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How Insurance Ombudsman can help you

Prakash Patil
/ Categories: Markets, DSIJ Mindshare
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Are you running from pillar to post trying to get your insurance claim settled by your insurance company? Or have your claim been settled but you are not satisfied with the amount paid by your insurer? Or worse, have your claim been rejected by the insurance company and you feel an injustice has been done to you because of such rejection? Or, may be, you have some issues regarding the amount of premium being charged by your insurance company or your insurance company has not issued you the policy even after paying couple of premiums. If you have any of these complaints, you can approach the insurance ombudsman to get your complaint resolved.

 

The insurance ombudsman accepts from the policyholder any of the following complaints:

(a) Any partial or total repudiation of claim by the insurance company,

(b) Any disagreement concerning premium paid or payable to the insurance company

(c) Any dispute on the legal construct and interpretation of the wordings of the policy

(d) Delayed in settlement of claim

(e) Non-issuance of insurance policy document by the insurer after payment of premium by the policyholder.

 

It must be noted that the insurance ombudsman can entertain complaints filed by the insured or the legal heirs of the insured for claims up to a maximum of Rs 20 lakh. The ombudsman cannot accept commercial complaints/disputes.

Before approaching the ombudsman, the policyholder or his/her heir has to file a written complaint to the insurance company for redressal of his/her grievance. If the insurance does not reply to the complaint within a month or if the company rejects the complaint partially or totally, the insured can approach the ombudsman. The policyholder has to file the complaint with the ombudsman within one year from the date of final rejection of the claim by the insurance company or the submission of the complaint to the insurance company.

After hearing both the parties, the ombudsman gives his award on the dispute and communicates it to both the parties. The insured has to communicate the acceptance or rejection of the award to the ombudsman and the insurance company within one month from the date of receipt of the award. If the insured accepts the award, the insurance company has to comply with the ombudsman’s order within 15 days of the receipt of acceptance of award by the insured.

If the insured rejects the award or does not communicate acceptance of the award, the insurance company is under no obligation to implement the award. However, while the insurance company is bound to accept the award of the ombudsman if the insured accepts it, the insured is under no such obligation.If the insured does not accept the award, he has the option to take suitable legal action against the insurance company to get his complaint redressed.

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