IOR Section 14 : Manner in which complaint to be made

Explanation using Example

Example 1: Filing a Complaint with the Insurance Ombudsman

Introduction: John, a resident of Mumbai, purchased a health insurance policy from XYZ Insurance Company. After a medical procedure, he submitted a claim for reimbursement, which was rejected by the insurer. Feeling aggrieved, John decides to approach the Insurance Ombudsman.

Application: According to Section 14(1) of The Insurance Ombudsman Rules, 2017, John can file a complaint with the Insurance Ombudsman within whose jurisdiction the office of XYZ Insurance Company or his residence is located. He must ensure that his complaint is in writing, as per Section 14(2), and includes his name, address, the insurer's details, facts of the case, and the relief sought.

Outcome: John first needs to make a written representation to XYZ Insurance, as per Section 14(3)(a). If XYZ Insurance rejects his complaint, fails to respond within a month, or provides an unsatisfactory reply, John can proceed to file his complaint with the Ombudsman. He must do this within one year of receiving the insurer's decision or after the one-month period lapses, as outlined in Section 14(3)(b).

Conclusion: By following these steps, John ensures his complaint is valid and can be addressed by the Ombudsman. Non-compliance with these procedural requirements could result in his complaint being dismissed.

Example 2: Delay in Filing a Complaint

Introduction: Priya, a policyholder from Delhi, faced a delay in receiving a response from her insurer regarding a claim for a car accident. She intended to file a complaint with the Insurance Ombudsman but missed the one-year deadline due to personal reasons.

Application: Section 14(4) of The Insurance Ombudsman Rules, 2017, allows the Ombudsman to condone delays in filing complaints if deemed necessary. Priya can request a condonation of delay, providing valid reasons for her late submission.

Outcome: The Ombudsman will consider Priya's request, call for objections from the insurer, and record reasons for condoning the delay if approved. If condoned, the date of condonation will be treated as the filing date, allowing Priya's complaint to proceed.

Conclusion: Priya's ability to have her delay condoned ensures access to justice despite missing the deadline. However, she must provide compelling reasons for the delay to avoid dismissal of her complaint.

Example 3: Complaint Not Maintainable Due to Pending Court Proceedings

Introduction: Raj, an insurance policyholder, has a dispute with his insurer over a denied claim. He has already initiated proceedings in a consumer court but is considering filing a complaint with the Insurance Ombudsman for quicker resolution.

Application: Section 14(5) of The Insurance Ombudsman Rules, 2017, states that a complaint is not maintainable before the Ombudsman if the same subject matter is pending before or has been disposed of by any court, consumer forum, or arbitrator.

Outcome: Since Raj's case is already pending in a consumer court, he cannot file a complaint with the Insurance Ombudsman on the same issue. This provision prevents duplication of proceedings and ensures judicial efficiency.

Conclusion: Raj must continue his case in the consumer court and cannot seek parallel relief from the Ombudsman, highlighting the importance of choosing the appropriate forum for dispute resolution.