Customer Care in Health Insurance Industry - Customer Grievances and Disputes

Customer Grievances and Disputes

Customer grievance is defined as feeling of resentment over something that is wrong or unfair in a particular product or service of a particular organization. This may involve the quality or the quantity of the product or the services of a particular organization. If the customer feels that the quality or the quantity of the product or a service is being compromised, such an individual becomes an aggrieved party and often results in a dispute. The dispute occurs between the aggrieved party (or individual) and the service-provider. Such an aggrieved individual or an aggrieved party has the option or is conferred the rights to file a complaint against the product or services of an organization with an appropriate forum.

It should be borne in mind that customer grievances do not need to be formal and elaborate. Only that, filing of disputes should be done within the specific guidelines as issued by the regulatory body governing the Insurance Companies in that particular country. The filing of grievances or adhering to the deadlines is region specific.

Customer Grievances in Insurance Industry

Health policies are bought by individuals with a view not only to secure their individual lives but also their family members. Health policy covers are availed to cover against any unforeseen risks in present or in future circumstances. Risks are ever-pervading in every corner and nook of human lives every moment, every second. To overcome these risks and lead a life of certainty free from financial constraints, individuals avail the health policy cover that suits their requirements.

Insurance companies are bound to honor legitimate claims within policy limits. In the same breath, it is essential to realize that insurance companies are not organizations meant for charity. The insurance companies cannot honor any claim, if it is not in accordance with agreed terms and conditions. It is also likely that a particular disease may be listed under the policy exclusion clause. But many a times, it has been noticed that claims are rejected by insurers on flimsy grounds. The reasons for rejections are difficult to enumerate here and beyond the scope of this article. Sometimes, however, the policyholder is also is also held responsible simply because he/she may have made false declarations at the time of availing the health policy. There are numerous instances wherein an individual does not read the fine print before buying a health policy cover.


Hence, it is not just sufficient by availing a policy cover. It is equally important to read the Terms and Conditions of the health-insurance product or service before purchasing it. Importance to fine-print must be given sufficient attention and must be not be neglected simply because that individual has no time to spare, is in a urgent hurry to fulfill the commitments for the day or feels bored or is uninterested in going through the fine-print or an account of laxity on the part of the individual. This is essential to curb any hassles or heartburns in the future. It helps in knowing as to how to file and what methods to be adopted, in case if something goes awry.

In order to deal with customer grievances and disputes pertaining to Health Insurance, the regulatory body in India called as IRDA (The Insurance Regulatory and Development Authority) has appointed 12 Ombudsmen across the country with well defined jurisdiction.

The Ombudsman may hold sitting at various places within their area of jurisdiction in order to expedite the process of Customer Grievances and/or Customer Disputes. The Ombudsman shall pass an award within a period of three months from the receipt of the complaint which is binding on the parties involved in the dispute. The awards are binding upon the insurance companies. In addition, the policy holder has the option of approaching consumer forums and court of law for redressal of his/her grievances, if he/she does not feel satisfied with the judgment passed by the Ombudsman.

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