How can you File a Complaint Against your Insurance Provider via the IRDAI Portal

“Mr. Pawan (45-years) purchased a comprehensive health insurance policy of Rs. 5 lakh 4 years ago from a reputed health insurer. For the last 3 years, Mr. Panwan didn’t make a single claim, and as per the policy terms, he is eligible for an NCB bonus. Mr. Pawan informed his insurance company many times, and every time, the company told him that it would look into it and would increase his sum insured amount accordingly. But it never happened. Moreover, two months before, Mr. Panwan was diagnosed with some kidney problems, and he was hospitalized for 7 days. Once he was discharged, he initiated a claim reimbursement of Rs. 1.25 lakh. He made so many follow-ups with his insure, but his amount is not yet reimbursed. Now, Mr. Pawan is highly disappointed with his insurance company, and he wants to initiate a complaint against the insurance company. But he is not fully aware of how to file a complaint against the insurance company in India.

Here, we are going to discuss how you can file a complaint against your insurer through the IRDAI complaint portal. But before that, let’s find out why policyholders are dissatisfied with their insurers.

There could be multiple reasons related to why a policyholder wants to raise a complaint against an insurance provider. For example, policyholders may not be satisfied with the services of insurance companies, including the purchasing process, the claim settlement process, or maybe some basic service requests like changing address, contact details, nominations, offering tax-saving certificates, changes of payment mode, and so on.

Some Reasons for Complaint Against Insurance Provider

• Complex clauses are responsible for disputes

Policy documents may not always be simple and straightforward. Thus, health insurance policies often appear like a maze to many policyholders with complex clauses. The clauses can be like proportionate deduction, sum insured enhancement, an active line of treatment, customary and reasonable charges, etc. These prime clauses need to be explained with proper interpretation.

• Claim refusal due to delayed intimation

The IRDAI instructed health insurance companies not to refuse policyholders’ claims because of delays in intimation. A timeframe is mentioned for document submission in the policy for a claim settlement process. An insured policyholder needs to submit all relevant documents within this stipulated time. But IRDAI mentioned that this timeframe should not impede the settlement of genuine claims.

• Leaving the decision-making power to TPAs

In 2016, IRDAI’s health insurance regulations mentioned that insurers should have the final decision-making power rather than the third-party administrators. Still, ombudsman offices are full of complaints regarding this as most general insurers are not equipped with an established system for review of claims that TPAs decline.

• Poor grievance redress mechanism

The insurance ombudsman complaint format also mentioned that most insurance companies have a lack of customized responses to policyholders’ grievances.

Suppose the insurance company is unable to deal with the problem within the stipulated time or may not offer a fruitful solution to the policyholder. In that case, the customer is free to register his complaint with the Grievance Redressal Cell of IRDAI.

If you are not content with your insurer and want to file a complaint against your insurance company, here are some ways you can register your complaints.

How to lodge a Complaint via the IRDAI Portal?

As a policyholder, you can lodge a fresh complaint or escalate it to the Integrated Grievance Management System (IGMS) by visiting the website (igms.irdai.gov.in) using an online complaint redressal portal IRDAI. IGMS permits the appellant to revise or modify his complaint midway. But before approaching IRDAI, you ensure that you have already registered a complaint with the relevant insurance company.

You can register the complaint either by making a call on a toll-free number 155255 (or) 1800-4254-732 or by sending an email to IRDAI complaint email id i.e. complaints@irdai.gov.in.

Once your complaint is received, you will be given the token of the generated complainant. This will be again forwarded to your insurer for re-examination or re-look. The insurance company needs to respond within two weeks. If the company gives an unsatisfactory reply, the complaint is escalated to the insurance ombudsman based on its nature.

Insurance Ombudsman

You may ask for help and assistance from the Insurance Ombudsman to escalate an issue that your insurance company does not fix. Check the below-mentioned conditions to file a complaint with the Insurance Ombudsman.

• Your claim must be either partially or fully rejected
• After paying the premium, you didn’t receive your policy
• The claim settlement process is delayed
• A dispute is experienced regarding premium payable/ premium paid
• There is a dispute regarding the terms and conditions mentioned in the policy schedule

Consumer Court

If your complaint remains unattended, you are free to register the same with the consumer court. A separate department in the consumer court deals with insurance grievances. This department takes care of issues like service problems, unfair trade practice problems, malpractice issues, etc.

These are some ways by which you can file a complaint against your insurer. If you have any problem with your insurance provider, talk to the company and try to resolve it. If the company is still not paying attention to your problems, then you must take a step forward and register a complaint against your insurance provider.”