Complaints and Grievances

     

It is defined as any communication that expresses dissatisfaction about an action or lack of action, about the standard of service / deficiency of service of an insurance company and / or any intermediary or seeks remedial action.

Every insurer must ensure the best of grievance redressal mechanism in place for providing excellence in customer service which in turn is the most important tool for business growth.

Grievance redressal is based on the following principles

Customers are treated fairly at all times

Complaints raised by customers are dealt with an open mind, with courtesy

Customers are informed through policy document of avenues of escalation process of their complaints and grievances within the organization

To treat all complaints efficiently and fairly as they can damage the company’s reputation and business if not handled properly.

IRDAI has through various regulations mandated the following requirements to be complied with by all insurers

  1. Ensure a board approved grievance redressal policy document is in place
  2. All complaints must be logged in through igms (integrated grievance redressal portal) of the authority
  3. Every insurer must have grievance redressal officer (GRO) whose contact details are provided in all the communication with the policy holder
  4. Insurer must abide by the grievance redressal guidelines advised by iRDAI
  5. Regular reporting of all category of complaints & reconciliation of pending complaints is order of the day
  6. The category of complaints number, intermediary involved, action taken, RCA (root cause analysis) to be placed before the committee of policy holder protection of interest at every meeting for discussion & directions

Policy holder can lodge a complaint in any of the manner as listed below

If you are unhappy with your insurance company

  • Approach the Grievance Redressal Officer of its branch or any other office that you deal with. All formal mail ids of Grievance Redressal Officers, GRO, of all insurance companies is made available in IRDAI policyholder.gov.in portal.
  • Complaint in writing along with the necessary support documents to be provided
  • Written acknowledgement of complaint  date to be obtained.

The insurance company should deal with all complaint within 15 days.

  • If that does not happen or if P H is  unhappy with the solution you can:
    • Approach the Grievance Redressal Cell of the Consumer Affairs Department of IRDA:
    • Make use of the Integrated Grievance Management System:
  • Send a letter to IRDAI with his complaint to

The General Manager,

Consumer Affairs Department - Grievance Redressal Cell, Insurance Regulatory and Development Authority of India (IRDAI)3-5-817/818, United India Towers, 9th Floor,Hyderguda, Basheerbagh, Hyderabad – 500 029

IRDAI guidelines on grievance redressal

Every insurer shall have a system and procedure for receiving, registering and disposing of grievances

in each of its offices. This and all other relevant details along with details of Turnaround Times (TATs) shall be clearly laid down in the policy. While insurers may lay down their own TATs, they shall ensure that the following minimum time frames are adopted:

 

(a). An insurer shall send a written acknowledgement to a complainant within 3 working days of the receipt of the grievance.

(b). The acknowledgement shall contain the name and designation of the officer who will deal with the grievance.

(c). It shall also contain the details of the insurer’s grievance redressal procedure and the time taken for resolution of disputes.

(d). Where the insurer resolves the complaint within 3 days, it may communicate the resolution along with the acknowledgement.

(e). Where the grievance is not resolved within 3 working days, an insurer shall resolve the grievance within 2 weeks of its receipt and send a final letter of resolution.

(g). Where, within 2 weeks, the company sends the complainant a written response which offers redress  or rejects the complaint and gives reasons for doing so,

(i). the insurer shall inform the complainant about how he/she may pursue the complaint, if dissatisfied.

(ii). the insurer shall inform that it will regard the complaint as closed if it does not receive a reply

within 8 weeks from the date of receipt of response by the insured/policyholder. Any failure on the part of insurers to follow the abovementioned procedures and time-frameswould attract penalties by the nsurance Regulatory and Development Authority.

 Insurance ombudsmen

With an objective to provide 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 Sectors.

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 Governing Body of Insurance Council and such staff is drawn from Insurance Companies. The total expenses on running the Institution are shared by all Insurance Companies, who are Members of the Insurance Council. 

The Insurance Ombudsman scheme was created by the Government of India for individual policyholders to have their complaints settled out of the courts system in a cost-effective, efficient and impartial way.

There are at present 17 Insurance Ombudsman in different locations and any person who has a grievance against an insurer, may himself or through his legal heirs, nominee or assignee, make a complaint in writing to the Insurance ombudsman within whose territorial jurisdiction the branch or office of the insurer complained against or the residential address or place of residence of the complainant is located.

Complaint is to be lodged with the Insurance Ombudsman under whose territorial jurisdiction the insurer’s office falls, at the address provided in website / insurer communication which includes policy document.

P H can approach the Ombudsman with complaint if:

 

 He has first approached your insurance company with the complaint and

  • they have rejected it
  • not resolved it to your satisfaction or not responded to it at all for 30 days
  • complaint pertains to any policy you have taken in your capacity as an individual and
  • the value of the claim including expenses claimed is not above Rs 20 lakhs.

Complaint to the Ombudsman can be about:

 

  1. a)    Delay in settlement of claims, beyond the time specified in the regulations, framed under the IRDAI Act, 1999.
  2. b)    Any partial or total repudiation of claims by the Life insurer, General insurer or the Health insurer.
  3. c)     Any dispute about premium paid or payable in terms of insurance policy
  4. d)    Misrepresentation of policy terms and conditions at any time in the policy document or policy contract.
  5. e)    Legal construction of insurance policies in so far as the dispute relates to claim.
  6. f)     Policy servicing related grievances against insurers and their agents and intermediaries.
  7. g)    Issuance of life insurance policy, general insurance policy including health insurance policy which is not in conformity with the proposal form submitted by the proposer.
  8. h)    Non issuance of insurance policy after receipt of premium in life insurance and general insurance including health insurance and
  9. i)      Any other matter resulting from the violation of provisions of the Insurance Act, 1938 or the regulations, circulars, guidelines or instructions issued by the IRDAI from time to time or the terms and conditions of the policy contract, in so far as they relate to issues mentioned at clauses (a) to (f)

 The Ombudsman will act as mediator and 

  • Arrive at a fair recommendation based on the facts of the dispute
  • If you accept this as a full and final settlement, the Ombudsman will
  • Inform the company which should comply with the terms in 15 days

 Award:

  • If a settlement by recommendation does not work, the Ombudsman will:
  • Pass an award within 3 months of receiving all the requirements from the complainant and which will be binding on the insurance company

Once the Award is passed

  • The Insurer shall comply with the award within 30 days of the receipt of award and intimate the compliance of the same to the Ombudsman.

 

There is no appellate authority governing Ombudsman order. The order is final & binding.