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Insurance provides financial protection to a common man against uncertainties of life. While buying a policy, a common man puts his trust and hopes that his Claim would be honored when the situation arises. It is important that this trust and confidence of a common man is not only maintained but nurtured for the welfare of the society.
Insurance companies across the world exist for a motive of profit and it is important to ensure their profit motive does not intervene in their fair behavior while issuing or honoring claims on policies. As a consequence, the Government of India has created the Insurance Ombudsman, which aims to speedily address any grievance that a buyer would have against the insurer. This would ensure that people as a whole are able to place their trust in the system and hence the insurance industry can prosper and grow.
Ombudsman is appointed by the insurance council and is a person from Insurance Industry, Civil Services or Judicial Service. The tenure of his services is 3 years. Currently, there are 12 ombudsmen in India and each has a jurisdiction.
To take a grievance to the ombudsman, the Insured or his legal heir can file a written complaint. While doing so, they need to take care of the following points -
1) The Insurance Ombudsman is not empowered to handle grievances on insurance plans whose value exceeds 20 lakhs.
2) Before you write a written complaint to the ombudsman, it is mandatory for the Policyholder to have shared his grievance with the insurance provider. The complaint can relate to any matter including claim settlement, a dispute related to Premium paid or premium payable and likewise.
Only if the Insurer does not reply to the grievance, or the policyholder is not satisfied with the reply, the matter can be elevated to the ombudsman. Dissatisfaction may be either due to complete or partial rejection of a policyholder’s claims.
3) Time Limits - The complaint to the insurance ombudsman should be filed within 12 months of receiving a final reply from the insurance company on the grievance and within 13 months of filing a complaint if the insurance company fails to give a reply.
4) If the complaint has also been filed in a court or consumer forum, and is pending a resolution, it cannot be taken to the ombudsman.
While handling the grievance, the ombudsman will play the role of a counselor and mediator between the insurer and the insured. Based on what the ombudsman believes as a fair opinion, he will issue a recommendation within a month of receiving the complaint. If the recommendation is acceptable to the complainant, the insurer will have to abide by it. If the recommendation is not found to be satisfactory by the complainant, then the ombudsman will issue an award within 3 months of receiving the complaint and if the complainant is still dissatisfied he can choose to take the matter further to an alternate authority. The insurance company does not have a choice and it has to compulsorily adhere to the order of the ombudsman, if the same is acceptable to the complainant.