The Insurance Ombudsman was established by the Indian government to give individual policyholders a fast, inexpensive, and unbiased way to have their complaints settled out of court. When a system like this is in effect, people can fully rely on it, make use of its advantages, and feel confident.

Insurance Ombudsman

About

• Establishment: In accordance to the Redressal of Public Grievances Rules of 1998, after the notification by the Government of India on 11th November, 1998 ,the institution of Insurance Ombudsman in India was established by the Governing Body of Insurance Council (GBIC) as a quasi-judicial body.
• Role: The role of the insurance ombudsman is to expeditiously handle and settle the complaints of covered clients. It is also in charge of enhancing policyholders' trust in the system.
• Term Period: The insurance ombudsman is selected for a period of three years, or until the nominated person turns sixty-five years old, whichever comes first. An Ombudsman cannot be reappointment at the end of his term.
• Removal: If an ombudsman is found engaged in gross misconduct during the course of his or her duties, the Insurance Ombudsman Council has the power to remove him or her on the basis of misconduct.

Misconduct or "gross misbehaviour" on part of Ombudsman would include physical incapacity, insanity, being convicted for a crime due to moral turpitude, bankruptcy, being found  involved in any other paid work, conflict of interest, providing false information during the appointment process, or failure to disclose material facts. 

Insurance Ombudsman: Powers

The two primary responsibilities of an Insurance Ombudsman are delivering the award and conciliation. A business is legally bound to accept and address the concerns of the customers. Any complaint filed against an insurance service provider may include:-

• Any denial, whether full or partial or rejection of a claim by the insurance company
• Conflicts related to paid or overdue premiums submitted
• Disagreement regarding the wordings of the legal framework of the policy
• Delay in resolution of the disputes
• In case the paperwork for the insurance has not been provided even after obtaining the payment for the premium.

Who can File an Insurance Grievance? 

Anybody with an issue against an insurer (insurance company) may, under the terms of the insurance ombudsman scheme, file a written complaint with the Insurance Ombudsman, whose territorial jurisdiction includes the insurer's branch or office, directly or through their legal heirs, nominee, or assignee.

When to File an Insurance Grievance?

You can file an insurance grievance with the Ombudsman:

• When you first brought the identical complaint with the insurance company, the provider either dismissed it, failed to answer for thirty days, or failed to satisfactorily resolve it.
• Your grievance relates to your life insurance policy.
• Your life insurance policy has a maximum value of 30 lakh rupees.

Steps to File a Grievance with Insurance Ombudsman

A grieving party must file a written complaint to the insurance ombudsman in the jurisdiction in which the insurance company's office is situated. The insured's legal heirs may also file a complaint. Prior to submitting a grievance:

• The complaint can be filed by sending a hard copy of it to the Insurance Ombudsman and following the appropriate procedure. Your grievance may also be submitted by email or fax.
• Your policy's relevant details must be included in the complaint. These include specifics regarding the policy issue, premiums paid and unpaid, a detailed complaint, the steps the insurance company took, etc. The local office of the Insurance Ombudsman needs certain documentation from you.
• After filing a complaint, you need to fill out Forms P-II and P-III for the Insurance Ombudsman. If you are filing a complaint via mail to the Insurance Ombudsman, you need to fill out these forms.
• After these steps, the Ombudsman will schedule a hearing.

Process of Settlement with Insurance Ombudsman

• Based on the details of the dispute between you as well as the insurance provider, the Ombudsman will make reasonable suggestions. This needs to be completed within a month of filing a complaint with the Insurance Ombudsman.
• The Insurance Ombudsman will inform the insurance provider by providing a letter of approval, which has to be acknowledged within 15 days if you approve the suggestions as the final agreement and agree with them.
• Within three months of collecting all the required data from you (the complainant), the Insurance Ombudsman is going to issue a legally binding verdict on the insurance provider if you reject the settlement.
• Within 30 days after obtaining the decision, the insurance company is required to follow the Insurance Ombudsman's ruling.
• If the insurance company abides by the award, they have to notify the Insurance Ombudsman.

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