IOR Section : The Insurance Ombudsman Rules, 2017

Explanation using Example

Example 1: Delayed Claim Settlement

Introduction: Mr. Sharma, a policyholder, files a claim with his insurance company after his car is damaged in an accident. Despite submitting all required documents, the insurance company delays the settlement for over six months.

Application: Under the Insurance Ombudsman Rules, 2017, Mr. Sharma can approach the Insurance Ombudsman for redressal of his grievance. The Ombudsman is empowered to address complaints regarding delays in claim settlements as per the rules established under the Insurance Regulatory and Development Authority Act, 1999.

Outcome: If the Ombudsman finds merit in Mr. Sharma's complaint, they can direct the insurance company to expedite the claim settlement process. Non-compliance with the Ombudsman's order could result in further legal action against the insurer.

Conclusion: By utilizing the Ombudsman mechanism, Mr. Sharma can seek a timely resolution to his grievance, ensuring that the insurance company adheres to its obligations under the policy.

Example 2: Rejection of Health Insurance Claim

Introduction: Ms. Kapoor files a claim under her health insurance policy for a surgery she underwent. The insurance company rejects her claim, citing a pre-existing condition exclusion, which Ms. Kapoor believes is unjustified.

Application: According to the Insurance Ombudsman Rules, 2017, Ms. Kapoor can file a complaint with the Insurance Ombudsman if she believes her claim was wrongly rejected. The Ombudsman can investigate whether the rejection was in accordance with the terms of the policy and applicable regulati...

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