How To File A Complaint Against Health Insurance Claim

How to File A Complaint Against A Health Insurance Claim? 

There are times when we are not satisfied with the level of service provided by our health insurance company. It could be related to claims, policy servicing, or any other aspect related to our policy. The grievance redressal systems are in place to help the policy holder/ customer/consumer. 

How Does This System Work?

The Grievance Redressal System is designed for the consumer end. This is a 3-tier process for the benefit of the consumer:

As shown in the diagram above, the process works as follows:

• Approach the insurance provider directly
• Take help of the IRDAI, when not satisfied with the insurance company
• Approach a consumer court or the insurance ombudsman.

Let us look at each tier in detail.

Step 1: Register Your Complaint With Your Insurance Provider

Insurance providers usually have a dedicated department for customer grievance. Usually the details are provided in the policy or other documents, insurer’s website. It is available with the insurance agent who serviced the policy. You can also get it on the website of the Insurance Regulatory and Development Authority of India. 

[IRDAI website showing list of registered providers for Life Insurance and General Insurance]

In some cases, a hierarchical structure like branch office to regional/zonal office is followed by escalation to the head office. It is outlined by the insurance provider. Information about exact procedures like the forms to be used, mode of communication, turn-around-time for complaints and queries, responsible authority, etc. are usually provided on the website by the means of Frequently Asked Questions (FAQs) or provided to you by the Grievance Handling Team.

Step 2: Approach IRDAI If Unsatisfied With The Response Of The Policy Provider

When the resolution provided by the insurance provider is not satisfactory, or there is no resolution provided, the policyholder has the option to approach IRDAI. 

On its “Grievances” link, IRDAI clearly mentions the four different ways by which a policy holder can lodge a complaint:
1. Toll free number: IRDAI grievance call center (IGCC) can be accessed through the toll free numbers 155255 or 1800 4254 732
2. E-mails: Emails can be sent to: “complaints@irdai.gov.in”.
3. Physical Address For Correspondence: All paper correspondence can be mailed or sent by Fax to the following address:
Insurance Regulatory and Development Authority of India, Consumer Affairs Department – Grievance Redressal Cell. Sy.No.115/1, Financial District, Nanakramguda, Gachibowli, Hyderabad – 500 032.
4. Integrated Grievance Management System (IGMS): The IGMS can be accessed by logging on to “igms.irda.gov.in”. It is also mentioned on IRDAI website.

The policyholder would need to register and create a profile. Once the profile is created, the complaint can be lodged. IRDAI would provide a token for tracking the complaint once it is registered successfully. The complaint is then transmitted to IRDAI grievance cell, as well as the insurance company simultaneously. The policyholder also has the right to appeal for a review if not satisfied with the resolution.  

Step 3: Approach The Consumer Court In The End

The final option available to a policy holder is to approach the Insurance Ombudsman in the jurisdiction or a consumer court for filing a civil suit for the redressal of grievance. The court would usually accept the cases which are outside the power or the domain of the IRDAI and the ombudsman or the court would initiate an inquiry. The court would decide as per the results of the inquiry done by them and the elements provided by both the parties.

Conclusion

We can see there are many, well-defined channels for protecting the rights of a policy holder against any foul play by the insurance provider. In most cases, the IRDAI grievance cell should be able to provide the desired relief. In certain cases, there could be regulatory implications beyond the scope of IRDAI; in such cases, approaching the judicial system works best.