Ministry Notification

14. Ombudsman to act fairly and equitably:

(i) The Ombudsman may, if he deems fit, adopt a procedure other than mentioned in sub-rule (1) and (2) of Rule 13 for dealing with a claim, Provided that the Ombudsman may ask the parties for necessary papers in support of their respective claims and where he considers necessary, he may collect factual information available with the insurance company.

(ii) The Ombudsman shall dispose of a complaint fairly and equitably.

15. Recommendations made by the Ombudsman:

(i) When a complaint is settled, through mediation of the Ombudsman, undertaken by him, in pursuance of request made in writing by complainant and insurer through mutual agreement, the Ombudsman shall make a recommendation which he thinks fair in the circumstances of the case. The copies of the recommendation shall be sent to the complainant and the insurance company concerned. Such recommendation shall be made, not later than one month from the date of the receipt of the complaint.

(ii) If a complainant accepts the recommendation of the Ombudsman, he will send a communication in writing, within 15 days of the date of receipt of the recommendation. He will confirm his acceptance to the Ombudsman and state clearly that the settlement reached is acceptable to him, totally, in terms of recommendations made by the Ombudsman in full and final settlement of the complaint.

(iii) The Ombudsman shall send to the insurance company, a copy of the recommendation along with the acceptance letter received from the complainant. The insurer shall thereupon comply with the terms of the recommendations not later than 15 days of the receipt of such recommendation, and the insurer shall inform the Ombudsman of its compliance.

16. Award:

(i) Where the complaint is not settled by agreement under Rule 15, the Ombudsman shall pass an award which he thinks fair in the facts and circumstances of a claim.

(ii) An award shall be in writing and shall state the amount awarded to the complainant, Provided that Ombudsman shall not award any compensation in excess of what is necessary, to cover the loss suffered by the complainant as a direct consequence of the insured peril, or for an amount not exceeding rupees twenty lakhs (including ex-gratia and other expenses), whichever is lower.

(iii) The Ombudsman shall pass an award within a period of three months from the receipt of the complaint.

(iv) A copy of the award shall be sent to the complainant and the insurer named in the complaint.

(v) The complainant shall furnish to the insurer, within a period of one month from the date of receipt of the award, a letter of acceptance that the award is in full and final settlement of his claim.

(vi) The insurer shall comply with the award within 15 days of the receipt of the acceptance letter under sub-rule (5) and it shall intimate the compliance to the Ombudsman.

17. Consequences of non-acceptance of award:

If the complainant does not intimate the acceptance under sub-rule (5) of rule 16, the award may not be implemented by the insurance company.

Post a Comment

Comments should be on the topic and should not be abusive. The editorial team reserves the right to review and moderate the comments posted on the site.

@Guest

Dear Sir/Madam Mera name Neeta Parmar hai or me Bhaynder,-east Mumbai, Maharastra me raheti hu mene mari Daughter ko fever tha or use ko lekar me Dr. Priya clinic me gai thi or unhone muje unke husbund jinka bada hospital hai [SAI GANGA HOSPITAL] vaha muje meri ladki ke sath bheja jab me vaha gai to Doctor ne meri ladki ka check up karne ke bad puchha ki aap ka mediclaim hai to me ne kaha ha hai or unhone meri ladki ko admit kar diya, usko 2/7/17 se leke 7/5/17 tak hospitalize rakha or 43000/- ka bill banaya jo mene vo paise mere gahene girvi rakh ke cash Doctor ko de diye. Usake bad jab mene mediclaim ke liye Jo paper Doctor ne diye the vo Paper mene Apollo Munich Health Insurance Company me diye, to company ne mera claim Doctor ki galti batake reject kar diya

Reply | Forward

shivdutt

Dear Sir,
Since year 2004, I and my wife have a med claim insurance policy of United India Insurance Company for Rs. 1,50,000/- each of us [Totaling Rs. 3,00,000/-].
In year 2012, I suffered a heart attack and availed med claim benefit. Thereafter, I felt that the insurance sum of Rs. 1, 50,000/- each which seemed to be adequate in year 2004 is now insufficient to cover present day expenses owing to market inflation.
Thus at each subsequent renewal, I am requesting local office of United India Insurance Co. for increasing the sum insured. But I am being refused for increase in sum insured because I have suffered heart attack in 2012.
Besides, my wife is also denied revision in sum insured because she had availed med claim for a gyno myomectomy surgical procedure in 2011.
I would, please, like to know â€“
- After having availed couple of med claim benefits in these years, Canâ€™t we revise the decades old sum insured for our continued med claim policy now?
- If yes, how to do it?
- If canâ€™t, would like to know regarding appropriate rules in this regard.
- Shiv dutt chadha

ATULM

I filed my complain against UNITED INDIA INSURANCE CO.LTD IN MUMBAI OMBDUSMANS OFFICE IN AUGUST-2012 CASE NO.OF THE SAME IS 953.NOW THEY ARE TELLING ME THAT,THERE IS NO OMBDUSMAN APPOINTED and CASES FROM DEC/2011 ARE PENDING I AM UNABLE TO UNDDERSTAND WHAT IS HAPPNING? WHEN LL IT BE APPOINTED,TO WHOME SHOULD I CONTACT REGA .THIS

mpoovali

i had taken a health insurance policy from, Medical check up was conducted and they informed me that I have complaint of Diabetic and so any claim related to that will be disallowed. I never had diabetic problem and I took another test to confirm this, my sugar level was found 98. I am requesting star health to provide me a copy of their report which they are refusing- what should I do?

jaina

Dear sir, My self and my wife has mediclaim policy from future generalii No.2011-H0023996-FHI.

My wife was ill and got hospitalised in Adinath Hospital, Indirapuram on 02.09.2011 as a case of dengue fever.

Hospital send request for cashless which was refused by Insurance compony on baseless ground and ask for rembursment.

My wife remain admitted till 07.09.2011 and Hospital raised a bill of Rs. 33752/-

Insurance person visited the hospital and varified the presence of pateint in Hospital.

Initially insurance compony was not resonding for claim and when ever contacted gives the answer that claim is under process but when complaint was registered with IRDA

Insurance compony rejected the claim on the following grounds;

1. Pt. has given a wronge residential address - How a residential address can be cause for no claim even when Pateint presence in hospital was confirm=
ed by insurance compony and all corospondance even renewal of policy was with same address.

2. My self is a doctor and director of the Adinath Hospital - how does being my self doctor and director of treating hospital leads to no claim for insura=
nce compony.

Insurance compony representative repeatedly visit the address and harash my wife and her sister in law once they was alone in the house.

Now you are requested to see the matter and ask insurance compony to pay the claim with intrest and panalty for harashment.

Thanks with regard

Jain