बिमाकर्ताओं की कार्यकारी परिषद कार्यालय
Office of the Executive Council of Insurers

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FAQ

INSURANCE OMBUDSMAN SCHEME MADE EASY TO UNDERSTAND.

Scheme of Insurance Ombudsman.

With an objective of providing a forum for resolving disputes and complaints from the aggrieved insured public or their legal heirs, nominee or assignee against Insurance Companies, the Government of India, in exercise of powers conferred by section 24 of the Insurance Regulatory and Development Authority Act, 1999(41 of 1999) framed "Insurance Ombudsman Rules, 2017", which came into force w.e.f. 25th April, 2017. These Rules aim at resolving complaints relating to the settlement of disputes with Insurance Companies and their agents and intermediaries on personal lines of insurance, group insurance policies, policies issued to sole proprietorship and micro enterprises in a cost effective, efficient and impartial manner. These Rules apply to all the Insurance Companies operating in General Insurance business and Life Insurance business, in Public and Private Sector.

To implement the above Rules, the Institution of Insurance Ombudsman has been established and is functioning since 1999. The Ombudsman functions within a set geographical jurisdiction and can entertain disputes relating to:

(a) Delay in settlement of claims.
(b) Any partial or total repudiation of claims by an insurer.
(c) Any dispute over premium paid or payable in terms of the policy.
(d) Misrepresentation of policy terms and conditions at any time in the policy document or policy contract
(e) Any dispute on the legal construction of the policies in so far as such disputes relate to claims.
(f) Policy servicing related grievances against insurers and their agents and intermediaries
(g)Issuance of life insurance policy, general insurance policy including health insurance policy which is not in conformity with the proposal form submitted by the proposer.
(h) Non-issue of any insurance policy to customers after receipt of premium in life insurance and general insurance including health insurance.
(i) Any other matter resulting from the violation of provisions of the Insurance Act, 1938 or the regulations, circulars, guidelines or instructions issued by the IRDAI from time to time or the terms and conditions of the policy contract, in so far as they relate to issues mentioned at clauses(a) to (f).

The Insurance Ombudsman is provided with a Secretarial Staff by the IRDAI as may be determined by the Executive Council of Insurers. The total expenses on running the Institution are borne by the Life Insurance Council AND THE General Insurance Council in such proportion as the Executive Council of Insurers may, by a general or special order specify, from time to time.

FREQUENTLY ASKED QUESTIONS (FAQS):

1) With whom is a complaint to be lodged?

A complaint is to be lodged with the Insurance Ombudsman under whose territorial jurisdiction the insurer's office falls, at the address given in"CONTACT US".

2) Does Insurance Ombudsman operate in any territorial jurisdiction?

Insurance Ombudsman operates only within the territorial limits specified in "CONTACT US"

3) How is this territorial jurisdiction to be applied to complaints?

The complaint will lie with the Insurance Ombudsman under whose territorial jurisdiction the Branch or Office of the Insurer complained against or the residential address or place of residence of the complainant is located.

4) Who can approach Ombudsman?

Any aggrieved individual who has taken an Insurance Policy on personal lines of insurance, group insurance policies, policies issued to sole proprietorship and micro enterprises may himself or through his legal heirs, nominee or assignee can approach Ombudsman.

5) What Is the meaning of Insurance on Personal Lines?

Insurance on personal lines means a policy taken or given in an individual capacity, e.g. life insurance, personal accident insurance, mediclaim insurance, insurance of personal property of the individual such as motor vehicle, household articles, etc.

6) What is Micro Enterprises?

The enterprise engaged in the manufacture of production of goods pertaining to any industry where the investment in plant and machinery does not exceed twenty-five lakh rupees and enterprises engaged in providing or rendering of services where the investment in equipment does not exceed ten lakh rupees.

7) What are the complaints that are entertained by the Ombudsman?

Any complaint relating to:
(a) Delay in settlement of claims.
(b) Any partial or total repudiation of claims by an insurer.
(c) Any dispute over premium paid or payable in terms of the policy.
(d) Misrepresentation of policy terms and conditions at any time in the policy document or policy contract
(e) Any dispute on the legal construction of the policies in so far as such disputes relate to claims.
(f) Policy servicing related grievances against insurers and their agents and intermediaries
(g)Issuance of life insurance policy, general insurance policy including health insurance policy which is not in conformity with the proposal form submitted by the proposer.
(h) Non-issue of any insurance policy to customers after receipt of premium in life insurance and general insurance including health insurance.
(i) Any other matter resulting from the violation of provisions of the Insurance Act, 1938 or the regulations, circulars, guidelines or instructions issued by the IRDAI from time to time or the terms and conditions of the policy contract, in so far as they relate to issues mentioned at clauses(a) to (f)

8) How is the complaint to be lodged?

The Complaint is to be made in writing duly signed by the complainant or through his legal heirs, nominee or assignee and may be lodged through personal approach or through post / fax / email (followed by hard copy).

9)Is there any time limit to approach the Ombudsman?

Within one year of the rejection by the insurer of the representation of the complainant or the Insurer's final reply to the representation or after expiry of one month from the date of sending written representation to the insurer and the insurer fails to furnish the reply.

10)Is there any maximum limit for the amount under dispute that can be entertained by the Ombudsman?

The maximum limit for the amount under dispute for which the Ombudsman can entertain a complaint is upto Rs. 30 lakhs.

11) Can a complainant, who has already approached Consumer Forum/court on the same subject, approach the Ombudsman?

Any complainant, whose complaint on the same subject matter is or was before a Court/Consumer Forum cannot approach Ombudsman.

12) What are the pre-requisite conditions in short, for lodging a complaint?

a. The complaint must be by an individual on a 'Personal Lines' insurance, group insurance policies, policies issued to sole proprietorship and micro enterprises and within the terms of reference of the Insurance Ombudsman as set out under FAQ 7.
b. A representation should stand made to the Insurance Company and either an unsatisfactory reply should have been received or the representation should stand unreplied for at least 1 month.
c. The complaint must be lodged within 1 year of the events mentioned in b. above.
d. The total relief sought must be within an amount of Rs.30 lakhs. 
e. The subject matter of the complaint should not currently be or have earlier been before a Court/Consumer Forum.

13) Should a complainant approach the Ombudsman through a lawyer?

No. As per the Insurance Ombudsman Rules, there is no provision to engage a lawyer.

14) Within what time shall the Ombudsman dispose off the complaint?

In case both parties agree for mediation, the Ombudsman shall give his Recommendation within 1 month of date of receipt of mutual written consent for such mediation, otherwise, he shall pass his Award within 3 months of the receipt of all requirements from the complainant.

15) Can the Ombudsman award ex-gratia payment?

The Ombudsman cannot, award ex-gratia payment.

16) Are there any fees / charges payable for lodging a complaint?

No fees / charges are required to be paid.

17) Does the Ombudsman conduct hearings of the parties?

Wherever considered necessary, the Ombudsman will conduct hearing of both the Parties.

18) If so, can the hearings be conducted outside headquarters?

Hearings may be conducted outside headquarters, where warranted.

19) Can a complaint be lodged against a Private Insurer?

Complaints can be lodged against any Insurer both in Public Sector and Private Sector in both Life and Non-Life sectors.

20) Can a Sole Proprietor of a business approach the Ombudsman for a complaint arising out of business interests?

A Sole Proprietor of a business can approach the Ombudsman for a complaint arising out of business interests.

21) Can Partnership Firms/Corporate Clients/Co-operative Societies/ Associations/Trusts approach Ombudsman?

Only individual policyholders, sole proprietorship or micro enterprises who have taken insurance on personal lines are eligible. However, a member covered under a Master Policy or a Group Insurance (or if deceased, the legal heir /nominee) can approach the Ombudsman, provided the payment of the claim under such policy is to be made to the individual, as beneficiary.

22) Is there any appeal against a decision given by the Ombudsman?

The Recommendation or Award of the Insurance Ombudsman are both subject to acceptance by the complainant in full and final settlement of the complaint. If such acceptance is not agreeable, the complainant may exercise the right to take recourse to the normal process of law against the insurance company. Further, dismissal of a complaint by the Insurance Ombudsman, does not vitiate the complainants' right to seek legal remedy against the insurers complained against, as per normal process of law.

23)Are routine administrative issues concerning agents (like non-issue of licence, non-receipt of commission etc.) or employees' grievances and complaints against staff of the member companies also entertained by the Ombudsman?

Such matters do not fall within the terms of reference of the Ombudsman and hence are not to be referred.

24) Are copies of complaints or queries and correspondence related thereto required to be forwarded to the Office of the Executive Council of Insurers?

The Ombudsman deals directly with complaint matters. Hence, copies of complaints or queries and correspondence need not be forwarded to the Office of the Executive Council of Insurers.

25) Can information be sought under the Right to Information Act?

Information can be sought from the Public Information Officer of the concerned Ombudsman Centre or the Executive Council of Insurers as applicable, in the prescribed format, forwarded together with the requisite prescribed fee. The Appellate Authority vests with the Secretary-General or the Deputy Secretary-General (as the case may be) of the Executive Council of Insurers.