5/27/2020 FAQ’s on Ombudsman Scheme

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FAQ’s on Ombudsman Scheme

Ref. No:-- Date:19-05-2017
FAQ’s on Insurance Ombudsman Rules 2017

1) Who can approach Insurance Ombudsman? What is the

procedure for lodging a complaint with an insurance
Ombudsman?
Any person including a sole proprietor, micro entrepreneur, members covered
in a group insurance policy who has a grievance against an insurer may by
himself or through his legal heirs, nominee or assignee or employer as the
case may be can approach an Insurance Ombudsman for Redressal of any
grievance arising out of an insurance policy by making a complaint in wri ng
to the Insurance Ombudsman within whose territorial jurisdic on the branch
or office of the insurer complained against or the residen al address or place
of residence of the complainant is located.

For territorial jurisdic ons of respec ve Insurance Ombudsman click here.

2) What is the meaning of Insurance on Personal Lines?

Insurance on personal lines means an insurance 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 ar cles, etc.

3) What are the complaints that are entertained by the Insurance

Ombudsman?
The Ombudsman will receive and consider complaints or disputes rela ng to
—

(a) delay in se lement of claims, beyond the me specified in the regula ons,
framed under the Insurance Regulatory and Development Authority of
India Act, 1999;
(b) any par al or total repudia on of claims by the life insurer, General insurer
or the Health insurer ;
(c) disputes over premium paid or payable in terms of insurance policy;
(d) misrepresenta on of policy terms and condi ons at any me in the policy
document or policy contract;
(e) legal construc on of insurance policies in so far as the dispute relates to
claim;
(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
submi ed by the proposer;
(h) non-issuance of insurance policy a er receipt of premium in life insurance
and general insurance including health insurance; and
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(i) any other ma er resul ng from the viola on of provisions of the Insurance
Act, 1938 or the regula ons, circulars, guidelines or instruc ons issued by
the IRDAI from me to me or the terms and condi ons of the policy
contract, in so far as they relate to issues men oned at clauses (a) to (f) .

4) How is the complaint to be lodged?

The complaint shall be made in wri ng on a plain, duly signed by the

complainant and shall state clearly the name and address of the complainant,
the name of the branch or office of the insurer against whom the complaint is
made, the facts giving rise to the complaint, supported documents if any, the
nature and extent of the loss caused to the complainant and the relief sought
from the Insurance Ombudsman.
5) Is there any me limit to approach the Insurance Ombudsman?
Yes. No complaint to the Insurance Ombudsman shall lie unless the complaint
is made within one year –

Ø From the date of receipt of the order of the insurer rejec ng the
representa on.
Ø From the date of receipt of decision of the insurer which is not to
the sa sfac on of the complainant;
Ø A er expiry of a period of one month from the date of sending the
wri en representa on to the insurer if the insurer named fails to
furnish reply to the complainant.
6) Is the Insurance Ombudsman empowered to entertain a
complaint which is received a er the expiry of the specified me
limit?
Yes, the Insurance Ombudsman, may, if considered necessary, can condone
the delay and a er calling for objec ons of the insurer against the proposed
condona on and a er recording the reasons for condoning the delay, can
entertain a complaint which is received a er the expiry of the specified me
limit. In such cases, the date of condona on is considered as the date of filing
of complaint.

7) What is the Financial Jurisdic on of an Insurance Ombudsman?

Ombudsman can,—

(i) award any compensa on up to the loss suffered by the

complainant
as a direct consequence of the cause of ac on; or
(ii) award compensa on not exceeding Rs Thirty lakhs (including
relevant expenses, if any).
8) Can a complainant, who has already approached Consumer
Forum/court on the same subject, approach the Insurance
Ombudsman?
No. Any complainant, whose complaint on the same subject ma er is or was
before a Court/Consumer Forum or an Arbitrator cannot approach an
Insurance Ombudsman.
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5/27/2020 FAQ’s on Ombudsman Scheme

9) Under what circumstances a complaint can not be filed before

and Insurance Ombudsman?

I. No complaint to the Insurance Ombudsman shall lie unless—

the complainant makes a wri en representa on to the insurer named
in the complaint and-
Ø either the insurer had rejected the complaint; or
Ø the complainant had not received any reply within a period of one month
a er the insurer received his representa on; or
Ø the complainant is not sa sfied with the reply given to him by the insurer;

II. No complaint before the Insurance Ombudsman can be maintainable on

the same subject ma er on which proceedings are pending before or
disposed of by any court or consumer forum or arbitrator.
10) Should a complainant approach the Ombudsman through a
lawyer?
Not necessary as formal court procedures are not involved.

11) Within what me shall the Ombudsman dispose of the

complaint?
In case both par es agree for media on, the Ombudsman gives his
Recommenda on within 1 month; otherwise, he passes an Award within 3
months from the date of receipt of all requirements from complainant.

12) Are there any fees / charges payable for lodging a complaint?
No fees / charges are required to be paid.

13) Does the Ombudsman conduct hearings of the par es?

Yes, if considered necessary, the Insurance Ombudsman will conduct hearing
of both the par es so as to provide them with reasonable opportunity of
being heard before an award is passed.

14) Is there any appeal against an Award of Insurance Ombudsman?

In case a complainant is not sa sfied with the Award of an insurance
Ombudsman he can exercise his right to take recourse to the normal process
of law against the insurance company. However, the award of Insurance
Ombudsman shall be binding on the insurers.

15) Is there any me limit for Compliance of Award by Insurers?

The Insurer shall comply with the Award within 30 days from the date of
receipt of the Award and in mate of its compliance to the Insurance
Ombudsman.

Insurance Regulatory and Development Authority of India. All Right Reserved.

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