Getting the ombudsman to help you

Here’s what someone seeking redressal must know

MUMBAI: Has your rightful claim been delayed or denied by your insurance company? Is the insurance company paying no heed to the letters you have written?

You could seek redressal from the insurance ombudsman.

People who have complaints pending with any life insurance or general insurance company, on matters related to life insurance policy, mediclaim, personal accident, property, vehicle, group insurance or other household article insurance, can approach the ombudsman.

These complaints can be regarding a delay in settlement of claims, partial or total denial of claims, issues regarding premium to be paid, legal construction of policy or not being given any insurance document in spite of paying premium.

However, one must first approach the insurance company concerned. The company’s website could have details of officials to be approached. It is only after the insurance company fails to respond even after a month or gives an unsatisfactory response to your written complaint can the matter be taken up with the insurance ombudsman.

Also, the ombudsman will hear the complaint only if you take up the matter within a maximum of one year after the insurance company rejected your letter or last responded.

The ombudsman can permit complaints for which the claim amount is up to Rs 20 lakh.
The complaint has to be made to the insurance ombudsman responsible for the particular territory in which the insurance company or its branch is located. So, if a person residing in Pune has taken insurance from an insurance company operating out of Mumbai, he will have to approach the ombudsman responsible for Mumbai. Currently, there is one ombudsman for the Maharashtra and Goa region.

One can find the contact details and names of the ombudsman responsible for their territory on the website http://www.gbic.co.in/contact.html. Details are also available on the website of the Insurance Regulatory and Development Authority The rule regarding the territory of the ombudsman differs in case of a complaint regarding a group insurance policy. If an individual has a dispute to be settled under a group policy, then he will have to approach the insurance ombudsman responsible for the area he resides in.

There is no need to go through a lawyer. One can send the complaint in writing via post, fax or email without giving having to deposit any fee, etc.

In case of email, one has to follow up with a hard copy. The letter should mention the policyholder’s name, insurance company’s name with the branch or location address, the loss or the relief sought from the insurance ombudsman, etc.

After receiving the complaint, the ombudsman conducts a mediation session between the policyholder and the insurance company.

In case it is difficult for you to travel to the city where the ombudsman is located, you may ask if the ombudsman has any meetings scheduled in any locations close to your residence.

Post such a meeting, if the policyholder and the insurance company mutually agree on a solution, the ombudsman will send a letter to the policyholder stating the recommendation. This would be done within one month of the ombudsman receiving the complaint.

If the policyholder who has made the complaint agrees with the recommendations sent by the ombudsman, he has to mention the acceptance in writing and send it to the ombudsman within 15 days of receiving the recommendation. This letter of acceptance, along with the recommendation, is then sent to the insurance company, which has to comply accordingly within the next 15 days.

On the other hand, if both the insurance company and the policyholder do not agree on a solution during the meeting then the ombudsman will decide the amount that the policyholder should get for the claim and will record and send the same in a letter to the policy holder. This letter has to reach the policyholder within three months since the ombudsman received the compliant. The same procedure of notifying acceptance is to be followed and the insurance company has to take action within 15 days.

As per the governing body of the Insurance Council, as of March 2007, the ombudsman has offered relief of over Rs 53 crore on around 50,000 complaints, with a settlement ratio of 84%. But, what if the policyholder is still not satisfied with the recommendations or decisions of the insurance ombudsman? If the decision is not acceptable, it cannot be challenged at a higher level, but a normal legal fight can be initiated against the insurance company. Even if an ombudsman rejects a complaint, the same can be taken up via the normal legal route as well.

The insurance ombudsman, though, will not accept complaints made to or pending at the consumer forum, arbitrator or any other forum. So, seek your rightful insurance cover amount by approaching the right people.
d_khyati@dnaindia.net