What to do if your claim is Repudiated or Rejected

• Get the denial in a written letter from the insurance company and reasons there of.
• Examine the copies of documents submitted by you in support of your claim,
• Check your policy and ensure that your claim is denied legitimately, IF NOT
• Contact your insurance broker or insurance company’s branch office from where you have taken the policy, talk to them, clear your doubts and complain about your grievances and ask for a review of the case.
• If that fails, file a formal written complaint with the insurance company’s grievance cell  attaching copies of the following supportive documents:
  1. Your Policy,
  2. Letter rejecting the claim,
  3. Bills and other documents submitted by you in support of your claim
  4. All correspondences between you and your insurance company, TPAs, Surveyors, etc.
  5. Claim form
  6. Any other documents

Grievance cell of each company is requirement as per regulation and would be prominently displayed on their promotional material as well as website.

Wait for 30 days before which you should be getting a reply form the insurance company.  If not or the reply received is not satisfactory, you can approach the insurance ombudsman.

The Insurance Ombudsman scheme was created by Government of India for individual policyholders to have their complaints settled out of the courts system in a cost-effective, efficient and impartial way.

There are 12 Insurance Ombudsman in different locations and you can approach the one having jurisdiction over the location of the insurance company office that you have a complaint against

You can approach the Ombudsman with complaint if:

• You have first approached your insurance company with the complaint and
  • They have not resolved it
  • Not resolved it to your satisfaction or
  • Not responded to it at all for 30 days
• Your complaint pertains to any policy you have taken in your capacity as an individual and
• The value of the claim including expenses claimed is not above Rs 20 lakh

Your complaint to the Ombudsman can be about:

• Any partial or total repudiation of claims by an insurer
• Any dispute about premium paid or payable in terms of the policy
• Any dispute on the legal construction of the policies as far as it relates to claims
• Delay in settlement of claims
• Non-issue of any insurance document to you after you pay your premium

The settlement process

Recommendation:

The Ombudsman will act as counselor and mediator and

• Arrive at a fair recommendation based on the facts of the dispute
• If you accept this as a full and final settlement, the Ombudsman will
• Inform the company which should comply with the terms in 15 days

Award:

• If a settlement by recommendation does not work, the Ombudsman will:
• Pass an award within 3 months of receiving the complaint and which will be
  • A speaking award with the detailed reasoning
  • Binding on the insurance company but
  • Not binding on the policyholder
• The Ombudsman can also award an ex-gratia payment

Once the Award is passed

• You have to accept the award in writing and the insurance company has to be informed of it within 30 days and
• The Insurance company has to comply with the award in 15 days after that

DON’T FORGET TO KEEP COPIES OF ALL THE DOCUMENTS SUBMITTED AT THE ABOVE DIFERENT LEVELS.