Page 227 - Ebook health insurance IC27

Sashi Publications

 If later on insured can arrange for the documents insurer can make the payment.
 While repudiating the claim the insurer must list out the reasons for rejecting the

claim or payment of reduced amount. If the customer can be taken into confidence
the chances of further dispute is reduced.
 If the customer is not satisfied he can approach Insurance Ombudsman for Redressal.

Grievance Redressal

Every insurer shall have in place proper procedures and effective mechanism to
address complaints and grievances of policyholders efficiently and with speed and
the same alongwith the information in respect of Insurance Ombudsman shall be
communicated to the policyholder along-with the policy document and as maybe
found necessary.

Procedure of making complaint/authorities for entertaining complaint
1. If a customer is not satisfied with the rejection of claim he can first approach grievance

or consumer complaints cell the insurer.
2. In the event of no response he may go to Grievance Redressal cell of IRDA which

will then take up the matter with the concerned insurance company. Only the matters
relating to delay or nonresponse regarding matters relating to policies and claims
can be taken up by the grievance cell.
3. For Rejection of claim or any other matter the policyholder may approach
Insurance Ombudsman set up under the Redressal of Public Grievance rules.
This is a cheap and cost effective way to make a complaint directly by the
policyholder and legal help is required. The ombudsman passes judgment in a
time bound manner. The ombudsman can take-up claims upto Rs.20 lakhs
4. If the policyholder is not satisfied with the order of the ombudsman he may approach
civil courts for Redressal.

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