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FORM OF COMPLAINT TO BE LODGED WITH THE INSURANCE OMBUDSMAN
(Rule 13(1) and Rule 14(2) of the Insurance Ombudsman Rules, 2017, as amended. One complaint per insurance company and per policy.)
To,
The Insurance Ombudsman
[CITY / PLACE OF THE OMBUDSMAN OFFICE]
[ADDRESS OR E-MAIL OF THE OMBUDSMAN OFFICE]
Date: [DD/MM/YYYY]
Madam/Sir,
Subject: Complaint against [NAME OF THE INSURANCE COMPANY / INSURANCE BROKER] — [REJECTION / PARTIAL SETTLEMENT / DELAY] of claim No. [CLAIM NUMBER] under policy No. [POLICY NUMBER]
Earlier complaint to the insurer
Before approaching your office, I made a written complaint to the insurer on [DD/MM/YYYY] through [GRIEVANCE REDRESSAL OFFICER BY E-MAIL / INSURER'S WEBSITE / BIMA BHAROSA / LETTER], complaint / reference No. [GRIEVANCE NUMBER]. [The insurer rejected my complaint by its letter dated [DD/MM/YYYY]. / The insurer replied on [DD/MM/YYYY], but the reply is not acceptable to me. / I have not received any reply within one month of the insurer receiving my complaint.] A copy of the complaint and of the reply (if any) is enclosed.
Details of the complaint
No. Particulars Details
1 Name of the complainant and relationship with the insured [FULL NAME] — [SELF / SPOUSE / SON / DAUGHTER / NOMINEE / LEGAL HEIR / ASSIGNEE]
2 Name of the insured [NAME OF THE INSURED PERSON]
3 Full address of the complainant [HOUSE NO., STREET, LOCALITY, CITY, STATE] — PIN [PIN CODE]
Phone (with STD code) / Mobile +91 [PHONE] / +91 [MOBILE]
E-mail [E-MAIL]
4 Policy / proposal number(s) [POLICY NUMBER]
4a Individual policy or group policy [INDIVIDUAL / GROUP — NAME OF EMPLOYER OR GROUP]
5 Complaint against (name and full address of the branch or office of the insurer / intermediary / insurance broker) [INSURER NAME, BRANCH OR OFFICE ADDRESS] — PIN [PIN CODE]
6(a) Date of complaint already made to the Grievance Redressal Officer of the insurer / insurance broker [DD/MM/YYYY] (copy enclosed)
6(b) Has the insurer / insurance broker replied within 30 days of receiving the complaint? [YES — REPLY DATED DD/MM/YYYY, COPY ENCLOSED / NO]
6(c) Are you satisfied with the reply given by the insurer? [NO]
7. Subject matter of the complaint (facts in date-wise order)
Date What happened
[DD/MM/YYYY] Policy [POLICY NUMBER] issued / renewed; sum insured ₹[AMOUNT].
[DD/MM/YYYY] [EVENT — e.g., hospitalised at [HOSPITAL] for [ILLNESS / PROCEDURE] / death of the insured / accident to vehicle No. [NUMBER]].
[DD/MM/YYYY] Claim intimated to the insurer / TPA [NAME]; claim No. [CLAIM NUMBER]; amount claimed ₹[AMOUNT].
[DD/MM/YYYY] [CASHLESS DENIED / CLAIM REJECTED / ₹[AMOUNT] DEDUCTED / NO DECISION] — reason given by the insurer: "[QUOTE THE REASON FROM THE LETTER]".
[DD/MM/YYYY] Written complaint to the insurer's Grievance Redressal Officer (see above).
[DD/MM/YYYY] [INSURER'S REPLY / NO REPLY].
Why the rejection / deduction is wrong: [EXPLAIN IN PLAIN WORDS — e.g., the illness is not a pre-existing disease and was not excluded; the waiting period of [N] months had already ended on [DATE]; the policy wording in clause [NUMBER] covers this treatment; all documents asked for were submitted on [DATE]; the deduction for [ITEM] is not provided for in the policy.]
Grounds under Rule 13(1): [(a) DELAY IN SETTLEMENT OF CLAIM / (b) PARTIAL OR TOTAL REPUDIATION OF CLAIM / (c) DISPUTE OVER PREMIUM / (d) MISREPRESENTATION OF POLICY TERMS / (e) LEGAL CONSTRUCTION OF THE POLICY RELATING TO THE CLAIM / (f) POLICY SERVICING / (g) POLICY NOT IN CONFORMITY WITH THE PROPOSAL FORM / (h) NON-ISSUANCE OF POLICY AFTER RECEIPT OF PREMIUM].
8. Proceedings in any court, consumer forum or before an arbitrator
Are any proceedings on the same subject matter pending before any court, consumer forum or arbitrator, or were they so earlier? [NO]
9. Documents enclosed
1. Copy of my complaint to the Grievance Redressal Officer of the insurer / insurance broker dated [DD/MM/YYYY].
2. Reply / letter of repudiation / partial settlement letter from the insurer dated [DD/MM/YYYY].
3. Copy of the policy (certificate of insurance, in case of a group policy).
4. [CLAIM FORM, DISCHARGE SUMMARY, HOSPITAL BILLS, INVESTIGATION REPORTS, DEATH CERTIFICATE, SURVEY REPORT, FIR — AS APPLICABLE].
5. [ANY OTHER DOCUMENT].
10. Monetary loss and relief sought
10. Nature and extent of monetary loss ₹[AMOUNT] — [CLAIM REJECTED IN FULL / AMOUNT DEDUCTED / AMOUNT NOT PAID SINCE DD/MM/YYYY]
10a. Quantum of relief sought (INR) ₹[AMOUNT] together with interest as provided under Rule 17(7) of the Insurance Ombudsman Rules, 2017
For mediclaim / health policy complaints
Is the policy fresh or ported? [FRESH / PORTED]
Date of porting [DD/MM/YYYY]
Previous insurance company [NAME]
Previous policy number(s) [NUMBERS]
Date of commencement of previous policies [DD/MM/YYYY]
Sum insured ₹[AMOUNT]
11. Declaration
I hereby declare and solemnly affirm that:
a) the information given above is true to the best of my knowledge and belief;
b) the complaint was lodged with the insurance company on [DD/MM/YYYY] as per the copy enclosed, and the company has [rejected my claim / complaint / not replied even after a month / replied on [DD/MM/YYYY] but the reply is not acceptable to me];
c) the period of one year has not elapsed from the date of the rejection letter or final reply from the insurance company [or, if no reply was received, from the expiry of one month after I sent my complaint];
d) the complaint is not on the same subject matter for which any proceedings before any court, consumer forum or arbitrator are pending or settled, or were so earlier;
e) the subject matter has not been decided earlier by your office or by any office of the Insurance Ombudsman.
Yours faithfully,
______________________________
[FULL NAME OF THE COMPLAINANT]
Place: [PLACE]
Date: [DD/MM/YYYY]
NOTES BEFORE FILING — delete this part
File with the Ombudsman for the area where the insurer's branch or office is located or where you live. You can file in person, by post, by e-mail or online at cioins.co.in/Complaint/Online. There is no fee.
Write to the insurer first. You can go to the Ombudsman only if the insurer rejected your complaint, did not reply within one month of receiving it, or replied and you are not satisfied.
File within one year of the insurer's rejection or final reply, or within one year after the one-month reply period ends if the insurer never replied. The Ombudsman may condone a delay, but do not count on it.
The Ombudsman cannot award more than the loss you actually suffered, and not more than ₹50 lakh including expenses.
Do not file the same matter in a consumer commission or court at the same time — the Ombudsman cannot take it up then.
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