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Consumer Guidance Seminar on Medical Insurance, Part 5: Complaints Handling by Ombudsman

Part 5 of 5: Complaints Handling by Ombudsman

Ms. Sudha Ramanujam, Deputy Secretary, Office of the Insurance Ombudsman, Chennai spoke next, sharing valuable tips on how to improve relations between the insured and the insurer and how to make the claims-handling process better. She clarified the role of the Insurance Ombudsman in this regard. She said many in the public thought it was just another insurance company.

She clarified that consumers did not need to pay any fees for its services, no advocate was needed, and that consumers could directly approach and give their insurance-related complaint to the Ombudsman. Anyone with a grievance could send a legal representative to the office and submit their complaint in writing together with supporting documents.

Firstly, consumers must try to solve their issues through the grievance cell of the regional office of their insurance company. If only still dissatisfied with the outcome, could they can approach the Ombudsman and this, within 1 year of the response from the insurer’s grievance cell. The Insurance Ombudsman is a quasi-judicial body with the powers of a district magistrate and authorized to provide financial relief upto Rs. 20 lakhs. If still not satisfied here, consumers can go to court or other forums.

The Ombudsman can accept only certain common complaints such as partial claims reimbursement, claims rejection, delays and ambiguities in policy interpretation. Recently, many cases of misselling by agents were also being investigated here.

Advice from Smt. Ramanujam

  1. Read the Terms & Conditions of policy clearly when you enrol.  Ask specifically for the Terms and Conditions document from the insurer.
  2. Cross-check with the IRDA website. See the T & C document for this policy plan and verify if benefits listed there tally with what was sold (to avoid misselling by the insurer). The proposal form must be filled by you only, not by the agent. Do not just sign without reading through the document. 
  3. Health insurance is an annual policy. When you enrol/renew, disclose all pre-existing diseases you have so that you can avoid claims rejection later. Do not conceal any medical condition you have existing, no matter what the agent says.
  4. If we follow all portability procedures clearly, then your new policy continues smoothly with the new company as before. Verify your ported policy and make sure that it is not a new one (because agents do not get any commission in portability so they may fill in a fresh new policy again just for the sake of commission).
  5. Get everything in writing and get a clear written acknowledgement. Record clearly whatever documents you have given to the insurer.
  6. Be very careful in remembering whatever information that you have given to the agent.

Response from Smt. Ramanujan to Q & A

  1. When you put your signature in the policy document, you are deemed to have accepted all the conditions specified within the policy document.
  2. One person from the audience said consumers who are illiterate or just with a high-school level education are unable to understand many parts of the documents and are confused whom to approach for help. She clarified that they can approach her office as well.

Conclusion of the Seminar

Smt. Saroja now summarized the proceedings of this seminar. She questioned all attendees on how useful the seminar had been. The response was that they had learnt about various ways of grievance redressal and about the importance of having health insurance today. She said that having a basic health insurance is the key take-away message. She added that no one there had argued whether we need health insurance at all! A senior lady in the audience commented that she got more mental courage from having a medical insurance. Ms. Saroja finally gave a sincere vote of thanks to the chief guest Mr. L. Singaram, speakers Dr. Jai Kishen Avula, Ms. Usha V. Girish, Mr. Sameer Mehta, Ms. Sudha Ramanujam, coordinator Dr. Arjun Rajagopalan, CAG team members, all organizers, students and all the audience for participating and making the seminar a success.

Video link available here:

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