corporate law
Insurance claims—including life insurance, health insurance, and general insurance—are frequently denied or inadequately compensated by insurance companies on technical grounds. As a result, policyholders often find themselves resorting to courts or consumer forums for resolution, a process that can be time-consuming, stressful, and financially burdensome. To address these challenges, the government established the Insurance Ombudsman, aimed at providing an efficient and cost-effective grievance resolution mechanism.
The Insurance Ombudsman serves as an alternative grievance redressal platform, specifically designed to resolve disputes involving policyholders, including those related to group and general insurance policies. This initiative enables the handling of complaints against insurance companies, their agents, and intermediaries in a manner that is both cost-effective and impartial. Currently, there are 17 Ombudsman Centres located across India in cities such as:
The Insurance Ombudsman is authorized to consider complaints arising from:
To initiate a complaint, the policyholder must submit a written request to the Insurance Ombudsman within whose jurisdiction the insurer's branch or the complainant’s residence is located. This action must be taken if the insurer has not resolved the claim satisfactorily or has not responded within 30 days. Notably, the Ombudsman’s jurisdiction is capped at claims valued up to Rs 30 lakhs.
The Ombudsman functions as a mediator, reviewing relevant facts and documents to reach a resolution. If the complainant accepts the Ombudsman’s recommendation, the insurance company must comply within 15 days. If the recommendation is not accepted, the Ombudsman issues a binding award within three months of receiving the necessary information. The insurance company is obligated to implement the award within 30 days and must inform the Ombudsman of compliance.
Should the complainant find the award unsatisfactory, they retain the right to approach a consumer court or a traditional court for further recourse. However, insurance companies cannot contest the Ombudsman’s decisions, which courts have upheld as non-violative of any rights held by the insurers.
In the case of Life Insurance Corporation Of India & Ors. vs. The Insurance Ombudsman & Ors (Writ Petition No. 2299 (W) of 2016), decided on September 15, 2017, the Calcutta High Court confirmed that:
“An award passed by an insurance ombudsman cannot be construed to violate any right of the insurance company. Therefore, it cannot approach a writ court as a party aggrieved by the award of the insurance ombudsman.”
Statistics indicate that a considerable number of cases resolved by the Insurance Ombudsman favor the insurance companies. The Ombudsmen are typically individuals with backgrounds in insurance, civil service, or administrative roles, which may limit their legal scrutiny. It is recommended that retired judges from District or High Courts be appointed as Ombudsmen to ensure complaints are adjudicated with legal precision.
In light of the existing challenges, many insured individuals remain unaware of the Insurance Ombudsman’s services. It is essential for the government to promote awareness and understanding of this grievance resolution alternative, thereby facilitating more effective settlements through the Insurance Ombudsman’s office.