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 against Insurance Companies, the Government of India, in exercise of powers conferred on it u/s 114(1) of Insurance Act, 1938 framed "Redressal of Public Grievances Rules, 1998", which came into force w.e.f. 11th November, 1998. These Rules aim at resolving complaints relating to the settlement of disputes with Insurance Companies on personal lines of insurance, 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 partial/ total repudiation of claims, delay in settlement of claims, any dispute on the legal construction of the policies in so far as such disputes relate to claims, disputes regarding premium paid or payable in terms of the policy and non-issuance of insurance documents.
The Insurance Ombudsman is provided with a Secretarial Staff by the Insurance Council and such staff is drawn from Insurance Companies. The total expenses on running the Institution are shared by all the Insurance Companies, who are Members of the Insurance Council.
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 is located. However, in case of Group Insurance policies, the complaint may be lodged with the Insurance Ombudsman under whose territorial jurisdiction the place of residence of the complainant falls.
4) Who can approach Ombudsman?
Any aggrieved individual who has taken an Insurance Policy on personal lines (or if deceased, the legal heir(s) under such policy) 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 are the complaints that are entertained by the Ombudsman?
Complaints pertaining to repudiation of claims totally or partially, delay in settlement of claims, any dispute on the legal construction of the policies in so far as such disputes relate to claims, disputes regarding premiums paid / payable and non-issue of insurance documents.
7) How is the complaint to be lodged?
The Complaint is to be made in writing and may be lodged through personal approach or through post / fax / email(followed by hard copy).
8) 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.
9) 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. 20 lakhs.
10) 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.
11) 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 and within the terms of reference of the Insurance Ombudsman as set out under FAQ 6. 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.20 lakhs. e. The subject matter of the complaint should not currently be or have earlier been before a Court/Consumer Forum.
12) Should a complainant approach the Ombudsman through a lawyer?
No. As per Redressal of Public Grievances Rules, there is no provision to engage a lawyer.
13) 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, otherwise, he shall pass his Award within 3 months.
14) Can the Ombudsman award ex-gratia payment?
If the Ombudsman deems it fit in the circumstances of the case, he may award ex-gratia payment.
15) Are there any fees / charges payable for lodging a complaint?
No fees / charges are required to be paid.
16) Does the Ombudsman conduct hearings of the parties?
Wherever considered necessary, the Ombudsman will conduct hearing of both the Parties.
17) If so, can the hearings be conducted outside headquarters?
Hearings may be conducted outside headquarters, where warranted.
18) 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.
19) Can a Sole Proprietor of a business approach the Ombudsman for a complaint arising out of business interests?
It was clarified in 2006 that since in such cases the subject matter of insurance is a commercial Interest, the insurance policy thereon cannot be deemed to fall under the definition of personal lines insurance.
20) Can Partnership Firms/Corporate Clients/Co-operative Societies/ Associations/Trusts approach Ombudsman?
Only individual policyholders 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) can approach the Ombudsman, provided the payment of the claim under such policy is to be made to the individual, as beneficiary.
21) Is there any appeal against a decision given by the Ombudsman?
As 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.
22) Are routine administrative issues concerning agents (like non-issue of licence, non-receipt of commission etc.) or employees' grievances or policy servicing matters(like transfer of policies etc.) 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.
23) Are copies of complaints or queries and correspondence related thereto required to be forwarded to the Office of the Governing Body of Insurance Council?
The Ombudsman deals directly with complaint matters.
24) 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 Office of the Governing Body of Insurance Council 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 Governing Body of Insurance Council.