Insurance Ombudsman Scheme to deal with consumer complaints – India Consumer Forum
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Insurance Ombudsman Scheme to deal with consumer complaints

Vide Notification dt.11.11.1998, the Govt. of India has introduced The Insurance Ombudsman scheme to deal with consumer complaints or public grievances with regard to servicing the insurance policies or deficiencies in rendering services by the insurance companies.

How to make a complaint:

If you are unhappy with your insurance company

Approach the Grievance Redressal Officer of its branch or any other office that you deal with.
Give your complaint in writing along with the necessary support documents
Take a written acknowledgement of your complaint with the date.

The insurance company should deal with your complaint within 15 days.

In case you are not satisfied with the Insurance Company’s response you may also file a complaint with the Insurance Ombudsman in your State. The Insurance Ombudsman is an independent office to provide speedy and cost effective resolution of grievances to the customers.

Powers of Ombudsman:

(1) The Ombudsman may receive and consider :

(a) Complaints in the prescribed manner
(b) Any partial or total repudiation of claims by an insurer;
(c) Any dispute in regard to premium paid or payable in terms of the policy
(d) Any dispute on the legal construction of the policies in so far as such disputes relate to claims
(e) Delay in settlement of claims
(f) Non-issue of any insurance document to customers after receipt of premium

(2) The Ombudsman shall act as counsellor and mediator in matters, which are within his terms of reference and, if requested to do so in writing by mutual agreement by the insured person and insurance company.

(3) The Ombudsman’s decision whether the complaint is fit and proper for being considered by it or not shall be final

Manner in which complaint is to be made:

(1) Any person who has a grievance against an insurer, may himself or through his legal heirs make a complaint in writing to the Ombudsman within whose jurisdiction the branch or office of the insurer complaint against is located.

(2) The complaint shall be in writing duly signed by the complainant or through his legal heirs and shall state clearly the name and address of the complainant, the name of the branch or office of the insurer against which the complaint is made, the fact giving rise to complaint supported by documents, if any, relied on by the complainant, the nature and extent of the loss caused to the complainant and the relief sought from the Ombudsman.

(3) No complaint to the Ombudsman shall lie unless:

(a) the complainants had before making a complaint to the Ombudsman made a written representation to the insurer named in the complaint and either insurer had rejected the complaint or the complainant had not received any reply within a period of one month after the insurer concerned received his representation or the complainant is not satisfied with the reply given to him by the insurer

(b) the complaint is made not later than one year after the insurer had rejected the representation or sent his final reply on the representation of the complainant; and

(c) the complaint is not on the same subject matter, for which any proceedings before any court, or Consumer Forum, or arbitrator is pending or were so earlier.

Ombudsman to act fairly and equitably:

(1) The Ombudsman may, if he deems fit, adopt a procedure other than mentioned above for dealing with a claim: Provided that the Ombudsman may ask the parties for necessary papers in support of their respective claims and where he considers necessary, he may collect factual information available with the insurance company.

(2) The Ombudsman shall dispose of a complaint fairly and equitably.

Recommendations made by the Ombudsman:

(1) When a complaint is settled, through mediation of the Ombudsman, undertaken by him in pursuance of request made in writing by complainant and insurer through mutual agreement, the Ombudsman shall make a recommendation which he thinks fair in the circumstances of the case. The copies of the recommendation shall be sent to the complainant and the insurance company concerned. Such recommendation shall be made not later than one month from the date of the receipt of the complaint.

(2) If a complainant accepts the recommendation of the Ombudsman, he will send a communication in writing within 15 days of the date of receipt of the recommendation. He will confirm his acceptance to Ombudsman and state clearly that the settlement reached is acceptable to him, in totally, in terms of recommendations made by the Ombudsman in full and final settlement of complaint.

(3) The Ombudsman shall send to the insurance company a copy of the recommendation along with the acceptance letter received from the complainant. The insurer shall thereupon comply with the terms of the recommendations immediately not later than 15 days of the receipt of such recommendation and the insurer shall inform the Ombudsman of its compliance.

Award:

(1) Where the complaint is not settled by agreement on the basis of recommendation made by the Ombudsman, the Ombudsman shall pass an award, which he thinks fair in the facts and circumstances of a claim.
(2) An award shall be in writing and shall state the amount awarded to the complainant: Provided that Ombudsman shall not award any compensation in excess of which is necessary to cover the loss suffered by the complainant as a direct consequence of the insured peril, or for an amount not exceeding rupees twenty lakhs (including ex-gratia and other expenses), whichever is lower.

(3) The Ombudsman shall pass an award within a period of three months from the receipt of the complaint.

(4) A copy of the award shall be sent to the complainant and the insurer named in the complaint.

(5) The complainant shall furnish to the insurer within a period of one month from the date of receipt of the award, a letter of acceptance that the award is in full and final settlement of his claim.

(6) The insurer shall comply with the award within 15 days of the receipt of the acceptance letter under sub-rule (5) and it shall intimate the compliance to the Ombudsman.

Consequences of non-acceptance of award:</strong> If the complainant does not intimate the acceptance of the Award, the award may not be implemented by the insurance company.

Power to make Ex-gratia payment.:</strong> If the Ombudsman deems fit, he may award an Ex-gratia payment.

(Detailed and updated information can be found at www.irda.gov.in)



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