The Role Of Insurance Ombudsman

Updated: Sep 5 2004, 05:36am hrs
The Redressal of Public Grievances Rules, 1998 have been framed in order to facilitate speedy redressal of grievances. The Insurance Ombudsman is appointed under these Rules. Let us now take a look at these Rules, the procedure for filing complaints before the Insurance Ombudsman, the pros and cons thereof, and what the ground realities and limitations are.

Redressal Of Public Grievances Rules

These rules are framed for speedy and simple redressal of grievances without much cost or delay. The Rules provide that certain disputes can be decided by The Insurance Ombudsman who is appointed under these rules.

Nature Of Disputes Which Can Be Taken Before The Ombudsman

The Insurance Ombudsman can entertain only those disputes which are filed by an individual or his legal heirs, and that too if the claim is upto Rs 20 lakh. Commercial disputes cannot be brought before the Ombudsman. The individual disputes can be in respect of :

(a) partial or total repudiation of any claim under an insurance policy;

(b) the amount of premium paid or payable for a policy;

(c) the legal construction and interpretation of a policy for considering a claim under the policy;

(d) delay in settlement of claims;

(e) non-issuance of a policy after receipt of premium.

Procedure For Filing Complaints

Prior to approaching the Ombudsman, the insured is required to make a representation to insurance company regarding his grievance. The insurance company has a months time to reply to the same. If the representation is rejected either totally or partially, or if no reply is received within a month, the insured can approach the Ombudsman.

A complaint to the Ombudsman is to be filed within one year from the date of final rejection of the claim. Supporting documents must be annexed to the complaint.

On receipt of the complaint, it is scrutinised. If it is in order, a proforma is sent and the complainant is required to submit his complaint as per the proforma. The Ombudsman has the authority to collect all factual information that he may deem necessary for deciding the dispute. There is no formal procedure to be followed. The only requirement is that the dispute should be disposed of in a fair and equitable manner.

The complainant and his representative and the insurance companys officials are afforded an opportunity to be heard. This is termed as a deposition and a summary of the same is transcribed and typed out.

Later the Ombudsman considers the rival contentions and makes an Award which he thinks is fair in the facts and circumstances of the case. The Ombudsman, if he considers it fit, has the power to award ex-gratia payment.

This award is to be sent to the complainant as well as to the insurance company. The complainant has one month's time to consider whether to accept the award or not. If the complainant is satisfied and willing to accept the order, he must communicate his acceptance to the insurance company within one month. The insurance company has to comply with the order with 15 days thereafter. In case the complainant does not communicate the acceptance of the order, then the insurance company may not implement the award. The complainant would then be entitled to take recourse to any other legal remedy which may be available to him.

Thus, while the award is binding upon the insurance company, the complainant has to option to choose whether or not to accept the award.

Where Can A Complaint Be Filed

There are several offices of the Insurance Ombudsman. The territorial jurisdiction depends on the location of the branch of the insurance company against which the complaint is being filed. As far as we are concerned, the Office of the Insurance Ombudsman for Maharashtra & Goa is located at Jeevan Seva Annexe, 3rd floor, S.V. Road, Santacruz (West), Mumbai 400054.

Time-bound Procedure And Ground Realities

The Ombudsman is required to dispose of complaints within three months from the date of receipt of the complaint. But this is practically not feasible due to tardy implementation. Let us consider the office of the Insurance Ombudsman for Maharashtra & Goa. Firstly, the posh looking office is shared between the Insurance Council and the Ombudsman. The infrastructure is miserably lacking.

The Ombudsman has two senior officials from Life Insurance Corporation to assist with life insurance complaints. Similarly there are two senior officials from the General Insurance sector for dealing with general insurance complaints. There is no other back-up staff. These officials have to do all the work, right from filing, to record keeping, research and assisting the Ombudsman during the hearing. They are supposed to be on a two year deputation, but there are instances when the deputation period is long over but these officials are not transferred back to their parent company. Consequently there is a feeling of stagnation and frustration.

There are just two stenographers who have to attend to all the work, including preparing and despatching of notices. Secondly, the office of the Insurance Ombudsman remained vacant for a considerable period of time and cases have piled up. As of date approximately 1,000 cases are pending before the Insurance Ombudsman and it takes 1 - 2 years for a complaint to be decided. It is learnt that the approximate inflow is 15-20 complaints per day while the disposal rate is about 5 complaints per day. Thus the backlog keeps on increasing.

The author is an award-winning consumer activist and will answer readers queries in FE Investor. Send in your queries to consumercourt@hotmail.com