According to a report by the Insurance Regulatory Development Authority of India (Irdai), insurance companies in India denied 11 per cent of health insurance claims and had six per cent of claims pending as of March 2024.
Health insurance claim rejections are a concern and the onus lies on the policyholders to do due diligence when filing a claim to avoid claim rejection.
How Does The Insurance Ombudsman Work
When a claim is rejected and a policyholder is not satisfied with the response from the insurer, he can approach the insurance ombudsman. If your complaint has not been addressed by your insurer in 30 days, it is time to approach the insurance ombudsman. Claim rejections is one of the common reasons for which you can approach an ombudsman. Remember, the complaint needs to be filed within one year of receiving the insurer’s final response.
“The Insurance Ombudsman process is a vital safety net for policyholders when things don’t go right with their insurers. It’s designed to be free, impartial, and time-bound, making it an effective grievance redressal option,” says Narendra Bharindwal, vice president, the Insurance Brokers Association of India (IBAI).
When You Should Approach The Ombudsman
However, to make the most of it, policyholders need to be prepared. Keep all communication with your insurer documented in emails, letters, and responses. This would include the policy copy, any correspondence with the insurer, and any documents which support your claim.
Clearly explain your issue in the complaint and back it up with supporting evidence. Remember, you need to file the complaint within one year of the insurer’s final response, and the Ombudsman can handle cases up to Rs 50 lakh.
“While the system works well, many policyholders aren’t fully aware of its scope or how to approach it. Better awareness will go a long way in making this process more impactful for everyone,” says Bharindwal.
