INSURANCE OMBUDSMAN

INTRODUCTION
The mechanism of Insurance Ombudsman is one for
Grievance Redressal
Other than the In-house Grievance Redressal Cell
Ombudsman system provides an impartial institution for
speedy disposal of grievances of the Customers/Insured.
Institution of Insurance Ombudsman was created by a Govt.
of India Notification dated 11
th
Nov. 1998, under which rules
were framed
Redressal of Public Grievance Rules 1998 (RPG Rules)
OBJECT
To resolve all complaints relating to settlement of
claims on the part of the insurance companies in
cost effective, impartial and effective and efficient
manner.
For quick disposal of the grievances of the
Insured customers and to mitigate their problems
involved in the redressal of those grievances.
GBIC
Insurance Ombudsman appointed by Governing
Body of the Insurance Council (GBIC).

The Governing Body of Insurance Council consists of
representatives of the insurance companies.
(Representative means Chairman, MD or CEOs of the
companies).
OMBUDSMAN
The Governing body has appointed 12 (twelve) Ombudsman
across the country allotting them different geographical areas
as their areas of jurisdiction: Bhopal, Bhubaneswar, Cochin,
Guwahati, Chandigarh, New Delhi, Chennai, Kolkata,
Ahmedabad, Lucknow, Mumbai, Hyderabad.
Has 2 types of function:
Conciliation
Award Making
GROUNDS OF COMPLAINT
Empowered to receive and consider complaints in respect of
personal line of insurance from any person who has grievance
against Insurance complaints on the following grounds
Any partial or total repudiation of claim;
Dispute regarding premium payable or paid in favour of
the policy;
Dispute on the legal construction of the policies, so far as
dispute relates to a claim & also the delay in settlement of
claims;
delay in settlement of claims
non-issue of any insurance document to customers after
receipt of premium
PRE-CONDITION TO COMPLAINT TO
OMBUDSMAN
Written representation made to the Insurer
before making the complaint -(either insurer has
rejected or no reply received)
The complaint is not made not later than one
year after the insurer had rejected the
representation or the complainant is not satisfied
with the reply of the insurer.
The complaint is not on the same subject matter
for which any proceedings before any forum is
pending.
RECOMMENDATIONS
If complaint is settled through mediation of the
ombudsman, he shall make a recommendation
which he thinks fair in the circumstances;
Recommendation within than one month from the
date of receipt of the complaint;
Complaint to accept the recommendation within 15
days from the date of receipt of communication;
Insurer to comply with the recommendation within
15 days of receipt of such recommendations and
inform the ombudsman of its compliance.
AWARD
Where mediation fails or not settled in terms
of agreement, the Ombudsman shall pass a
speaking award with detailed reasoning
Award within a period of 3 months from the
receipt of complaint
Award shall be in writing and shall state the
amount awarded
Cannot be more than Rs. 20 lakhs
Can award ex-gratia payment
COMPLIANCE OF AWARD
Letter of acceptance to be furnished by the
complainant to the insurer within 30 days from the
date of receipt of the award
Insurer to comply with the award within 15 days
and intimate compliance to the Ombudsman
If the complainant does not intimate the
acceptance, the award may not be implemented by
the insurance companies.
APPEAL
There is no provision under the RPG Rule to
file appeal.
However, where ever there are errors
apparent, on the face of record & there is
gross irregularity observed, writ Jurisdiction
under Article 226 & 227 of the Constitution
can be invoked, by filing Writ in appropriate
High Court having jurisdiction.
SELF CONTAINED NOTE (SCN)
A self contained note (SCN) is required to be
submitted by the Insurer detailing the stand of the
company in the complaint.
SCN should be submitted well in time before the
date of hearing.
SCN should give policy details. Premium payment
history and Insurers decision based on evidences
Facts in SCN should be consistent with repudiation
letter or decision of Insurer intimated earlier
MAIN AREAS OF COMPLAINTS
MEDICLAIM,
MOTOR,
FIRE
PA, JPA
Mediclaim constitutes 75% of the total
complaints, followed by Motor.
THANK YOU
HO Tech-Legal Deptt