COMMON MAN’S SWORD AGAINST REJECTION OF INSURANCE CLAIM

  COMMON MAN’S SWORD AGAINST REJECTION OF INSURANCE CLAIM

There is no denying that we have greater peace of mind if we know that we are financially secure from various unforeseen situations. Uncertainties in life can crop up at any moment such as medical emergency, theft of a vehicle or an unfortunate death. Bearing the financial impact of these situations can burn a hole into a pocket. Thus, there is a pressing need of insurances for proper coverage and financial support against all risks linked to the life, health, and property.Butit is seen thatgetting claims sanctioned from insurance companies is a next level task.It has been seen that few Insurance companies for some or the other reasons deny claims and hence, cause the miseries in the life of the policyholders. But do not forget, there’s a saying that‘Justice may be delayed but cannot be denied.’ Supreme Court in the case titled as “Om Prakash versus Reliance General Insurance and Anr (Civil Appeal No. 15611 of 2017)”, held that insurance claims cannot be denied to a person merely on the ground of delay in filing the claim. The apex court has ruled that rejection of the claims on technical grounds will result in loss of confidence of policyholders in the insurance industry. It was held that rejection of claims shouldbe based on valid grounds. This judgment indeed provides a great relief to all policyholders, witnessing severe hardships to get their claims approved from insurance companies.

Not only this, we also have various remedies which we can avail to seek redressal of our grievances against rejection of insurance claims and hence,can save lives of many.

INSURANCE

Here, let’s discuss all those remedies.

  1. Approach Insurer’s Redressal Cell

The Insurance Companies have constituted their own redressal cell to resolve the grievances of the policyholders. Aggrieved customer may either-:

  • Contact Grievance Redressal Officers (GRO) of the insurance companies on their official number.
  • Drop an e-mail to concerned GRO;
  • Contact Customer Care executives on provided helpline numbers;
  • Write letters to GRO of the company.
  1. Approach IRDAI(Insurance Regulatory and Development Authority of India)

If the grievance is not resolved within a reasonable period by there dressal cell of the Insurance Company or if it does not provide a satisfactory response, aggrieved claimant may approach IRDAI.

The insurance companies in India are governed by IRDAI (Insurance Regulatory and Development Authority of India). IRDAI is a regulatory body responsible for regulating the insurance sector in India with the aim to protect the interests of the policyholders.

Claimants may address their grievances to IRDAI in the following ways:

  • Call the Grievance Redressal Cell of the IRDAI on Toll Free Number 155255 or 1800 4254 732
  • Send an email to complaints@irdai.gov.in
  • Visit policyholder.gov.in and fill and submit the complaint registration form there.
  • Register complaints through online portal established by IRDAI called Integrated Grievance Management System(IGMS) at igms.irda.gov.in by submitting a complaint form. If it is hard to access insurance companies for any reason, IFMS provides a gateway to register complaints with insurance companies. A complaint registered through IGMS will reach both the regulator and insurance company.
  • Send complaint letter with copies of all the supporting documents to the following address:

The General Manager

Consumer affairs Department-Grievance Redressal Cell,

Insurance Regulatory and Development Authority of India

4th Floor, Survey No.115/1,

Financial District, Nanakramguda, Gachibowli,

Hyderabad-500032

For effective and smooth governance of this mechanism, Central Government is vested with the powers under section 114(1) of Insurance Act,1938 to frame rules which are called ‘The Redress of Public Grievances Rules,1998’. The Purpose of these rules is to resolve complaints of the aggrieved policyholders relating to disputes with Insurance Companies in a time- bound and efficient manner. To implement the rules, the Institution of Insurance Ombudsman i.e. IRDAI was created by the government of India to redress the grievances of the insured customer in speedily manner. The Insurance Ombudsmen are appointed by the Governing Body of Insurance Council(GBIC).These rving term of the Insurance Ombudsman is three years.

Any person who has a grievance against an insurer, may himself or through his legal heirs make a complaint in writing to the Insurance Ombudsman i.e. IRDAI within whose territorial jurisdiction the branch or office of the Insurer complained against or the residential address of the complainant is located. The Ombudsman will act as a mediator and resolve the disputes fairly and equitably.

In the following cases complaint can be made to the Insurance Ombudsman:-

  • If the complaint is rejected by the Grievance Redressal Machinery of the Insurer or
  • If the complainant has not received any reply within a period of one month from date of lodging complaint or
  • If the complainant is not satisfied with the reply given by the insurer or
  • If the complaint is made within one year from the date of rejection by the insurance company or
  • If the complaint is not on the same subject matter for which any proceedings before any court or consumer forum is pending.

Following are the subject matters on which complaint may be initiated to the Insurance Ombudsman.

  • Any partial or total repudiation of claims by an insurer
  • Delay in settlement of claims
  • Any disputes in regards to premiums paid or payable in terms of the policy
  • Any dispute on the legal construction of the policies in so far as the dispute relates to claim.
  • Non-issuance of Insurance documents to customers after receipt of premium.
  1. Approach Consumer Court

At the first instance or, if all the aforesaid remedies do not provide satisfactory response, the complainant can approach the appropriate Consumer Dispute Redressal Commission and file the complaint against the concerned insurer. It is the most laudable machinery for the speedy redressal of the grievances.

But the question that comes here is, how to determine pecuniary jurisdiction in matters relating to insurance cases under Consumer Protection Act,2019?

In the  case ‘ M/s PyarideviChabiraj Steels Pvt Ltd V National Insurance Company Ltd &Ors’,National Commission had the occasion of determining the pecuniary jurisdiction under the Consumer Protection Act,2019 which set out the new threshold limit for instituting the complaint in various commissions.  Answering to the above question, NCDRC held that the jurisdiction of appropriate Consumer Disputes Redressal Commission is based only on the value of the consideration paid. The amount of premium paid by the claimant is to be taken into consideration for determining the pecuniary jurisdiction.