A Guide for Presenting Your Case to the Insurance Ombudsman Effectively

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An Overview

In today’s complex world, dealing with insurance companies can sometimes be a challenging experience. Whether it’s a denied claim, delayed payment, or a lack of responsiveness, policyholders often find themselves wondering where to turn for help. If you’re facing such a situation, it’s important to know your options for filing a complaint against your insurance company. In this guide, we’ll explain the complete process of filing your complaint with the Insurance Ombudsman for redressal.

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Process of filing your complaint

Step 1: The first step is to approach the GRO (Grievance Redressal Officer) of the Insurance Company for redressal

Insurance companies have a dedicated cell to address all the queries and complaints of the policyholder. Before proceeding to the Insurance Ombudsman, it is mandated to first approach the Grievance cell of the Insurance Company. When writing your appeal letter to the insurance company, it’s essential to present a clear and concise account of your claim. Include a chronology of events, the names of individuals you’ve spoken to, and copies of relevant bills or documents. By providing comprehensive information, you enhance your chances of receiving a prompt and satisfactory response. If you don’t receive a positive response or there is no response within 30 days of writing to the GRO, you can proceed to step 2.

Step 2: Seek Help from an Ombudsman 

If your attempts to resolve the complaint with your insurance company have been unsuccessful, it may be time to seek assistance from an ombudsman. An ombudsman is an official designated to protect policyholders and investigate complaints against insurance companies. When raising a complaint with the Ombudsman, make sure to follow the below steps:

  • Write a detailed complaint, mentioning the event details and the response of the insurance company, if any, along with your contact details and address.
  • In case you have received a rejection from the Insurance company, make sure you mention the relevant points in your support for the Ombudsman to consider.
  • Make sure to attach all the relevant documents related to your case along with proof of identification.
  • Now comes the jurisdiction. The Ombudsman is divided into 17 Jurisdictions. You need to check your state and city to file a complaint accordingly.

Filing a complaint with the Ombudsman:

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You can file the complaint with the Ombudsman through either of the following processes:

  • Online Registration: You can directly register your complaint with the Insurance Ombudsman online.
  • Through Email: You can also send an email to the Ombudsman, mentioning the detailed complaint along with attaching the relevant documents of the case.
  • Courier: You can also courier your complaint along with the relevant documents to the Ombudsman Office.

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Step 3: Ombudsman Process

The Ombudsman officials now check your complaint along with all the relevant documents and may request further documents if required, registering the complaint for further proceedings. After the registration of the complaint, the Ombudsman intervenes in the matter to assist in resolving the complaint through a hearing. The hearing can either be conducted online or offline. During the hearing process, the policyholder presents the case to the Ombudsman Judge (Note: No legal personnel/lawyer is allowed), after which an award/recommendation is passed by the Ombudsman. The award of the Insurance Ombudsman shall be binding on the insurers. However, if the complainant is not satisfied with the decision of the Insurance Ombudsman, he/she may exercise the right to take recourse to the normal process of law against the Insurance Company.

Important Note:
1) The process of complaint resolution through the Ombudsman takes 90 days from receiving all the documents related to the case.
2) The amount of compensation sought in the Insurance Ombudsman should not exceed Rs. 30 Lakhs.

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Bottom Line

This guide empowers you to address insurance company issues effectively. Start with the Grievance Redressal Officer and escalate to an Ombudsman if needed. Be thorough in your complaint, follow jurisdiction rules, and choose your filing method. The Ombudsman’s decision is binding on insurers, but legal options are available if you’re unsatisfied. Expect a 90-day process, and remember that compensation shouldn’t exceed Rs. 30 Lakhs.

By: Bhavana Kapoor- Deputy General Manager

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