Avoiding a face-off with your insurance company due to prolonged court battles? Get speedier and budget-friendly resolutions to insurance conflicts.
The Government of India started the Insurance Ombudsman scheme, with a focus on resolving disputes for policyholders. This system ensures efficient and impartial resolution of conflicts. Currently, it is available in 17 different cities.
When Can You Approach the Ombudsman Scheme?
As a layman, it is possible you’ve had grievances with your insurance provider if you are unhappy with the resolution you can approach the Ombudsman, if:
- You had approached your insurance company earlier, but the issues were not addressed or resolved.
- It can be done if they have not been resolved as per your satisfaction.
- If the insurance company has not responded to your queries in 30 days.
In other cases, the Insurance Ombudsman scheme focuses on resolving issues related to claims. They can be approached for:
- Partial or total repudiation of claims by your insurance company
- Disputes regarding the premium paid or even due to be payable, as per their terms and conditions
- Disputes regarding legal construction of the policies if it relates to claims
- Delay in resolving or settling claims
- Non-issue of insurance documents to the policyholder, despite the premium being paid
How Is the Settlement Process Executed?
To ensure a fair settlement of the claim under the Insurance Ombudsman scheme, the regulatory body acts as a counsellor and a mediator. This would help you arrive at a fair recommendation as this would be done based on the facts regarding the dispute.
If you, accept the full and final settlement, the Ombudsman would then:
- Ensure the health insurance company complies with it
- Be done within the term of 15 days
In case, you are unhappy with the settlement of the Ombudsman, they would help you with the following:
- Pass an award within 3 months of receiving the complaint
- The speaking award would have detailed reasoning of the claim
- This would be binding on the insurance company and not policy holder
The Ombudsman has the authority to pass an ex-gratia payment, which benefits the policyholder. It is paid as a goodwill to a claimant who was under no obligation to receive it.
What the Policy Holder Has to Do?
On passing this award:
- You can accept the award in writing. Your insurance company will also be informed of the decision within 30 days.
- The Insurance Company is under obligation to comply with the award. This should be done within 15 days post the award.
It is true that most people want to avoid legal hassles and prolonged court procedures, however, not claiming what’s rightfully yours is not morally correct. The Insurance Ombudsman scheme helps you get faster resolutions towards your disputes.