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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: 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? 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: What paperwork do i need to complain to the Ombudsman’s office? How much will it cost me? Where do I get in touch with the Ombudsman? So, how does it work? What else should I know? What if I am not satisfied by the Ombudsman’s ruling? 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.