Insurance ombudsman complaint: the no-fee route after a rejected claim

What the Insurance Ombudsman decides, and who can complain

The Insurance Ombudsman, also called the Bima Lokpal, is an independent officer who decides complaints by policyholders against insurers and, since the 2021 amendment, against insurance brokers. Under Rule 13 the ombudsman hears complaints about:

• delay in settling a claim, or its partial or total rejection;
• disputes over premium paid or payable;
• misrepresentation of policy terms at the time of sale;
• the reading of policy wording, so far as it affects a claim;
• policy servicing, and a policy not issued after the premium was paid;
• breach of IRDAI's regulations by the insurer.

Individuals, sole proprietors, micro enterprises and members of group policies may complain. On a death claim, the nominee, a legal heir or an assignee can file.

Four conditions must be met. You must first have complained to the insurer in writing. The insurer must have rejected that complaint, failed to reply within one month, or replied in a way you do not accept. You must file within one year of the reply, or of the end of that month if there was none. And the same dispute must not be pending before, or decided by, a court, consumer commission or arbitrator.

IRDAI complaint, ombudsman or consumer commission?

For a claim of moderate size with clear papers, the ombudsman is usually quicker and cheaper. Where the claim is large, the policy is in a company's name, or you need interest and costs decided, our consumer case service for rejected claims fits better.

Health, motor and life claims the ombudsman sees most

Health insurance claim rejected or cut down

Typical disputes are a cashless request refused and then the reimbursement claim rejected too, deductions for charges the insurer calls not reasonable and customary, proportionate cuts because the room rent exceeded the policy's sub-limit, and waiting-period objections. Another common ground is that hospitalisation was not needed and the treatment could have been given as an outpatient. The treating doctor's notes on why admission was necessary often decide that one.

Motor insurance claim rejected

On own-damage claims the usual fights are about depreciation on parts, whether a zero-depreciation add-on applies, a repair settlement offered where the vehicle is a total loss, and objections over the driving licence. Claims by a third party for injury or death in an accident do not go to the ombudsman; they are decided by the Motor Accident Claims Tribunal.

Life policies and nominee claims

Death claims rejected for alleged non-disclosure, delays in paying the nominee, and disputes over surrender or maturity values all come here. So do complaints that a market-linked plan was sold as something it was not, which falls under misrepresentation of policy terms.

What our fixed fee covers

• A reading of the policy wording, claim papers and the insurer's letters.
• A check that the four conditions are met and that the amount is within the ombudsman's limit.
• A letter to the insurer's grievance officer, if you have not yet complained in writing.
• The ombudsman complaint: facts in date order, the grounds, and a claim computation that follows the policy terms.
• An index of annexures, and help completing the forms the ombudsman's office sends you.
• A hearing note: the points to make, and which pages to have open.
• One round of revisions.

The Rules let the policyholder, or the nominee, heir or assignee, bring the complaint, and the ombudsman's office deals with that person directly. So the complaint is signed by you and you attend the hearing, usually by video. Our part is to put the papers and your arguments in order before that day. A later consumer case, if you need one, is a separate service.

What you send us

• The policy schedule and full policy wording for the year of the claim.
• The claim form and claim papers: discharge summary and bills, survey report and garage bills, or the death certificate and medical records.
• Every letter or email from the insurer, especially the rejection or deduction letter.
• Your written complaint to the insurer and its reply, with dates. Include any Bima Bharosa reference.
• The proposal form, if the insurer alleges you hid something.

Scans or clear photographs by email or WhatsApp are enough. If something is missing, such as the proposal form, we tell you how to ask the insurer for it.

How an insurance ombudsman complaint works, step by step

1. Complain to the insurer. Write to its grievance redressal officer, and keep the acknowledgement. You can also register the grievance on IRDAI's Bima Bharosa portal.
2. Wait for the reply. If it rejects you, or one month passes without an answer, you may go to the ombudsman.
3. Draft and file. We prepare the complaint. You file it online through the Council for Insurance Ombudsmen's complaint system, by email or by post to the office with jurisdiction.
4. Mediation. The office calls for the insurer's response and may try to settle the matter. If both sides accept a recommendation, the insurer acts on it.
5. Hearing and award. If there is no settlement, the ombudsman hears both sides, often by video, and passes an award within three months of receiving everything needed. The insurer must comply within 30 days.

Insurance ombudsman in Mumbai, Thane or Pune: which office?

You may file with the ombudsman covering the insurer's branch or office you dealt with, or the one covering your home address. In the Mumbai region, the Mumbai office sits in Santacruz (West). The Thane office covers Navi Mumbai, Thane, Raigad and Palghar districts and several eastern Mumbai wards, and Pune covers most of the rest of Maharashtra. Check the current jurisdiction list on the Council's website before filing, as it is revised from time to time.

How do I check my insurance ombudsman complaint status?

Online complaints are given a reference number, which you can track on the Council for Insurance Ombudsmen's portal. For complaints sent by email or post, write to the same office quoting your policy number and the date you filed.

Fees, limits and deadlines

• Filing fee: none.
• Before filing: a written complaint to the insurer, and a reply or one month's silence.
• Time limit: one year from the insurer's reply, or from the end of that month. The ombudsman can condone a delay, but only for recorded reasons after hearing the insurer.
• Money limit: the ombudsman can award compensation only up to the ceiling in the Rules. We check your claim against the current ceiling before you file.
• Award: within three months of the office receiving all requirements; the insurer must comply within 30 days.
• Effect: binding on the insurer. If you do not accept it, you are not bound and other remedies stay open, subject to their own time limits.

There is no stamp duty or registration involved. The only cost of the forum itself is your time.

Mistakes that get ombudsman complaints dismissed

• Skipping the insurer. A complaint without a prior written complaint to the insurer is returned.
• Using two forums at once. If a consumer case or arbitration on the same claim is pending, the ombudsman will not hear it.
• Counting the year wrongly. It runs from the insurer's reply, not from the date of hospitalisation or the accident.
• The wrong person signing. An agent or a relative who is not the nominee, heir or assignee cannot complain on your behalf.
• No figure. Ask for a specific amount, worked out from the policy, not "the full claim with damages".
• Missing the hearing. Join the video link on time with the papers ready; the hearing is short and you may not get another.

Related services

If you would rather go straight to a consumer commission and argue it yourself, our consumer complaint drafting service prepares the complaint for you to file. For a wider look at your options after a rejection, read our post on insurance claims rejected in India.