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Insuring promptness

In case of a delay in payment by an insurance company, file a complaint with the Ombudsman

Insuring promptness

If your complaint is pending in a consumer court or has already been decided by a consumer court, then the Ombudsman will not entertain your complaint Tribune Photo: Nitin Mittal



Pushpa Girimaji

It’s more than six months since I claimed the insured amount towards the loss of some household effects following a robbery in my house. But the insurance company is yet to make the payment, causing me lot of financial distress and harassment. What should I do?

I would suggest that you file a complaint with the Insurance Ombudsman about the delay. In exercise of the powers conferred under Section 114 (1) of the Insurance Act, the government has framed the Redressal of Public Grievances Rules, 1998, for quick, simple and inexpensive resolution of disputes pertaining to personal life insurance policies. There are 12 Insurance Ombudsmen in the country and if you log on to www.policyholder.gov.in – a website created by the Insurance Regulatory and Development Authority, for the benefit of policy holders, you will get the contact details of the Ombudsmen and also the territories that they cover. 

Your choice of the Ombudsman will depend on the location of the insurance company’s branch office or office. However, in case of group-insurance policies, the territorial jurisdiction is determined on the basis of where the policy holder resides.
 
The procedure before the Ombudsman is very simple — just write down on a plain paper, your case details and attach photocopies of your policy, your claim letter, FIR about the robbery, report of the insurance company’s investigator, any correspondence that you have had with the insurance company, and any other information relevant to the case. 
 
The Ombudsman basically acts as a mediator and arrives at a fair recommendation (within a month of your filing the complaint), based on the facts of the dispute. If the claimant or the policy holder accepts this as a full and final settlement, then the Ombudsman will inform the insurer, who will have to comply within 15 days. If this settlement by recommendation fails, then he will pass an award within three months of receiving the complaint and this speaking award will be binding on the insurance company, but not on the policy holder. If the policy holder accepts it and informs the insurer of it in writing within 30 days, then the insurance company has to comply with the award within 15 days. 
 
If you are not happy with the award, then you can reject it and seek redress elsewhere- the consumer court for example. 
 
On the IRDA website meant for policy holders’ you can find the decisions of the Ombudsmen. I would suggest that you go through them, as you will get a fair idea of how the Ombudsman responds to complaints.  
 
What kind of complaints can be taken before the Ombudsman? 
 
The Ombudsman has the jurisdiction to resolve complaints pertaining to (a) partial or total repudiation of claims by an insurer (b) any dispute about premium paid or payable in terms of the policy (c) dispute on the legal construction of the policies as far as it relates to claims (d) delays in settlement of claims and (e) non-issue of any insurance document after the payment of premium. The Ombudsman will, however, only look at complaints pertaining to personal line policies or to put it differently, policies that you have taken as an individual, where the value of the claim is below Rs 20 lakh. In other words, you can seek the help of the Ombudsman in respect of personal accident insurance, mediclaim, motor vehicle policies, householder policies, travel insurance, etc. You can also approach the ombudsman for any grievance pertaining to a group insurance policy.
 
Whenever you have a complaint against an insurance company, please approach the grievance cell of the insurance company. You can get the details of the grievance cell, on the IRDA policy holder website: www.policyholder. gov.in. If there is no response within 15 days, you can approach the grievance cell of the Insurance Regulatory and Development Authority. They have a toll free number: 155255 and 1800 4254732. IRDA basically monitors the complaint resolution process by the insurer.
 
If your complaint is not resolved within 30 days or not resolved to your satisfaction, then you have a right to approach the Ombudsman. However, if your complaint is pending before a consumer court or has already been decided or rejected by a consumer court, then the Ombudsman will not entertain your complaint. 

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