Insurance claim rejected: two drafts and the route to the Ombudsman
Banthry Prep. General information, not legal advice. Fill the blanks and remove what does not apply. References are to the Insurance
Ombudsman Rules, 2017 as amended up to 9 November 2023 (the Rules).
The route
| Step | What | Where it comes from |
|---|---|---|
| 1 | Written complaint (a "representation") to the insurer, by letter, email or the insurer's website. Keep the acknowledgement or complaint number | Rule 14(3)(a) |
| 2 | IRDAI's Bima Bharosa portal (bimabharosa.irdai.gov.in), toll-free 155255 or 1800 4254 732, complaints@irdai.gov.in. The portal says a complaint "will be attended to within 14 days" | IRDAI Bima Bharosa site |
| 3 | Insurance Ombudsman, if the insurer rejected your representation, did not reply within one month, or replied and you are not satisfied | Rule 14(3)(a) |
Ombudsman time limit. Within one year of receiving the insurer's order rejecting your representation (or its unsatisfactory
decision), or within one year after one month has passed from sending the representation with no reply (rule 14(3)(b)). The Ombudsman
may condone delay after hearing the insurer (rule 14(4)).
Do not go to court first if you want the Ombudsman. No Ombudsman complaint is maintainable on the same subject matter if
proceedings are pending before, or have been decided by, a court, consumer forum or arbitrator (rule 14(5)).
Fees. The Council for Insurance Ombudsmen says the Ombudsman does not charge any fee. File online at cioins.co.in.
What the Ombudsman can award. Compensation up to the loss suffered, and not more than Rs 50 lakh including relevant expenses
(rule 17(3); raised from Rs 30 lakh by notification of 9 November 2023). The award is passed within three months of receiving all
requirements from you (rule 17(4)); the insurer must comply within 30 days of receiving it (rule 17(6)). The award is binding on the
insurer (rule 17(8)).
Keep: policy document and schedule, claim form, all bills and reports, the rejection letter, every email, and each complaint
number with its date.
Draft 1: Representation to the insurer (rule 14(3)(a))
To: [Insurer's grievance email / grievance cell address, from the policy document or the insurer's website]
Subject: Representation against rejection of claim no. [ ] under policy no. [ ]
- I hold policy no. [ ], [type: health / motor / life / other], valid from [ ] to [ ]. Policyholder: [name]; insured person: [name].
- I made claim no. [ ] on [date] for Rs [amount], for [hospitalisation from [ ] to [ ] at [hospital] / accident on [ ] / other].
- By letter / email dated [ ], the claim was [rejected / partly settled at Rs [ ]] on the ground that [quote the reason given].
- This decision is not correct because: [explain briefly and specifically, with the policy clause and page number, and the documents that show it; for example: the condition was disclosed in the proposal form dated [ ]; the exclusion applies only to [ ]; the waiting period ended on [ ]].
- Please review the claim and pay Rs [amount], or give me a written reasoned decision. Please acknowledge this representation and give me a complaint reference number.
Attached: policy schedule; claim form; bills and discharge summary / reports; rejection letter; [other].
[Name], [Address], [Phone], [Email], [Date]
Draft 2: Complaint to the Insurance Ombudsman (rule 14), outline
File online at cioins.co.in or with the Ombudsman office for your area. The online form asks for most of these details.
To: The Insurance Ombudsman, [office]
- Complainant: [name, address, phone, email]. Insurer: [name, branch / office address].
- Policy no. [ ]; type [ ]; period [ ]. Claim no. [ ]; amount claimed Rs [ ].
- Representation to the insurer: sent on [date] by [email / letter / website], reference no. [ ].
- Insurer's response: [rejected on [date] / no reply within one month of [date] / reply dated [ ] which is not satisfactory].
- This complaint is filed within one year of [that rejection / the expiry of one month], under rule 14(3)(b).
- The same matter is not pending before, and has not been decided by, any court, consumer forum or arbitrator (rule 14(5)).
- Grounds: [why the rejection is wrong, clause by clause].
- Relief sought: payment of Rs [ ] with interest as applicable, [and expenses], within the limits of rule 17(3).
Attached: everything in Draft 1, plus the representation, the insurer's reply (if any) and proof of sending.
[Name], [Signature], [Date]
Sources: Insurance Ombudsman Rules, 2017, rules 14 and 17, as amended by G.S.R. 147(E) (2 March 2021), G.S.R. 334(E) (18 May 2021) and
G.S.R. 828(E) (9 November 2023); IRDAI Bima Bharosa portal; Council for Insurance Ombudsmen website.
Banthry Prep · banthry.in · General information, not legal advice.