subject: The Role of Ombudsman in Health Insurance in India [print this page] Remember those times when you fought with your brother or sister regarding whose chance was it to ride the cycle or who should have the greater share in the box of sweets? The dispute sometimes went on and on until you had to go to someone older in order to resolve it.Ombudsman is a similar concept applied to disputes regarding health insurance cases. Ombudsman is generally appointed by the organization to act as an impartial judge who listens to both the sides and gives recommendations to settle the dispute.
Ombudsman in India
The concept of Ombudsman began in Sweden where an independent executive was appointed by the government to look into the disputed matters of the citizens. Generally ombudsman is a person appointed by the organization to resolve disputes between someone outside the organization and the organization.
Government of India created Institution of Insurance Ombudsman in 1998 to handle the grievances of consumers regarding insurance policies. This institution is of great importance to the consumers as they are given a platform to express their issues with Insurance companies and get the issues resolved. Since the institution of Ombudsman is for protecting the policy holder's interest, it puts consumer's faith in the insurance companies and ensures that insurance companies are accountable in their transactions.
Some more information:
Insurance Council consisting of representatives of the insurance companies appoints Insurance Ombudsman considering the recommendations of the committee comprising of members of IRDA, Chairman, LIC, GIC and a representative of the Government.
There are 12 Ombudsman offices spread across all of India in cities like Mumbai, New Delhi, Kolkata, Chennai and Bhubaneswar etc.
How do they function?
Ombudsman is responsible for two main functions, firstly for reconciliation or settlement of a grievance between person who has a complaint and the insurance company and secondly to award compensation to the complainant. The awards that Ombudsman announces are binding on the Insurance companies.
When can you approach them?
If you think the insurance company has not fully paid a valid claim.
If there is a disagreement about the payment of premium between the insurance company and you.
If there is disagreement between the interpretation of the policy wordings.
If there is delay in the payment of the claim.
If the insurance company does not provide any insurance document after acceptance of the proposal and even after you have paid the premium.
In the above cases, you can approach the Insurance Ombudsman.
Remember before lodging a complaint,
You need to communicate to the insurance company about your grievance and if the company does not respond within a month or if the reply does not satisfy you, you can lodge the complaint.
You need to lodge a complaint within a month of the insurance company's response.
You cannot lodge a complaint if the same case is pending before any court, any consumer forum or arbitrator.
How should you approach them?
You need to lodge a written complaint addressed to the Insurance Ombudsman of your jurisdiction. You can find the insurance ombudsman of your jurisdiction throughthe document provided at the time of buying the policy or by referring to the IRDA website.
What is the procedure that follows?
After listening to both the sides, if the matter is settled, Ombudsman makes recommendations that are fair to the case. He has to make those recommendations within one month and send the copies to the person who lodged the complaint and to the insurance company.
If the complainant agrees,
The person who had complained has to send his reply saying whether or not he has accepted the settlement within 15 days of the recommendations. If the Ombudsman has recommended that the person complaining gets an award then the insurance company is binded to pay it. The payment has to be made within 3 months of the receipt of the recommendation.
If the complainant disagrees,
If the recommendations of ombudsman do not satisfy the complainant, then he can send a reply rejecting the recommendation to both the ombudsman and the insurance company. He can then approach other forums like consumer forum or courts of law. To know more about The Role of Ombudsman in Health Insurance in India
