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Insurance Ombudsman
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A detailed guide on Insurance Ombudsman

Most young adults would like to provide for their families in case of their unfortunate demise. The best way to do that is by using a term insurance plan. A term insurance plan gives you the financial security your family needs if something happens to you. However, if you don’t buy the policy correctly, you may end up not getting what you deserve.

One of the most important steps taken by the Insurance Regulatory and Development Authority (IRDAI), which aims to resolve insurance conflicts, is to create an insurance Ombudsman in India. The insurance Ombudsman helps you get a fair hearing for your insurance grievances from your insurance company. The Ombudsman is an independent officer who listens to both sides of the dispute and gives a fair decision.

What is an Ombudsman in Insurance? Ombudsman is a redressal mechanism set up by IRDAI that gives control to the policyholder to keep a check on erring insurance companies. If you are a policyholder and face any service issues with the insurance company or product, the insurance company should be your first point of contact for any complaints. But in case you are not satisfied with the resolution, after 30 days of your complaint, you can approach the insurance ombudsman.

When to Choose the Insurance Ombudsman in India

To help insurance policyholders get their complaints resolved off the court in an efficient, effective, and unbiased way, the Government of India had created the Insurance Ombudsman scheme. A total of 17 Insurance Ombudsman Centres are operational in India at Mumbai, Pune, Delhi, Bangalore, Ahmedabad, Bhopal, Chandigarh, Bhubaneswar, Chennai, Guwahati, Jaipur, Hyderabad, Kolkata, Kochi, Lucknow, Noida, and Patna.

If your insurer doesn’t resolve your complaints after you have approached them for solutions, you can approach the Ombudsman. They will address your problems, and make sure that the company fulfills its commitment to you.

One can approach the Insurance Ombudsman in India on the following concerns if they are not satisfied with the services or response received from the insurance company.

  • Delay in settlement of claims or maturity proceeds of term insurance or any other insurance policy beyond the period specified by the IRDAI (Insurance and Regulatory Development Authority of India), 1999.
  • In case of rejection of the claim by the insurance company, either in full or partially.
  • In case of any dispute or disagreement on the premiums paid or payable by you to the insurer.
  • In case of any discrepancy or misrepresentation in the term and conditions of the insurance contract or policy documents issued by the insurance company.
  • In case of any complaints relating to how your grievances were addressed
  • If you are issued a policy different from the one chosen by you at the time of issue.
  • In case of denial of insurance, even after timely payment of premiums to the insurer.
  • In case of any other matter that may cause a violation of the terms and specifications of the Insurance Act, 1938. 

Complaining to the Insurance Ombudsman

If you have any complaint related to your insurance plan, or if your insurance company has not been paying your claims, you can take this up with the Insurance Ombudsman.

You can file a complaint at the Ombudsman Insurance consumer complaint cell against the insurance company for failing to respond to your complaint. In addition, if the company does not answer or resolve your issue, you can file a complaint online through the Insurance Ombudsman email id.

Make sure to include all the details of the insurance company along with necessary copies of your documents (especially any document that supports your claim) like medical reports or any other related proofs at the Insurance Ombudsman address. Also, remember to mention the exact policy number, name of the insurance company, short description of the complaint and reason for rejection, suggested course of action, etc., with the complaint as they are vital details that the Ombudsman requires to take up your case for hearing and settlement.

To file the complaint against an insurer with the Ombudsman, you need to follow the steps. 

  • No matter the type of complaint you have against the insurance company, there is a forum for you. You can file a complaint in either of the Insurance Ombudsman offices in India, one in Delhi and the other in Mumbai. 
  • You can file your complaint online using their handy complaint form or download a complaint form from their website. Either way, they’ll gladly review your complaint and respond.
  • File your complaint online, and they will connect you with an expert so you can resolve your issue quickly and easily.
  • The claim must include a formal request for a review of your insurance company’s decision. Your complaint will describe the circumstances that led to your dispute about coverage or payment of out-of-pocket expenses that resulted in your differences with the insurance company. Your document must contain all necessary information related to your contact, address, and id, any other relevant information.
  • To file a complaint to be considered by the Insurance Ombudsman, you must fill in forms. If you use the postal service to file your complaint, form P-II and P-III will be provided for you.
  • After the formal invitation, the Ombudsman issues an official date for a hearing. This is done by duly promulgating an official notification to this effect.

Settlement process of Insurance Ombudsman in India:  The Ombudsman acts as a mediator between the policyholder and the insurance company, creating a platform for both to arrive at a fair and mutually satisfying solution. After hearing both parties, the Ombudsman gives a judgment based on the submitted documents and facts. If the policyholder agrees to the settlement, the insurance company would need to comply with the terms in 15 days.

In case if the settlement doesn’t work, the Ombudsman will pass a final award within three months of the complaint, which will eventually be binding on the insurer. To this, the insurance company will need to comply with the award within 30 days.

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