What Is a Life Insurance Ombudsman?

Updated On May 20, 2021

What Is Life Insurance Ombudsman?
Claim Settlement Process
Takeaway

To ensure that a life insurance claim process is efficient and hassle-free, the Indian Government has created the Insurance Ombudsman. It aims to speed up the settlement of any grievance that the customer may have against the insurer.

Getting such a structure in place means that everyone has an equal place and that people can truly put their faith in the system and enjoy the advantages that it has to offer. The insurance sector also sees optimal growth in this way, and this is a great sign for all.

What Is Life Insurance Ombudsman?

The insurance ombudsman scheme was developed by the Government of India to encourage individual policyholders to resolve their complaints out of the court system in a cost-effective, reliable and unbiased manner.

There are currently 17 insurance ombudsmans in different locations and any person who has a claim against the insurer can, on his own or through his legal heirs, nominee or assignee; lodge a complaint to the insurance ombudsman under whose local jurisdiction the division or office of the insurer claimed against or the domicile or place of residence of the claimant is situated.

You will bring a complaint to the Ombudsman if:

You first contacted the insurance provider with a complaint and-
They denied it
If it's not answered to your expectations or
Not replied to at all for 30 days.
Your complaint applies to any programme you have implemented in your capacity as a person and
The amount of the petition, including the costs claimed, does not surpass Rs 30 lakhs.

Your grievance to the Ombudsman may be as follows:

(a) Delay in the resolution of lawsuits within the period set out in the Legislation under the IRDA Act, 1999.

(b) Any partial or absolute refutation of claims by the life insurer, the general insurer or the health insurer.

(d) Misrepresentation of policy terms and conditions at some point in the policy document or the policy contract.

(e) The legitimate construction of insurance contracts in so long as the dispute applies to the lawsuits.

(f) scheme handling of related grievances against insurers and their brokers and intermediaries.

(g) the issuance of a life insurance policy, a general insurance policy or a health insurance policy which is not in compliance with the proposal form requested by the offeror.

(h) failure to issue insurance following issuance of a premium for life insurance and general insurance, including health insurance, and

(i) Any other matter arising out of an infringement of the rules of the Insurance Act, 1938 or of the Legislation, Circulars, Guidelines or Directives provided by the IRDAI from time to time, or of the terms and conditions of the service contract, in so far as they apply to matters referred to in section (a) to (f)

Claim Settlement Process

Recommendations

The Ombudsman shall serve as a mediator and

Arrive on a reasonable recommendation based on the details of the conflict
If you consider this as a complete and final resolution, the Ombudsman shall notify the company to comply with the terms and conditions within 15 days.

Award

If the resolution of the recommendation does not succeed, the Ombudsman will:

Award within 3 months of receipt by the claimant of all the conditions and which shall be binding on the insurance company;

After The Award is Passed

The insurer needs to comply with the reward within 30 days of receipt of the award and shall notify the Ombudsman accordingly.

Takeaway

The Ombudsman serves as a mediator of these cases and attempts to arrive at an honest recommendation based on the evidence present in the conflict. If you approve the decision made by them, they shall notify the insurance firm of the same and the company shall comply with the conditions within 15 days.