3) Grievance & appeal process for Insurance claim rejection

Frequently Faced Challenges

Section III – Grievance & appeal process for Insurance claim rejection

If you have a grievance:

  • Register your grievance with the insurance company.
  • If you are not satisfied with its disposal by the company, you may escalate it to IRDA through IGMS. IGMS (Integrated Grievance Management System) has been introduced by The Consumer Affairs Department of the Insurance Regulatory and Development Authority. This is an online system for registering and tracking of grievances.igms.irda.gov.in
  • In case you are not able to access the insurer’s grievance system directly, IGMS also provides you a gateway to register your grievance with the insurer.
  • Apart from IGMS (i.e., web), you have several channels for grievance registration:
    • Email to complaints@irda.gov.in
    • Write a letter to – Consumer Affairs Department, Insurance Regulatory and Development Authority, 3rd Floor, Parishram  Bhavan, Basheerbagh, Hyderabad.
    • Call IRDA Call Centre at Toll Free 155255,
      1. through which IRDA shall register your complaint against insurance company (free of cost)
      2. will assist by filling up the complaints form based on the call.
      3. will facilitate in filing of complaints directly with the insurance companies as the first port of call by giving information relating to the address, telephone number, website details, contact number, e-mail id etc. of the insurance company.
      4. IRDA Call Centre offers a true alternative channel for prospects and policyholders, with comprehensive tele-functionalities, serving as a 12 hour x 6 days service platform from 8 AM to 8 PM, Monday to Saturday in Hindi, English, and various Indian languages.
      5. When a complaint is registered with IRDA, it facilitates resolution by taking it up with the insurance company. The company is given 15 days’ time to resolve the complaint.
      6. If required, IRDA carries out investigations and enquiries.
      7. Wherever applicable, IRDA advises the complainant to approach the insurance ombudsman in terms of redressal of Public Grievances Rule, 1998.
    • Approach the Insurance Ombudsman

Insurance Ombudsman : (https://www.policyholder.gov.in/ombudsman.aspx)

  • The Insurance Ombudsman scheme was created by the Government of India for individual policyholders to have their complaints settled out of the courts system in a cost-effective, efficient, and impartial way.
  • There are at present 17 Insurance Ombudsman in different locations
  • You can approach the Ombudsman with complaint if:
    • You have first approached your insurance company with the complaint and
      1. They have rejected it
      2. Not resolved it to your satisfaction or
      3. Not responded to it at all for 30 days
    • Your complaint pertains to any policy you have taken in your capacity as an individual And
    • The value of the claim including expenses claimed is not above Rs 30 lakhs.
  • Your complaint to the Ombudsman can be about:
    • Delay in settlement of claims, beyond the time specified in the regulations,
    • Any partial or total repudiation of claims by the Life insurer, General insurer or the Health insurer.
    • Any dispute about premium paid or payable in terms of insurance policy
    • Misrepresentation of policy terms and conditions at any time in the policy document or policy contract.
    • Legal construction of insurance policies in so far as the dispute relates to claim.
    • Policy servicing related grievances against insurers and their agents and intermediaries.
    • Issuance of life insurance policy, general insurance policy including health insurance policy which is not in conformity with the proposal form submitted by the proposer.
    • Non issuance of insurance policy after receipt of premium in life insurance and general insurance including health insurance and
    • Any other matter resulting from the violation of provisions of the Insurance Act, 1938 or the regulations, circulars, guidelines or instructions issued by the IRDAI from time to time or the terms and conditions of the policy contract, in so far as they relate to issues mentioned at clauses (a) to (f)

The Settlement Processes : 

Recommendation:

The Ombudsman will act as mediator and

  • Arrive at a fair recommendation based on the facts of the dispute
  • If you accept this as a full and final settlement, the Ombudsman will inform the company which should comply with the terms in 15 days

 Award:

If a settlement by recommendation does not work, the Ombudsman will:

  • Pass an award within 3 months of receiving all the requirements from the complainant and which will be binding on the insurance company

Once the Award is passed

  • The Insurer shall comply with the award within 30 days of the receipt of award and intimate the compliance of the same to the Ombudsman.

Click the following links for more information on Ombudsman

Last updated on 21 August, 2021

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