बीमा लोकपाल परिषद
Council for Insurance Ombudsmen


FAQ

INSURANCE OMBUDSMAN SCHEME MADE EASY TO UNDERSTAND.

Scheme of Insurance Ombudsman.

With an objective of providing a forum for resolving disputes and complaints from the aggrieved insured public or their legal heirs, nominee or assignee against Insurance Companies & agents & intermediaries., the Government of India, in exercise of powers conferred by section 24 of the Insurance Regulatory and Development Authority Act, 1999(41 of 1999) framed "Insurance Ombudsman Rules, 2017", which came into force w.e.f. 25th April, 2017. These Rules have been further amended by Gazette notification no. G. S. R. 147 ( E ) dated 02.03.2021.

The Executive Council of Insurers(ECOI) formerly Governing body of Insurance Council (GBIC) has been renamed as Council for Insurance Ombudsmen(CIO) vide above Gazette notification dated 02.03.2021.

These Rules aim at resolving complaints relating to the settlement of disputes with Insurance Companies and their agents and intermediaries on personal lines of insurance, group insurance policies, policies issued to sole proprietorship and micro enterprises in a cost effective, efficient and impartial manner. These Rules apply to all the Insurance Companies operating in General Insurance business, Health Insurance business and Life Insurance business, in Public and Private Sector.

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 shall receive and consider complaints alleging deficiency in performance required of an insurer (including its agents and intermediaries) or an insurance broker, on any of the following grounds:—

(a) delay in settlement of claims, beyond the time specified in the regulations, framed under the Insurance Regulatory and Development Authority of India Act, 1999;
(b) any partial or total repudiation of claims by the life insurer, General insurer or the health insurer;
(c) disputes over premium paid or payable in terms of insurance policy;
(d)misrepresentation of policy terms and conditions at any time in the policy document or policy contract;
(e) legal construction of insurance policies in so far as the dispute relates to claim;
(f) policy servicing related grievances against insurers and their agents and intermediaries;
(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;
(h) non-issuance of insurance policy after receipt of premium in life insurance and general insurance including health insurance; and
(i) any other matter arising from non-observance of or non-adherence to the provisions of any regulations made by the Authority with regard to protection of policyholders’ interests or otherwise, or of any circular, guideline or instruction issued by the Authority, or of the terms and conditions of the policy contract, insofar as such matter relates to issues referred to in clauses (a) to (h).

The Insurance Ombudsman is provided with a Secretarial Staff by the IRDAI as may be determined by the Council for Insurance Ombudsmen. The total expenses for running the Institution are borne by the Life Insurance Council AND THE General Insurance Council in such proportion as the Council for Insurance Ombudsmen may, by a general or special order specify, from time to time.

FREQUENTLY ASKED QUESTIONS (FAQS):

1) With whom is a complaint to be lodged?

A complaint is to be lodged with the Insurance Ombudsman under whose territorial jurisdiction the Branch or Office of the Insurer or the insurance broker, complained against OR the residential address or place of residence of the complainant falls, at the address given on our website under the heading "CONTACT US".

2) Does Insurance Ombudsman operate in any territorial jurisdiction?

Insurance Ombudsman operates only within the territorial limits specified in "CONTACT US"

3) How is this territorial jurisdiction to be applied to complaints?

The complaint will lie with the Insurance Ombudsman under whose territorial jurisdiction the Branch or Office of the Insurer or insurance broker, complained against or the residential address or place of residence of the complainant is located.

4) Who can approach Ombudsman?

Any aggrieved individual who has taken an Insurance Policy on personal lines of insurance, group insurance policies, policies issued to sole proprietorship and micro enterprises may himself or through his legal heirs, nominee or assignee can approach Ombudsman.

5) What Is the meaning of Insurance on Personal Lines?

Insurance on personal lines means a policy taken or given in an individual capacity, e.g. life insurance, personal accident insurance, mediclaim insurance, insurance of personal property of the individual such as motor vehicle, household articles, etc.

6) What is Micro Enterprises?

The enterprise engaged in the manufacture of production of goods pertaining to any industry where the investment in plant and machinery does not exceed twenty-five lakh rupees and enterprises engaged in providing or rendering of services where the investment in equipment does not exceed ten lakh rupees.

7) What are the complaints that are entertained by the Ombudsman?

Any complaintalleging deficiency in performance required of an insurer (including its agents and intermediaries) or an insurance broker on any of the following grounds:
(a) delay in settlement of claims, beyond the time specified in the regulations, framed under the Insurance Regulatory and Development Authority of India Act, 1999;
(b)any partial or total repudiation of claims by the life insurer, General insurer or the health insurer;
(c) disputes over premium paid or payable in terms of insurance policy;
(d) misrepresentation of policy terms and conditions at any time in the policy document or policy contract;
(e) legal construction of insurance policies in so far as the dispute relates to claim;
(f) policy servicing related grievances against insurers and their agents and intermediaries;
(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;
(h) non-issuance of insurance policy after receipt of premium in life insurance and general insurance including health insurance; and
(i) any other matter arising from non-observance of or non-adherence to the provisions of any regulations made by the Authority with regard to protection of policyholders’ interests or otherwise, or of any circular, guideline or instruction issued by the Authority, or of the terms and conditions of the policy contract, insofar as such matter relates to issues referred to in clauses (a) to (h).

8) How is the complaint to be lodged?

The Complaint can be made by the complainant or by his legal heirs, nominee or assignee either through a written representation duly signed or through electronic mail or online through the online platform developed by the Council of Insurance Ombudsmen through their website www.cioins.co.in

9)Is there any time limit to approach the Ombudsman?

Within one year of the rejection by the insurer/insurance broker of the representation of the complainant or the Insurer's/insurance broker’s, final reply to the representation or after expiry of one month from the date of sending written representation to the insurer/insurance broker and the insurer/insurance broker fails to furnish the reply.

10)Is there any maximum limit for the amount under dispute that can be entertained by the Ombudsman?

The Insurance Ombudsman shall not award compensation exceeding rupees Thirty Lakhs (including relevant expenses , if any)

11) Can a complainant, who has already approached Consumer Forum/court on the same subject, approach the Ombudsman?

Any complainant, whose complaint on the same subject matter is or was before a Court/Consumer Forum cannot approach Ombudsman.

12) What are the pre-requisite conditions in short, for lodging a complaint?

a. The complaint must be by an individual on a 'Personal Lines' insurance, group insurance policies, policies issued to sole proprietorship and micro enterprises and within the terms of reference of the Insurance Ombudsman as set out under FAQ 7.
b. A representation should stand made to the Insurance Company/Insurance broker within one year and has :-
(i) after the order of the insurer or insurance broker, as the case may be, rejected the representation of the complainant OR
(ii) after receipt of decision of the insurer or insurance broker, as the case may be, which is not to the satisfaction of the complainant; OR
(iii) after expiry of a period of one month from the date of sending the written representation to the insurer or insurance broker, as the case may be, if the insurer or insurance broker, as the case may be, named fails to furnish reply to the complainant.

13) Should a complainant approach the Ombudsman through a lawyer?

No. As per the Insurance Ombudsman Rules, there is no provision to engage a lawyer.

14) Within what time shall the Ombudsman dispose off the complaint?

In case both parties agree for mediation, the Ombudsman shall give his Recommendation within 1 month of date of receipt of mutual written consent for such mediation, otherwise, he shall pass his Award within 3 months of the receipt of all requirements from the complainant.

15) Can the Ombudsman award ex-gratia payment?

The Ombudsman cannot, award ex-gratia payment.

16) Are there any fees / charges payable for lodging a complaint?

No fees / charges are required to be paid.

17) Does the Ombudsman conduct hearings of the parties?

Wherever considered necessary, the Ombudsman will conduct hearing of both the Parties either in person or through video conferencing. The Ombudsman may, on his own or on the request of the complainant, hear a matter through video-conference if he is satisfied that circumstances so require, after notifying the complainant and the insurer or insurance broker concerned.

18) If so, can the hearings be conducted outside headquarters?

Hearings may be conducted outside headquarters, where ever warranted.

19) Can a complaint be lodged against a Private Insurer?

Complaints can be lodged against any Insurer both in Public Sector and Private Sector in both Life and Non-Life sectors.

20)Can a complaint be lodged against Insurance broker?

Complaints can be lodged against Insurance Broker.

21)Can a Sole Proprietor of a business approach the Ombudsman for a complaint arising out of business interests?

A Sole Proprietor of a business can approach the Ombudsman for a complaint arising out of business interests.

22) Can Partnership Firms/Corporate Clients/Co-operative Societies/ Associations/Trusts approach Ombudsman?

Only individual policyholders, sole proprietorship or micro enterprises who have taken insurance on personal lines are eligible. However, a member covered under a Master Policy or a Group Insurance (or if deceased, the legal heir /nominee) can approach the Ombudsman, provided the payment of the claim under such policy is to be made to the individual, as beneficiary.

23) Is there any appeal against a decision given by the Ombudsman?

The Recommendation or Award of the Insurance Ombudsman are both subject to acceptance by the complainant in full and final settlement of the complaint. If such acceptance is not agreeable, the complainant may exercise the right to take recourse to the normal process of law against the insurance company/insurance broker. Further, dismissal of a complaint by the Insurance Ombudsman, does not vitiate the complainants' right to seek legal remedy against the insurers complained against, as per normal process of law.

24)Are routine administrative issues concerning agents (like non-issue of licence, non-receipt of commission etc.) or employees' grievances and complaints against staff of the member companies also entertained by the Ombudsman?

Such matters do not fall within the terms of reference of the Ombudsman and hence are not to be referred.

25) Are copies of complaints or queries and correspondence related thereto required to be forwarded to the Office of the Council for Insurance Ombudsmen?

The Office of the Insurance Ombudsman deals directly with complaint matters. Hence, copies of complaints or queries and correspondence need not be forwarded to the Office of the Council for Insurance Ombudsmen.

26) Can information be sought under the Right to Information Act?

Information can be sought from the Public Information Officer of the concerned Ombudsman Centre or the Council for Insurance Ombudsmen as applicable, in the prescribed format, forwarded together with the requisite prescribed fee. The Appellate Authority vests with the Secretary-General or the Deputy Secretary-General (as the case may be) of the Council for Insurance Ombudsmen.