How to file complaint against Health Insurer
There are situations when you are not satisfied with the services offered by your insurer. In that case, you can approach the IRDA for a resolution. There are different ways to approach the insurance regulator for scaling the issue.
The Insurance Regulatory and Development Authority of India has laid down the turnaround time for various services offered by the insurance providers to the insured as per the IRDA Protection of Policyholder’s Interest Regulations, 2002. The maximum turnaround time set for the life insurance companies and generic companies is based on the service or grievance redressal provided by the company.
In case, the insurance provider does not provide insurance services or resolve the grievance within the stipulated time, then the policyholder is free to approach IRDA for a resolution. The complaint can be escalated and IRDA will resolve the dispute with the insurance provider. The policyholder can also approach the Consumer Court or Consumer Forum in case adjudication and/ or inquiry is required for the same, the policyholder will have to approach the Consumer Court or Consumer Forum.
The procedure to complain to Health insurer are as follows:
- Before filing a complaint against any health insurance provider, the policyholder must approach the grievance Redressal office of the branch of the respective insurance provider. The complaint must be in writing along with the attaching associated documents.
- After you file a complaint a written acknowledgment will be given to the complainant along with mentioning the date of submission.
- Generally, the insurance provider must resolve the grievance within 15 days. In case this does not happen, the issue can be escalated to the IRDA.
- For doing a complaint against a health insurance provider with the IRDA, the policyholder must get in touch with the Grievance Redressal Cell of the Consumer Affairs Department of IRDA either via mail or customer care helpline number.
- Once a complaint is lodged, with the help of the Integrated Grievance Management System, a policyholder can monitor your complaint and its progress. The policyholder can also contact the Insurance Regulatory and Development Authority by writing a letter or sending a fax.
The maximum TAT (Turn Around Time) on complaints/ requests/ grievances related to some of the services offered by health insurance companies are as follow:
| Service rendered | Maximum Turnaround Time |
Processing the proposal, issue of policy, or cancellation of policy.
| 15 Days
|
Obtaining a copy of the policy proposal.
| 30 Days
|
Service requests for errors or refund or NCB (No Claim Bonus) related service requests
| 10 Days
|
Related to annuity, surrender value
| 10 Days
|
Survival Benefit, Maturity Claim or penal interest not paid.
| 15 Days
|
Raising claim requirements after registering a complaint.
| 15 Days
|
Death claim settlement without investigation requirement.
| 30 Days
|
Death Claim repudiation or settlement with investigation requirement
| 06 Months
|
Acknowledging a grievance
| 03 days
|
Resolving a grievance
| 03 days
|
Main channels for lodging a complaint
These are the main channels for lodging a complaint - the Insurance Ombudsman, the Integrated Grievance Management System, and the Consumer Court. These are explained below:
Insurance Ombudsman:
You can take the assistance of the Insurance Ombudsman to escalate an issue for which there is no resolution. A complaint can be filed with the insurance ombudsman under the following conditions:
- When your insurance claim was partially rejected.
- When you have not received your policy even after making payment of premium.
- Any kind of delay in making a claim settlement.
- Any dispute regarding premium payable or paid.
- Any dispute regarding the terms or conditions specified under the policy schedule.
Integrated Management System
IRDA has come up with the Integrated Grievance Management system i.e. an online platform where the policyholders who are having any dispute or grievance with the insurance provider can escalate the same. You can also register a complaint as well as track the complaint status using the integrated management system.
This grievance redressal and monitoring tools help the IRDA to provide centralized access to the policyholder and to classify complaints based on predefined norms.
Under this system, complainants and departments for resolution are assigned with a unique complaint ID. It helps in monitoring the market conduct issues as well. A TAT is also set for the complaints registered and set up alerts’ facility is also there for all the pending tasks to ensure efficient complaint resolution with rule-based workflows and detailed reports.
Consumer Court
If the complaint is not resolved by the Integrated management system or insurance ombudsman, then a policyholder is free to register a complaint with the consumer court. It has a separate department to handle health insurance grievances, especially those arising out of Unfair Trade Practice/ malpractice/ service issues.
