When to Approach Insurance Ombudsman?

Shailesh Kumar

3 years ago

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The insurance ombudsman aims to resolve insurance-related grievances of unhappy and aggrieved policyholders. It resolves grievances outside of the courts in a cost-effective and efficient way. Customers of life, health, and general insurance can approach the insurance ombudsman as per their residential address. For each state, there are designated ombudsmen and the list is generally given in the policy document.

However, the insurance ombudsman will only entertain complaints related to insurance after the policyholder has already approached his insurance company with his complaint and they have either-

Rejected the complaint; or
Not resolved it to your satisfaction; or
Not responded to the complaint within 30 days.

Insurance Ombudsman

Types of Grievances Represented to Insurance Ombudsman

The following are the types of grievances represented to the Insurance Ombudsman:

Delay in settlement of claims
Partial claim paid by the insurance company
Claim rejected (repudiated) by the insurance company
Disputes over premium paid or payable.
Misrepresentation of policy terms and conditions.
Grievances related to the policy servicing against insurers and their agents and intermediaries.
Premium policy not issued even after paying the premium and receiving the receipt, etc.

Read how Insurance Samadhan Helped A Customer to Take His Case to Insurance Ombudsman

Ranveer’s wife had a high fever, rigor nausea, throat pain, cough, dysuria nausea, and weakness for some time. They tried home treatment but her condition did not improve. They visited the hospital for consultation. After diagnosis, it was discovered that she had Lower Respiratory Tract Infection. The doctor recommended immediate hospitalization to treat the infection. She was hospitalized for 3 days. As his wife had a health insurance policy, Ranveer notified the insurance company about the condition of his wife and submitted the claim form along with the necessary documents.

The couple was expecting an early health insurance reimbursement claim but were disheartened to receive a claim rejection letter from the insurance company. The letter stated that “the insured patient could have been managed as an outpatient and hospitalization of the insured patient is not warranted”.

Ranveer had a mail trail with the insurance company but he did not receive a positive response. The couple lost hope to get the claim money. Then someone informed them about Insurance Samadhan. Ranveer approached us with his case. We verified the details of the case and accepted it. We guided him on how to present his case to the Ombudsman.

Within 20 days, the case was resolved and the claim amount was also received.

If you have taken an insurance product and are facing a problem related to it, then you can approach Insurance Samadhan. We have resolved 14500+ insurance complaints like claim rejection, delay in the claim, mis-selling and fraud in insurance.

*Insurance Samadhan is a private organization and has no association with IRDA or any Government body.