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Thursday, March 17, 2011

How you can resolve your insurance grievances

Noted consumer activist Jehangir Gai has a story to tell: "A person had undergone three surgeries simultaneously, incurring a total cost of Rs 33,000. When the claim was lodged, the insurance company's third-party administrator held that though the surgeries pertained to three different body parts, these were conducted at the same time and, hence, the eligible claim was only Rs 10,000."

Despite explaining that the company would have had to shell out a higher amount had the insured decided to have the surgeries on different dates, the company refused to budge. "Ultimately, we approached the insurance ombudsman, who held that the eligible claim amount was Rs 30,000," says Gai.

This is not the only instance of insurance companies trying to wriggle out of their commitment to policyholders. But, like Gai, you no longer need to rely on the whims of insurance firms. Here's how you can resolve your grievances.

Round one

Most insurance companies offer various channels, branch office, phone, e-mail and snail mail, to register complaints. You can also approach the company's grievance redressal officer . Insurance companies have to send a written acknowledgement within three working days of receiving the complaint and specify the period within which it is likely to be resolved. If the complaint is resolved within three days, the insurer has to inform the individual along with an acknowledgement. If this is not possible, the company will have to resolve it within two weeks of receiving the complaint and send a final letter of resolution to the aggrieved.

If the insurance company decides to reject the complaint, it has to give a reason, along with information on further redressal avenues, that the complainant can pursue. In case you are not satisfied with the insurer's response, you have to inform it within eight weeks, or the company will assume that the complaint has been resolved.

Round two

If the above approach doesn't solve your problem, you can contact either Irda's Grievance Redressal Cell or the insurance ombudsman, depending on the nature of the complaint. The ombudsman can make recommendations within one month of the receipt of the complaint and give a verdict within three months. If necessary, he can award compensation to the policyholder.

If you are satisfied with the settlement, you have to send your acceptance within 15 days. If the insurance firm does not comply with the order, you can approach consumer forums or civil courts. These offices handle cases dealing with insurance contracts with a value of up to Rs 20 lakh. The ombudsman addresses issues related to rejection or delay in settlement of claims, disputes on premiums, and non-issuance of a document after collecting the premium.

Irda's Grievance Redressal Cell

Though this cell does not have the authority to pass orders, complaints addressed to it are taken up with the insurers. These could include delay or lack of response pertaining to policies or claims and complaints about agents' conduct. "Irda's toll-free number, 155255, has been publicised widely to create awareness about the recourses available to policyholders. You can approach the cell directly, and where required, you will be redirected to the ombudsman under whose jurisdiction the complaint falls," informs an official in the insurance ombudsman's office. You can get in touch with the cell via mail on 
Ensure that you send the complaint yourself as the ones forwarded by third parties, including lawyers or agents, are not entertained by the cell. Also, the complaint should have complete information. So, disclose all the details in the complaints registration form available on Irda's website.


You must first register your complaints with the insurer. You can approach the ombudsman only if you have not received any feedback from the insurer or are not satisfied with the given response.

After you have received a copy of the ombudsman's recommendations and are satisfied with it, you have to send a written communication, indicating your acceptance within 15 days.

The ombudsman handles cases with a value of up to `20 lakh and has the authority to mediate and give a recommendation, or award compensation, which is binding on the insurer.

You can also get in touch with the Insurance Regulatory and Development Authority's Grievance Redressal Cell through a toll-free number (155255).

The ombudsman does not hear matters related to the conduct of agents. This can be taken up by Irda's Grievance Redressal Cell.

You can approach the civil and consumer courts directly to resolve your grievance. However, the ombudsman will not accept your case if it is pending with other courts. 

Curtesy: This article first appeared in ET

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