IOR Section 13 : Duties and Functions of Insurance Ombudsman

Explanation using Example

Example 1: Delay in Settlement of Claims

Introduction: Mr. Sharma, a policyholder, filed a claim with his health insurance provider after undergoing surgery. The insurer, however, delayed the settlement of his claim beyond the time specified in the regulations under the Insurance Regulatory and Development Authority of India Act, 1999.

Application: According to Section 13(1)(a) of The Insurance Ombudsman Rules, 2017, Mr. Sharma can file a complaint with the Insurance Ombudsman alleging a deficiency in service due to the delay in claim settlement.

Outcome: If the Ombudsman finds merit in Mr. Sharma's complaint, the insurer may be directed to settle the claim promptly. Non-compliance with the Ombudsman's decision can lead to reputational damage and potential regulatory scrutiny for the insurer.

Conclusion: This example illustrates the importance of insurers adhering to specified timelines for claim settlements to avoid legal complaints and potential penalties.

Example 2: Misrepresentation of Policy Terms

Introduction: Mrs. Kapoor purchased a life insurance policy based on the assurance from the insurance agent that it included a critical illness cover. Upon reviewing the policy document, she discovered that such a cover was not included.

Application: Under Section 13(1)(d) of The Insurance Ombudsman Rules, 2017, Mrs. Kapoor can lodge a complaint with the Insurance Ombudsman for misrepresentation...

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