Claim refusal is a nightmare. Especially when it seems insurer is refusing it arbitrarily. In our recent post, we thoroughly discussed this topic ‘What to do if insurance claim is denied?‘ Actually, as an insurance advisor, I tried to make a roadmap for you that you can follow. After reading that post, your all doubts will be cleared. I strongly recommend you read that post. Today, in this post, I will walk you through how to file a complaint against health insurance company in India.
If you have faced an insurance claim refusal and you think your claim is valid then this is what you’re supposed to do to get your claim be honored.
Note: This post is not limited to health insurance companies, it is applicable to all other insurance companies.
How to file a complaint against health insurance company in India
Before you straight jump in and file a complaint against health insurance company, I would like to mention that if you already know that your claim is invalid or your policy does not cover the cause of loss then do not waste your precious time and energy because in the end of the day all efforts will go in vain.
On the contrary, if you know your claim is valid and your policy documents clearly mention that cause of loss/damage/injury is covered then keep your chin up, we’re not lost yet.
This process will take time but result will be fruitful.
Now let us know how to file complaint against insurance company in India if it denies your claim unreasonably.
Does my policy cover the cause?
This is the first and most important thing you are supposed to do before you file a complaint against your insurer. Do your homework. Grab your policy documents and read inclusions and exclusions.
If the cause of the injury/illness is not covered then your journey ends here. There is no hope in filing a complaint against insurance company.
I’m not demoralizing you but helping you face the reality which will eventually save your and other’s valuable time.
Not able to understand policy wordings? Call your insurance agent and take his help.
Now, if the event of loss/injury/illness is covered then get ready to teach a bitter lesson to your insurance company.
Where you can file a complaint against insurance company in India
- Register complaint with grievance redressal officer of the insurance company
- Escalate the matter to IRDAI (Insurance Regulatory and Development Authority of India)
- Approach the insurance ombudsman within 12 months
- Approach court (consumer or civil)
Important: Avoid verbal tussles with the insurance company, nothing will come out of it. Just follow the standard protocol and gather proofs (bills, acknowledgement slips and the like).
Approach grievance cell of the company
Once you’re assured that your claim is valid and according to the terms and conditions insurer should pay you claim, visit your insurance company’s nearest office and submit a written complaint and take written acknowledgement from the concerned officer (date must be mentioned on it).
Submit your complaint with supporting documents, highlight the cause if it’s mentioned on your policy documents.
After submitting the complaint, your insurance company will need to resolve your complaint within specified time (15 days in most of the cases).
In case you’re not satisfied with the resolution offered by your insurer then head to next authority.
Insurance Regulatory and Development Authority of India is the authority who protects interests of policyholders and helps them get their claim settled.
Policyholders can approach IRDA consumer grievance redressal cell if they are disappointed with the settlement offered by their insurers.
Policyholder can call to IRDA customer care number to register a complaint against health insurance company –
Alternatively they can also call to 155255.
A written complaint with supporting documents can also be sent to IRDA customer care email address firstname.lastname@example.org.
Similarly, complaint can be also be lodged by visiting https://igms.irda.gov.in/ website.
To send written complaint via post, download IRDA complaint form. Fill in the details, attach supporting documents and send it to mentioned address.
General Manager Insurance Regulatory and Development Authority of India(IRDAI) Consumer Affairs Department – Grievance Redressal Cell. Sy.No.115/1, Financial District, Nanakramguda, Gachibowli, Hyderabad – 500 032.
Note: Verify the address. It will also be mentioned on the form.
Register your complaint with insurance ombudsman
There are 17 insurance ombudsman across the country appointed by IRDAI who work to protect interests of policy holders. Ombudsmen are usually from Insurance Industry, Judicial Services and Civil Services.
Ombudsmen perform two functions: conciliation and award making. After hearing the dispute, he can settle the claim with mutual consent or he can pass appropriate reward. Insurers are obliged to honor the decision made by Ombudsman but policy holders are not.
Insurance disputes for up to 20 Lakhs can be registered with Insurance Ombudsman.
On your policy documents, you can find more details or you can visit IRDA official website.
Register complaint against insurance company in consumer court or civil court
After all efforts go in vain but you still know your insurance claim is valid then this should be your last stop. It is very time consuming, it may take years.
You can bring your insurance dispute to the consumer court or civil court. To lodge complaint against insurance company in consumer court you don’t need help of an lawyer (if you wish you can take help of him).
After hearing the both sides, a right decision will be made by honorable court.
Insurance marketplace in the country is evolving very rapidly which directly increasing competition. Therefore, nowadays insurers refrain from denying claim requests unreasonably. As mentioned in the very beginning if you’re sure that your claim should not be denied then go head; otherwise, don’t waste your and others precious time, I repeat, nothing will come out of it.