Page 236 - Ebook health insurance IC27

The Insurance Times

in claimed amounts are usually due to deficiency of supporting documents, or for
expenses not covered by the policy. In case of the former case, the claim may be
reconsidered if the relevant documents can be made available.

Repudiation of claims can be prevented if the scope of coverage, co-payments,
sub-limits and exclusions applicable are carefully read and understood. In case of
repudiation of claim, the insurer should send a letter clearly stating the reason for
repudiation. In case the insured is not satisfied, he/she can represent the same to
the insurer. Grievances not resolved by the insurers within one month can be
taken up with the Insurance Ombudsman.

Q4. Write a note on Grievance redressal in health insurance.
Ans. Policyholders should be provided with inexpensive and speedy mechanism for

complaints resolutions. As per Regulation 5 of IRDA Protection of Policyholders
Interests regulations, 2002, every insurer should have a proper redressal system
in place to address the customer complaints.

Over and above this , one can approach the Insurance Ombudsman for complaints
related to personal insurance, up to a limit of Rs.20 lacs. The other available
channels are Consumer Courts and Civil Courts. The IRDA too has a Grievance
Redressal Cell, which plays a facilitative role by taking up complaints against
insurers for speedy resolution.

When a policyholder has a complaint, he/she must approach the Grievance
Redressal Cell of IRDA, which will then take up the matter with the concerned
company for re-examination. Only the cases of delay/no-response are taken up
by the Cell for speedy disposal. If the complainant is looking for adjudication in
respect of claims, he/she may approach the Insurance Ombudsman.

240 Guide for Health Insurance