When Claims Go Wrong: Complaints and the Ombudsman

How to escalate insurance complaints from the insurer to IRDAI's Bima Bharosa system and the free Insurance Ombudsman.

If you have a problem with an insurance claim or policy, there’s a clear path to get help.

Step 1: The insurer

Complain to the insurer’s grievance redressal officer. Insurers must acknowledge complaints quickly and resolve them within set timelines.

Step 2: IRDAI’s Bima Bharosa

If unsatisfied, register a complaint on IRDAI’s Bima Bharosa portal (earlier IGMS), which tracks complaints with insurers.

Step 3: The Insurance Ombudsman

The Insurance Ombudsman is a free, independent forum for resolving disputes. There are ombudsman offices in many cities.

You can approach the ombudsman if the insurer rejects your complaint or doesn’t respond within 30 days.
Claims up to 50 lakh rupees can be handled.
Complaints must usually be filed within one year of the insurer’s final reply.
The ombudsman’s award is binding on the insurer if you accept it.

Consumer courts

You can also approach consumer commissions under consumer protection law.

Common disputes

Claim rejections or partial payments.
Delays.
Mis-selling.
Policy servicing problems.

Tips

Keep records of all communications.
Be clear about what outcome you want.
Many disputes are resolved in the customer’s favour when documented well.

The partial payment

An insurer pays only part of a hospitalisation claim, citing unclear reasons. The customer complains to the insurer, gets no satisfactory answer and files with the Insurance Ombudsman, which orders the insurer to pay the remaining amount.

Thinking fighting an insurer requires expensive lawyers

The Insurance Ombudsman is free and doesn't require a lawyer.

Key takeaways

Complain first to the insurer's grievance officer.
Escalate through IRDAI's Bima Bharosa portal.
The free Insurance Ombudsman handles claims up to 50 lakh rupees.
Consumer commissions are another option.