Grievance Redressal and the Insurance Ombudsman: S-01 Chapter 16
Most general insurance disputes rest on a survey report. The ladder a policyholder climbs, and where your report is read again.
Most insurance disputes in general insurance are about one of two things: a claim was rejected, or it was paid at less than the insured expected. Both usually rest on a survey report. That is why S-01 gives a full chapter, chapter 16, to grievance redressal.
A surveyor needs to know the ladder a policyholder can climb, because the report will be read again at each step, by people who were never at the site.
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The Grievance Ladder
The first two steps are with the insurer. After that, the policyholder picks a forum.
- 1
Policy issuing office
A written complaint to the office that issued the policy, or its regional office.
- 2
Grievance Redressal Officer (GRO)
Every insurer has one. The complaint goes in writing with supporting documents, and the insurer is expected to resolve it within two weeks.
- 3
Bima Bharosa (IRDAI's grievance system)
If the insurer does not resolve it, the complaint can be registered on IRDAI's Bima Bharosa portal, by email to [email protected], or on the toll-free numbers 155255 and 1800 4254 732. A token number tracks it.
- 4
Insurance Ombudsman
A low-cost forum under the Insurance Ombudsman Rules, 2017, for personal lines, group policies, sole proprietorships and micro enterprises.
- 5
Consumer commission
Under the Consumer Protection Act, 2019, at district, state or national level depending on the amount involved.
Ombudsman or Consumer Commission?
Law
Insurance Ombudsman
Insurance Ombudsman Rules, 2017
Consumer commission
Consumer Protection Act, 2019
When you can go
Insurance Ombudsman
Within one year of the insurer rejecting the complaint, or after one month with no reply
Consumer commission
After the insurer's own process; no Ombudsman award needed first
Who can use it
Insurance Ombudsman
Individuals, group policyholders, sole proprietorships and micro enterprises
Consumer commission
Any consumer of the insurance service
Amount
Insurance Ombudsman
Up to a ceiling set in the Rules (see our IC-38 Ombudsman page for the current figure)
Consumer commission
District up to ₹50 lakh; State above ₹50 lakh up to ₹2 crore; National above ₹2 crore
Cost and pace
Insurance Ombudsman
Low cost; meant to be impartial and quick
Consumer commission
Court-like; can take longer
| Insurance Ombudsman | Consumer commission | |
|---|---|---|
| Law | Insurance Ombudsman Rules, 2017 | Consumer Protection Act, 2019 |
| When you can go | Within one year of the insurer rejecting the complaint, or after one month with no reply | After the insurer's own process; no Ombudsman award needed first |
| Who can use it | Individuals, group policyholders, sole proprietorships and micro enterprises | Any consumer of the insurance service |
| Amount | Up to a ceiling set in the Rules (see our IC-38 Ombudsman page for the current figure) | District up to ₹50 lakh; State above ₹50 lakh up to ₹2 crore; National above ₹2 crore |
| Cost and pace | Low cost; meant to be impartial and quick | Court-like; can take longer |
Ombudsman Grounds That Touch a Survey
From the grounds listed in rule 13 of the Ombudsman Rules.
- check_circleDelay in settling a claim, including delay caused by a late survey report.
- check_circlePartial or total repudiation of a claim, the most common dispute built on a survey.
- check_circleThe legal construction of the policy, where the dispute relates to a claim.
- check_circleNon-observance of IRDAI regulations protecting policyholders' interests.
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Where the Surveyor Fits
The insured's complaint is against the insurer, not the surveyor, because the insurer decides the claim. But the survey report is the main evidence. A report that names the policy term behind every cut, records the insured's consent or objection, and attaches photos and documents is one that holds up before the Ombudsman.
Complaints about the surveyor's own conduct go to the insurer. The regulations require the insurer to enquire into any breach of the surveyor code of conduct brought to its notice and to report proven cases to IRDAI.
One Forum at a Time
Bima Bharosa, the Ombudsman and the consumer commissions run under three different frameworks. A policyholder generally cannot pursue the Ombudsman while the same dispute is before a court, consumer commission or arbitrator.
FAQs
What is Bima Bharosa?expand_more
IRDAI's online grievance system, earlier called IGMS. A complaint registered there is forwarded to the insurer and tracked with a token number.
When can a policyholder approach the Insurance Ombudsman?expand_more
After complaining to the insurer, within one year of the insurer's rejection, or once a month has passed with no reply.
Can a policyholder complain about the surveyor's assessment?expand_more
Yes, but the complaint is against the insurer's decision on the claim. The survey report is the main evidence in that dispute.
Which consumer commission hears an insurance dispute?expand_more
It depends on the amount: district up to ₹50 lakh, state above ₹50 lakh up to ₹2 crore, national above ₹2 crore.
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