IRDA Insurance Ombudsman Scheme IRDAI

Organisation : IRDA Insurance Regulatory & Development Authority
Facility : Insurance Ombudsman Scheme

Scheme Page here : https://policyholder.gov.in/
Website : https://policyholder.gov.in/

Ombudsman :

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.

Related : IRDA IGMS Integrated Grievance Management System : www.statusin.in/19121.html

There are 17 Insurance Ombudsman in different locations and you 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
** ** They have not resolved it
** ** Not resolved it to your satisfaction or
** ** 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 :
Recommendation:
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 and
** The Insurance company has to comply with the award in 15 days after that.

Rules :
Application. – These Rules shall apply to all the insurance companies operating in general insurance business and in life insurance business.

Provided that the Central Government may exempt an insurance company from the provisions of these Rules, if it is satisfied that an insurance company has already a grievance redressal machinery, which fulfills the requirements of these Rules.

The objects of these Rules are to resolve all complaints relating to settlement of claim on the part of insurance companies in cost effective, efficient and impartial manner.

Definition. – In these rules unless the context otherwise requires:
(a) “Act” means Insurance Act, 1938.
(b) “Committee” means an advisory committee referred to in Rule 19.
(c) “Financial year” means period of twelve months commencing from the 1st day of April of any year and ending on 31st day of March of the succeeding year.
(d) “General Insurance Corporation of India” means a government company formed under sub-section (1) of section 9 of the General Insurance Business (Nationalisation) Act, 1972 and shall include a subsidiary company of such company.
(e) “Governing body” means governing body of the Insurance Council constituted under sub-rule (1) of rule
(f) “Insurance Council” means the Life Insurance Council and the General Insurance Council referred to in section 64C of the Act.
(g) “Insurance Regulatory Authority” means a body established by Government of India vide Resolution No. 17(2) / 94 Ins. V dated 23-01-1996 to monitor the orderly growth of insurance industry.
(h) “Insurance Company” means the Life Insurance Corporation of India, the General Insurance Corporation of India and any other company, which has been given a license to carry on business of life insurance or of the general insurance, as the case may be.
(i) “Insured person” means an individual by whom or on whose behalf an insurance policy has been taken on personal lines.
(j) “Life Insurance Corporation of India” means the Life Insurance Corporation of India established under the Life Insurance Corporation Act, 1956.
(k) “Personal lines’ means an insurance policy taken or given in an individual capacity.

Governing body of Insurance Council –
(1) There shall be a Governing Body of the Insurance Council, which shall consist of one representative from each of the insurance companies.
(2) The representatives of an insurance company shall ordinarily be Chairman or Managing Director or any one of the Directors of such company.
(3) The Governing body shall formulate its own procedure for conducting its business including the election of the Chairman.

Provided that the Chairman of the Life Insurance Corporation of India shall act as the first Chairman of the governing body.

Ombudsman :
(1) The governing body shall appoint one or more persons as ombudsman for the purpose of these rules.
(2) The Ombudsman selected may be drawn from a wider circle including those who have experience or have been exposed to the industry, civil service, administrative service, etc. in addition to those drawn from judicial service.
(3) An Ombudsman shall be appointed by the Governing Body from a panel prepared by the Committee consisting of –
(a) Chairman of Insurance Regulatory Authority – Chairman
(b) Two representatives of Insurance Council including one each from the Life Insurance Business and from General Insurance Business respectively – Member
(c) One representative of the Central Government – Member