Imagine a scenario where you’ve incurred some medical bills due to ill health and are secure in the knowledge that they will be paid for by your insurance company. After all, you have been paying insurance premiums regularly for this very day. Now if for some reason your insurance claim gets rejected by the Third Party Administrator and then the insurance agency, you need not worry.

You can take your case to your area’s Ombudsman who can mediate between you and your insurance provider to see if your claim is valid. If so, the Ombudsman can rule on insurance claim disputes for all health insurance companies operating in India.

Why is an Ombudsman required?
This is a quick way of addressing consumer complaints about health insurance, without having to go to court. The office of the Insurance Ombudsman is a body created by the IRDA to generate faith and confidence amongst the consumers in the insurance system. This institution is of great relevance for the protection of interests of policy holders.

What are the functions of an Ombudsman’s office?
An insurance Ombudsman has two types of functions to perform:

Conciliation
The insurance Ombudsman is empowered to receive and consider complaints from any person who has a grievance against an insurer. The complaint may relate to any of the following:

• Any partial or total rejection of claims by the insurance companies.
• Dispute with regard to premium paid or payable in terms of the policy.
• Dispute on the legal construction of the policy wordings in case such dispute relates to claims.
• Delay in settlement of claims.
• Non–issuance of any insurance document to customers after receipt of premium.

Award making
An Ombudsman is empowered to provide awards in value not exceeding Rs. 20 lakhs. The insurance companies are required to honour the awards passed by an insurance Ombudsman within three months.

When do I get in touch with the Ombudsman?

• If your insurance claim has been rejected by the TPA, you need to make a representation to your insurer…
• If your insurance company rejects your claim or does not respond within one month of their receiving your claim; or you are not satisfied with the insurer’s response, you can get in touch with the Ombudsman.

How do I complain to the Ombudsman’s office?
There are some regulations to be followed if you wish to take your claim to the Ombudsman:

• Your complaint has to be in writing.
• It has to be addressed to the insurance Ombudsman of the jurisdiction under which the office of the insurer falls.

What paperwork do i need to complain to the Ombudsman’s office?

• Make sure you have all copies of your claim forms and all supporting documents from the hospital, surgeon and other medical expenses.

How much will it cost me?

• Nothing, as the services of the Ombudsman’s office are free of charge and there is no need to hire an advocate.

Where do I get in touch with the Ombudsman?

• There are twelve Ombudsman across the country with different geographical areas as their areas of jurisdiction. The Ombudsman may hold sittings at various places within their area of jurisdiction in order to expedite disposal of complaints.
• The offices of the twelve insurance Ombudsmans are located at (1) Bhopal, (2) Bhubaneswar, (3) Cochin, (4) Guwahati, (5) Chandigarh, (6) New Delhi, (7) Chennai, (8) Kolkata, (9) Ahmedabad, (10) Lucknow, (11) Mumbai, (12) Hyderabad.
• To find out the contact information for the Insurance Ombudsman for your region visit the IRDA website.

So, how does it work?

• When a complaint is settled through the mediation of the Ombudsman, he shall make the recommendations which he thinks fair in the circumstances of the case.
• Such a recommendation shall be made not later than one month and copies of the same shall be sent to the complainant and the insurance company concerned.
• If the complainant accepts the recommendations, he will send a communication in writing within 15 days of the date of receipt accepting the settlement.
• The Ombudsman shall pass an award within a period of three months from the receipt of the complaint. The awards are binding upon the insurance companies.
• If you, as the policy holder are not satisfied with the amount awarded by the Ombudsman, you can approach other venues like Consumer Forums and Courts of law for redressal of your grievances.

What else should I know?

• As per current regulations, every insurance company has to inform you of the Ombudsman in whose jurisdiction your insurer’s office falls for the purpose of any subsequent grievances redressal. So, if you do not see that information whilst buying your policy, please ask for it.
• Your complaint can also be lodged through your legal heirs.
• Always have all communications in writing. Keep copies of all documents for your record and always use Registered Mail (with acknowledgement due) to ensure that you have proof that the other party has received your mail.
• Bear in mind that you need to take your complaint to the Ombudsman no later than one year of receiving a reply from your insurance company. Also, the same complaint should not be pending before any court, consumer forum or arbitrator.

What if I am not satisfied by the Ombudsman’s ruling?

• While the decision of the Ombudsman is binding on the insurance provider, you still have the option to go to consumer court if his decision is not acceptable to you. You will need to consult a lawyer at this point to file a case.

There has been a steady increase in the number of complaints received by various Ombudsmen since this office was created. This shows that the policy–holders are reposing their confidence in the institution of Insurance Ombudsman. If you are ever in a situation where you need to avail of your Ombudsman’s mediation, please don’t be disheartened. Be firm in your resolve and fight to get what is rightfully yours.