insured. This dispute is not beneficial for the insurer and the insured, for insurer it brought bad image and reputation and insured will dissatisfied with the services of the insurer. It is duty of the insurer to avoid such types of disputes to maintain its reputation as image.

Insurance is now become need of every Indian and this COVID-19 pandemic has taught us lot and forced us to have an insurance cover for our life, family and assets.

The government has provided various forums for resolution of disputes of dissatisfied policyholders and the “Insurance Ombudsman" is one of them.

With an objective of providing a forum for resolving disputes and complaints from the aggrieved insured public or their legal representatives against the insurance companies the Government of India , in exercise of powers conferred on it under Section114(1) of the Insurance Act,1938 framed the "Redressal of Public Grievances Rules,1998" w.e.f. 11/11/1998. This rules provides resolution on complaints of the insured public against the companies on “ personal lines “ of insurance business. This is a cost effective ,efficient and impartial settlement of grievance system.

THE INSURANCE OMBUDSMAN RULES, 2017

The Government of India has promulgated The Insurance Ombudsman Rules, 2015 with the objective to resolve all complaints of all personal lines of insurance, group insurance polices, policies issued to sole proprietor and micro enterprises on the part of insurance companies and their agents or intermediaries in a cost effective and impartial manner.

INSURANCE ON PERSONAL LINES - Means a policy taken or given in an individual capacity e.g. life insurance, personal accident insurance, Mediclaim insurance and insurance of personal property of individual such as motor vehicle, household articles ,etc.

Please note that- firms and organizations are not allowed to take benefit of Ombudsman Scheme.

Rule 7(2) provides that an Ombudsman shall be selected from amongst person having experience of insurance industry , civil service , administrative service or judicial service and shall be appointed for a period of three years or at the age of 70 years.

PLEASE NOTE THAT: The Union government amended the Insurance Ombudsman Rules, 2017, on 2^nd March,2021 bringing insurance brokers within the ambit of the Insurance Ombudsman and also allowed policy holders to file online complaints.

1. Enlarged the Scope Of Complaints

Earlier it was only disputes. Now the amended rules will cover even the deficiencies in service on the part of insurers, agents, brokers and other intermediaries.

2. Introduced IT Enabled Complaint Redressal

a) Enables making complaints electronically.
b) Complaints management system to enable policyholders to track the status of their complaints online.
c) Video-conferencing for hearings.
d) These amendments will strengthen the timeliness and cost-effectiveness of the mechanisms.

3. Empowering Ombudsman

a) A number of amendments have been made for securing the independence and integrity of the ombudsman selection process, while also building in safeguards to secure the independence and impartiality of the appointed persons while serving as ombudsmen.

b)The selection committee will now include an individual with a track record of promoting consumer rights or advancing the cause of consumer protection in the insurance sector.

MANNER IN WHICH COMPLAINT TO BE MADE

(1) Any person who has a grievance against an insurer or insurance broker, may himself or through his legal heirs, nominee or assignee, make a complaint in writing to the Insurance Ombudsman within whose territorial jurisdiction the branch or office of the insurer or the insurance broker, as the case may be, complained against or the residential address or place of residence of the complainant is located.

(2) The complaint shall be in writing, duly signed or made by way of electronic mail or online through the website of the Council for Insurance Ombudsmen, by the complainant or through his legal heirs, nominee or assignee and shall state clearly the name and address of the complainant, the name of the branch or office of the insurer or the insurance broker, as the case may be, against whom the complaint is made, the facts giving rise to the complaint, supported by documents, the nature and extent of the loss caused to the complainant and the relief sought from the Insurance Ombudsman.

(3) No complaint to the Insurance Ombudsman shall lie unless -

(a) the complainant has made a representation in writing or through electronic mail or online through website of the insurer or insurance broker concerned to the insurer or the insurance broker, as the case may be, named in the complaint and -

(i) either the insurer or the insurance broker, as the case may be, had rejected the complaint; or

(ii) the complainant had not received any reply within a period of one month after the insurer or the insurance broker, as the case may be, received his representation; or

(iii) the complainant is not satisfied with the reply given to him by the insurer or the insurance broker, as the case may be;

(b) The complaint is made within one year - 

(i) after the order of the insurer or the insurance broker, as the case may be, rejecting the representation is received; or

(ii) after receipt of decision of the insurer or the insurance broker, as the case may be, which is not to the satisfaction of the complainant;

(iii) after expiry of a period of one month from the date of sending the written representation to the insurer or the insurance broker, as the case may be, if the insurer or the insurance broker, as the case may be, named fails to furnish reply to the complainant .

(4) The Ombudsman shall be empowered to condone the delay in such cases as he may consider necessary, after calling for objections of the insurer or the insurance broker, as the case may be, against the proposed condonation and after recording reasons for condoning the delay and in case the delay is condoned, the date of condonation of delay shall be deemed to be the date of filing of the complaint, for further proceedings under these rules.

(5) No complaint before the Insurance Ombudsman shall be maintainable on the same subject matter on which proceedings are pending before or disposed of by any court or consumer forum or arbitrator.

LET'S ANALYSE THE PROCESS

1. You have first approached your insurance company with the complaint and
   • They have rejected it;
   • Not resolved it to your satisfaction ;or
   • Not responded to it at all for 30 days.
2. Your complaint pertains to any policy you have taken in your capacity as an individual; and
3. The value of the claim including expenses claimed is not above Rs 30 lakhs.
4. The complaint must be lodged within 1(one) year after receiving reply from the insurance Company, agents or brokers .
5. The subject matter of complaint should not currently be or have earlier been before a Court/Consumer Forums.

YOUR COMPLAINT TO THE OMBUDSMAN CAN BE ABOUT

a) Delay in settlement of claims, beyond the time specified in the regulations, framed under the IRDAI Act, 1999.

b) Any partial or total repudiation of claims by the Life insurer, General insurer or the Health insurer.

c) Any dispute about premium paid or payable in terms of insurance policy.

d) Misrepresentation of policy terms and conditions at any time in the policy document or policy contract.

e) Legal construction of insurance policies in so far as the dispute relates to claim.

f) Policy servicing related grievances against insurers and their agents and intermediaries.

g) Issuance of life insurance policy, general insurance policy including health insurance policy which is not in conformity with the proposal form submitted by the proposer.

h) Non issuance of insurance policy after receipt of premium in life insurance and general insurance including health insurance and

i) Any other matter resulting from the violation of provisions of the Insurance Act, 1938 or the regulations, circulars, guidelines or instructions issued by the IRDAI from time to time or the terms and conditions of the policy contract, in so far as they relate to issues mentioned at clauses (a) to (f)

THE SETTLEMENT PROCESS

RECOMMENDATION

The Ombudsman will act as mediator and

1) Where a complaint is settled through mediation, the Ombudsman shall make a recommendation which it thinks fair in the circumstances of the case, within one month of the date of receipt of mutual written consent for such mediation and the copies of the recommendation shall be sent to the complainant and the insurer or the insurance broker, as the case may be, concerned.

(2) If the recommendation of the Ombudsman is acceptable to the complainant, he shall send a communication in writing within fifteen days of receipt of the recommendation, stating clearly that he accepts the settlement as full and final.

(3) The Ombudsman shall send to the insurer or the insurance broker, as the case may be, a copy of its recommendation, along with the acceptance letter received from the complainant and the insurer or the insurance broker, as the case may be, shall, thereupon, comply with the terms of the recommendation immediately but not later than fifteen days of the receipt of such recommendation, and inform the Ombudsman of its compliance.

AWARD

(1) Where the complaint is not settled by way of mediation under rule 16 of the Regulations, 2017 (amended), the Ombudsman shall pass an award, based on the pleadings and evidence brought on record.

(2) The award shall be in writing and shall state the reasons upon which the award is based.

(3) Where the award is in favour of the complainant, it shall state the amount of compensation granted to the complainant after deducting the amount already paid, if any, from the award:

Provided that the Ombudsman shall

(i) not award any compensation in excess of the loss suffered by the complainant as a direct consequence of the cause of action; or

(ii) not award compensation exceeding rupees 30(thirty lakhs) (including relevant expenses, if any).

(4) The Ombudsman shall finalise its findings and pass an award within a period of three months of the receipt of all requirements from the complainant.

(5) A copy of the award shall be sent to the complainant and the insurer or the insurance broker, as the case may be, named in the complaint.

(6) The insurer or the insurance broker, as the case may be, shall comply with the award within 30 (thirty days) of the receipt of the award and intimate compliance of the same to the Ombudsman and upload the details in the complaints management system.

(7) The complainant shall be entitled to such interest at a rate per annum as specified in the regulations, framed under the Insurance Regulatory and Development Authority of India Act, 1999, from the date the claim ought to have been settled under the regulations, till the date of payment of the amount awarded by the Ombudsman.

(8) The award of Insurance Ombudsman shall be binding on the insurers or the insurance broker, as the case may be If a settlement by recommendation does not work, the Ombudsman will:- Pass an award within 3 months of receiving all the requirements(documents, information and evidences to substantiate his/her claim and reply of insurance company etc.)from the complainant and which will be binding on the insurance company.

PLEASE NOTE THAT

1. The award passed by 'Ombudsman' will be applicable to the insurer and the insured but and insurer is bound to comply with award and not the insured ,if he dissatisfied with the award. An insured(complainant)) after being aggrieved with the award of the Ombudsman may apply to other available forums.
2. The dismissal of a complaint by the Ombudsman does not vitiate the the complainants' right to seek legal. Remedy against. The insurer's complained against as per the normal process of law.

CONCLUSION

The Insurance Ombudsman system of redressal of grievance process if a welcome step of the government . It provides much relief to small policyholders and save them from expenses of litigation and their time to lodge claim in other forums. This scheme is applicable for only individuals and not for firms or other organisations . An insured being individual can file complaint with Ombudsman on after dissatisfied with the decision of insurance company, brokers r other insurance intermediaries. The complaint must be filed within a period of one year from the date of rejection or receiving of reply from the insurer or other intermediaries. There are at present 17 Insurance Ombudsman in different locations and any person who has a grievance against an insurer, may himself or through his legal heirs, nominee or assignee. You have to make complaint with the Ombudsman Office having jurisdictional area in which you are residing or the office of insurer of insurance intermediaries established.

DISCLAIMER: the article produced here is only for knowledge and information of readers , for more clarification ,please visit IRDAI extant regulations and circulars. The article has been prepared on the basis of materials and information available at the time of preparation and care has been taken to avoid any misstatement or mistake. It is advisable to consult insurance professionals before acting on any part of this article. The views produced here is the personal view of the author.