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Insurance Ombudsman: Everything You Need to Know

Dec 5, 2023


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Insurance Ombudsman: Everything You Need to Know

What is an Insurance Ombudsman?

Insurance Ombudsman is an initiative established by the Government of India to simplify and organize the process of addressing grievances raised by Insurance policyholders and settle these grievances out of court. The main objective of the Ombudsman is to address and resolve any challenges that arise during the settlement of Insurance Claims. It aims to provide a fair, unbiased system for resolving grievances raised by policyholders. At present, there are 17 offices of the Insurance Ombudsman, the powers of each extending to their corresponding jurisdiction.

What is the need for an Insurance Ombudsman?

When a person purchases an Insurance Policy, they expect to be reimbursed in case of an admissible claim under the policy. However, in some cases, the Policyholder does not receive reimbursement and a dispute arises between the Insured and the Insurance Company due to various reasons like coverage denial, policy misrepresentation or disputes in claim settlement amounts.

In order to get a redressal to the dispute, the Insured can approach the Insurance Ombudsman, who acts as a mediator and helps settle cases between the Insured and the Insurer. In this article, we will examine the role and functions of the Insurance Ombudsman and provide information on how to approach the ombudsman for any disputes with your insurer.

Council for Insurance Ombudsman

The Council for Insurance Ombudsman (CIO) oversees the various Offices of Insurance Ombudsman, which were established under the Insurance Ombudsman Rules, 2017.

The Office of Insurance Ombudsman serves as an alternative platform for addressing and resolving grievances raised by policyholders who are dissatisfied with Insurance Companies or Insurance Intermediaries like Insurance Brokers or Insurance Agents. Its primary objective is to offer a quick and cost-effective mechanism for resolving these grievances.

The Role and Functions of Insurance Ombudsman

The Insurance Ombudsman performs two main functions: conciliation and award making. It possesses the legal authority to receive and address customer complaints regarding Insurance Services. These complaints can cover various issues related to insurance providers, such as:

  • Complete or partial rejection or denial of Insurance Claims by the Insurance Provider.
  • Disputes concerning due or paid Insurance Premiums.
  • Disputes regarding the language used in the policy’s legal framework.
  • Delays in resolving claims.
  • Non-issuance of Insurance Policy despite the payment of premiums.

What to do if your Insurance Claim is rejected?

If the Insured feels that his claim has been unduly rejected and he wants to escalate the matter, the first step is to lodge a written complaint with the Grievance Redressal Officer of the Insurance Company. The Insured should provide supporting documents. The Insurance Company should solve the complaint within 1 month of receipt.

If the Insured is not satisfied with the claim resolution, he has 3 options:

  1. Register the Complaint with the Bima Bharosa Online Portal of IRDAI – https://bimabharosa.irdai.gov.in
  2. Approach the Insurance Ombudsman
  3. The third option is to file a compliant with the Consumer Court or Civil Court

When should you approach the Insurance Ombudsman to file a Complaint?

You can submit your grievance to the Insurance Ombudsman under the following conditions.

  • You have raised a complaint to the Insurance Company and they have failed to furnish you a reply within 1 month of your complaint or you are not satisfied with the solution provided.
  • The complaint is being made to the Insurance Ombudsman within one year of the date of rejection of the complaint by the Insurance Company/Insurance Broker.
  • The amount of Compensation sought from the Insurance Ombudsman does not exceed Rs. 50 Lakhs.

How to Lodge a Complaint with the Insurance Ombudsman?

You can lodge a complaint with the Insurance Ombudsman in the following ways:

  1. Walk-in to the local Insurance Ombudsman office and submit a hard copy of your complaint to the Insurance Ombudsman office using the prescribed complaint procedure.
  2. Alternatively, you can send your grievance via email or Post
  3. You can register the complaint online on the Insurance Ombudsman Portal Online

Your complaint should include all relevant information about your Insurance Policy, such as Policy Number, Premiums paid and unpaid, a detailed description of the complaint, and actions taken by the Insurance Company.

When submitting your complaint to the Insurance Ombudsman, you may be required to provide supporting documentation such as Claim Rejection letter by the Insurer, written complaint made to the Insurance Company etc.

After following these procedures, the Ombudsman will set a hearing date to address your complaint.

How to Lodge an Online Complaint with the Insurance Ombudsman?

The Insured can also register his complaint with the Insurance Ombudsman online by following the below mentioned process:

  1. Goto the website https://www.cioins.co.in/ and click on the “Register Complaint” option on the home page.
  2. Fill in the required details and upload the documents.
  3. An OTP is generated. As soon as the OTP is received, the complaint will be filed.

What are the documents required for filing a Complaint with the Insurance Ombudsman?

The Insured needs to submit the following documents to file a complaint with the Insurance Ombudsman:

  1. Copy of representation sent to the Insurance Company or Insurance Broker
  2. Letter/E-mail from Insurance Company/Insurance Broker rejecting the representation/repudiating the claim.
  3. KYC particulars, Aadhar card, Pan Card, Driving License, etc
  4. Copy of Insurance Policy
  5. Photograph

What is the Claim Settlement Process with Insurance Ombudsman?

  1. **Recommendation: **The Ombudsman acts as a mediator between the Insured and the Insurance Company and makes a fair recommendation for resolving the issue based on the facts of the case.
  2. Compliance Notification: Once the Insurance Company accepts the recommendation as a full and final settlement, it must comply with the terms within 15 days as per the Ombudsman rules.
  3. Award: In case the settlement by recommendation fails, the Ombudsman will proceed with the following steps:
    1. After receiving all the necessary requirements from the complainant, the Ombudsman will pass an award within 3 months. This award will be binding on the insurance company.
    2. Once the award is passed, the insurance company is required to comply with the award within 30 days of receiving it. The company must also notify the Ombudsman of its compliance.

If the Insured is unsatisfied with the resolution offered by the Ombudsman, he can seek legal remedy with a Civil Court or a Consumer Court.

What type of complaints are accepted by the Insurance Ombudsman?

  1. Claims that are not settled within the specified time period, outlined in the IRDAI Act, 1999.
  2. Disputes about premiums paid or payable under an Insurance Policy
  3. Grievances against Insurance Companies and their agents related to policy servicing.
  4. The document or contract containing the policy terms and conditions has been misrepresented, anytime.
  5. Issue of life insurance policies, general insurance policies, and health insurance policies that do not conform to the proposal submitted by the proposer.
  6. Failure to issue an insurance policy after receiving a premium in life insurance and general insurance.

List of Insurance Ombudsman in India

As the office of insurance ombudsman operates in a territorial jurisdiction, find below the contact details of the different offices of the insurance ombudsman.  However please note that the complaint will lie with the Insurance Ombudsman under whose territorial jurisdiction the Office of the Insurer complained against is located.

Office of the Ombudsman Telephone Email ID Areas of Jurisdiction
Ahmedabad 079 – 25501201/02/05/06 bimalokpal.ahmedabad@cioins.co.in Gujarat, Dadra & Nagar Haveli, Daman and Diu
Bengaluru 080 – 26652048 / 26652049 bimalokpal.bengaluru@cioins.co.in Karnataka
Bhopal 0755 – 2769201 / 2769202 bimalokpal.bhopal@cioins.co.in Madhya Pradesh, Chhattisgarh
Bhubaneswar 0674 – 2596461 / 2596455 bimalokpal.bhubaneswar@cioins.co.in Odisha
Chandigarh 0172 – 4646394 / 2706468 bimalokpal.chandigarh@cioins.co.in Punjab, Haryana, Kashmir, Ladakh, Chandigarh
Chennai 044 – 24333668 / 24333678 bimalokpal.chennai@cioins.co.in Tamil Nadu, Pondicherry and Karaikal
Delhi 011 – 23237539 bimalokpal.delhi@cioins.co.in Delhi and certain districts of Haryana
Guwahati 0361 – 2632204 / 2602205 bimalokpal.guwahati@cioins.co.in Assam, Meghalaya, Manipur, Mizoram, Arunachal Pradesh, Nagaland and Tripura
Hyderabad 040 – 23312122 bimalokpal.hyderabad@cioins.co.in Andhra Pradesh, Telangana, Yanam and part of Union Territory of Puducherry.
Jaipur 0141 – 2740363 / 2740798 bimalokpal.jaipur@cioins.co.in Rajasthan

Find the complete address details here

Frequently Asked Questions

Does the Insurance Ombudsman Operate in a Territorial Jurisdiction?

Yes, Insurance Ombudsman operates only within the territorial limits specified above

How is this Territorial Jurisdiction to be Applied to Complaints ?

The complaint will lie with the Insurance Ombudsman under whose territorial jurisdiction the Branch or Office of the Insurer complained against is located. However, in case of Group Insurance policies, the complaint may be lodged with the Insurance Ombudsman under whose territorial jurisdiction the place of residence of the complainant falls.

What types of Complaints are entertained by the Insurance Ombudsman?

  • Complaints pertaining to repudiation of claims, totally or partially.
  • Delay in settlement of claims
  • disputes regarding premiums paid

Should You Consult a Lawyer to file a complaint with the Insurance Ombudsman?

No. Not necessary. You can directly raise a complaint through one of the above channels or online at www.cioins.co.in

Is there any maximum limit for the amount under dispute to be entertained by the Ombudsman?

Yes. The maximum limit for the amount under dispute for which the Ombudsman can entertain a complaint is up to Rs.50 lakhs.