Insurance Grievance redressal, Claim settlement, Key feature document

Insurance Grievance redressal

A grievance 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 a grievance redressal mechanism is in place for providing excellent 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 Management System 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 one are unhappy with the insurance company procedures or claim settlement, one can

• Approach the Grievance Redressal Officer of its branch or any other office that one deals with. All formal mail IDs of Grievance Redressal Officers, GRO, of all insurance companies is made available in IRDAI portal:  policyholder.gov.in
• 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 policyholder is  unhappy with the solution he can:
  • Approach the Grievance Redressal Cell of the Consumer Affairs Department of IRDA:
    • Call Toll Free Number 155255 (or) 1800 4254 732 or
    • Send an e-mail to complaints@irda.gov.in
  • Make use of the Integrated Grievance Management System:
    • Register and monitor your complaint at igms.irda.gov.in

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 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.

Policyholders 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:

1999. a)    Delay in settlement of claims, beyond the time specified in the regulations, framed under the IRDAI Act, 1999.
2000. b)    Any partial or total repudiation of claims by the Life insurer, General insurer or the Health insurer.
2001. c)     Any dispute about premium paid or payable in terms of insurance policy
2002. d)    Misrepresentation of policy terms and conditions at any time in the policy document or policy contract.
2003. e)    Legal construction of insurance policies in so far as the dispute relates to claim.
2004. f)     Policy servicing related grievances against insurers and their agents and intermediaries.
2005. 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.
2006. h)    Non issuance of insurance policy after receipt of premium in life insurance and general insurance including health insurance and
2007. 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

Claim settlement

Claim settlement is one of the most important services that an insurance company can provide to its customers. Insurance companies have an obligation to settle claims promptly. You will need to fill a claim form and contact the financial advisor from whom you bought your policy. Submit all relevant documents such as original death certificate and policy bond to your insurer to support your claim. Most claims are settled by issuing a cheque within 7 days from the time they receive the documents. However, if your insurer is unable to deal with all or any part of your claim, you will be notified in writing.

Types of claims

Maturity Claim: On the date of maturity life insured is required to send maturity claim / discharge form and original policy bond well before maturity date to enable timely settlement of claim on or before due dates. Most companies offer/issue post dated cheques and/ or make payment through ECS credit on the maturity date. Incase of delay in settlement kindly refer to grievance redressal.

Death Claim (including rider claim): In case of death claim or rider claim the following procedure should be followed.

Follow these four simple steps to file a claim:

• Claim intimation/notification

The claimant must submit the written intimation as soon as possible to enable the insurance company to initiate the claim processing. The claim intimation should consist of basic information such as policy number, name of the insured, date of death, cause of death, place of death, name of the claimant. The claimant can also get a claim intimation/notification form from the nearest local branch office of the insurance company or their insurance advisor/agent. Alternatively, some insurance companies also provide the facility of downloading the form from their website.

2. Documents required for claim processing
   The claimant will be required to provide a claimant’s statement, original policy document, death certificate, police FIR and post mortem exam report (for accidental death), certificate and records from the treating doctor/hospital (for death due to illness) and advance discharge form for claim processing. Based on the sum at risk, cause of death and policy duration, insurance companies may also request some additional documents.

3. Submission of required documents for claim processing
   For faster claim processing, it is essential that the claimant submits complete documentation as early as possible. A life insurer will not be able to take a decision until all the requirements are complete. Once all relevant documents, records and forms have been submitted, the life insurer can take a decision about the claim.
4. Settlement of claim
   As per the regulation 14 (2)(i) of the IRDAI (Policy holder’s Interest) Regulations, 2017, the insurer is required to settle a claim within 30 days of receipt of all documents including clarification sought by the insurer. However, the insurance company can set a practice of settling the claim even earlier. If the claim requires further investigation, the insurer has to complete its procedures expeditiously, in any case not later than 90 days from the date of receipt of claim intimation and claim shall be settled within 30 days thereafter.

Claim Intimation

In case a claim arises you should:

• Contact the respective life insurance branch office.
• Contact your insurance advisor.
• Call the respective Customer Helpline.

Claim Requirements

For death claim:

• * Death Certificate
  * Original Policy Bond
  * Claim Forms issued by the insurer along with supporting documents

For maturity claims:

• * Original Policy Bond.
  * Maturity Claim Form