Refer all insurance queries of your patients to the ombudsman

Health Care Comments Off

An ombudsman or public advocate is an official, usually appointed by the government or by parliament, but with a significant degree of independence, who is charged with representing the interests of the public by investigating and addressing complaints of maladministration or a violation of rights. The typical duties of an ombudsman are to investigate complaints and attempt to resolve them, usually through recommendations (binding or not) or mediation.

The Insurance Ombudsman scheme was created by 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 17 Insurance Ombudsman in different locations and one can approach the one having jurisdiction over the location of the insurance company office that you have a complaint against.

You can approach the Ombudsman with complaint if:

• You have first approached your insurance company with the complaint and
o They have not resolved it
o Not resolved it to your satisfaction or
o Not responded to it at all for 30 days
• Your 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 lakh

Your complaint to the Ombudsman can be about:

• Any partial or total repudiation of claims by an insurer
• Any dispute about premium paid or payable in terms of the policy
• Any dispute on the legal construction of the policies as far as it relates to claims
• Delay in settlement of claims
• Non-issue of any insurance document to you after you pay your premium

The settlement process

Recommendations

• The Ombudsman will act as counsellor and 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 the complaint and which will be
• A speaking award with the detailed reasoning
• Binding on the insurance company but
• Not binding on the policyholder
• The Ombudsman can also award an ex-gratia payment

Once the Award is passed

• You have to accept the award in writing and the insurance company has to be informed of it within 30 days.
• The Insurance Company has to comply with the award in 15 days after that.

Dr KK Aggarwal
National President IMA & HCFI