Customer Care in Health Insurance Industry - Ombudsman

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Written by Dr. Sameer Sippy | Medically Reviewed by The Medindia Medical Review Team  on Sep 18, 2014
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Ombudsman

In 1999, an act was enacted in the Indian Parliament to specifically deal with the disputes arising in the Insurance industry called called as The Insurance Regulatory and Development Authority (IRDA) Act The mission of the IRDA is to protect the interests of the policyholders and to regulate, promote and ensure systematic growth of the insurance industry and otherrelated areas.

For a case to valid, no single individual can complain anything under the sun whatever he/she wishes. It is important to remember that Ombudsman do have limitations and complaint can be made only against the items prescribed in the notification.

List of 12 Ombudsmen in India

Region Address of the Ombudsman
Delhi, Rajasthan First Floor, Universal Insurance Building, Asaf Ali Road, New Delhi 110002
West Bengal, Bihar 29, N.S. Road, Kolkata
Maharashtra 101, Arun Chambers, Tardeo Main Road, Mumbai 400034
Tamil Nadu, Pondicherry Fatima Akhtar Court, Fourth Floor, 312 Anna Salai, Chennai 600018
Andhra Pradesh 6-2-47, Yeturu Towers, A.C. Guards Lakdi-Ka-Pool, Hyderabad 500004
Gujarat Second Floor, Shree Jayshree Ambica House, 5, Navyug College, Ashram Road, Ahmedabad 380014
Kerala, Karnataka Pulinat Building, Second Floor, M.G. Road, Kochi 682015
North-Eastern States Aquanus, Bhaskar Nagar, R.G. Baruah Road, Guwahati 781021
Uttar Pradesh Chintal House, First Floor, 16 Station Road, Lucknow 226001
Madhya Pradesh First Floor, 117 Zone 2, Maharana Pratap Nagar, Bhopal 462011
Punjab, Haryana, Himachal Pradesh, Jammu & Kashmir, Chandigarh 101-103, Batra Building, Sector 17D, Chandigarh
Orissa 62, Forest Park, Bhubaneswar -751009

Functions of Ombudsman

  • The main function of this Ombudsman are as follows:-
  • To specifically deal with the diputes arising out of Insurance cases
  • To dispose the grievances of policyholders in a swift manner
  • To minimize the problems involving redressal complaints
  • To help in generating and sustainance of goodwill, faith and confidence amongst the consumers and insurance companies.
  • To resolve the consumer disputes in an amicable manner which is binding on the involved parties concerned
  • To effectively tackle customer grievances in a time-bound framework

Filing a complaint

There is no prescribed format or a specified format for filing complaints. For an individual, it is required to give the complaint in writing stating and describing the facts along with relevant and sufficient documentary proof to substantiate the grievance of the claim.

Once the complaint is taken up it is not required that the complainant has to be present. Presence of the complainant is required only in the mediation stage wherein it would be mandatory for the aggrieved party to attend the hearing at the ombudsman’s office for presenting the complainant’s version of the case. Hiring a lawyer for the case to resolve the disputes arising out of claims rejection is a sheer waste of time, money and energy.

The process of filing a complaint is simple. Firstly, the complaint must be made in writing with the insurance company. In addition, complaint must be reported to the Ombudsman within a year of the repudiation of the claim by the concerned Insurance company. It must be noted that Ombudsman intervenes in the case only if the complainant has not approached any court or any Consumer Forum with regards to his matter. It must be remembered that the complaint with the ombudsman must be filed in that region only from where the health insurance policy was purchased. The complainant or any proxy on his behalf can file a complaint regarding the grievances or disputes.

Before approaching the Ombudsman, it is mandatory that the complainant should have made a prior representation to the insurance company and received a reply which may be unsatisfactory in its contents or there is absence of reply for a period that exceeds 30 days (a month).

It should be borne in mind that the aggrieved party should not have approached any other social forum or any community gathering in order for his complaint to be eligible by the Ombudsman.

References:

  1. Customer Satisfaction in 7 Steps - (http://articles.sitepoint.com/article/satisfaction-7-steps)
  2. Have an insurance complaint? Read this - (http://www.rediff.com/money/2004/mar/22perfin.htm)

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After purchasing and continuing a reliance medical policy for last 3 yrs,when we went for a claim they denied it on baseless ground,I warn everybody before buying any products of them.Asis Pal[frm Panipat]

jillsj

MY NAME IS SAM THOMAS, I BUY A MEDI CLEAM POLICY FROM ROYAL SUNDERAM , POLICY NO IS "HQM-000140000100, STLL 5 MONTHS NOW, I DID'T GET ANY PAPPER AND ANY CARD FROM THIS COMPANY
THIS IS THE RULES AND REGULATION FROM THE COMPany

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