Grievance Mechanism And Insurance Ombudsman

INTRODUCTION

To protect the interest of policyholder.

To have speedy and effective grievance redressal systemIRDA has issued guidelines on 27th July ,2010.Applicable for disposal of grievance/complaints

1. Definition

2. Grievance redressal policy

3. Grievance officers

4. Grievance redressal system

11. Turnaround times

5.Closure of grievance

6. Categorisation of complaints

7. Minimum software requirements

8. Calls relating to grievances

9. Publicizing grievance redressal procedure

10. Policyholder protection committee

SUBPOINTS

Guidelines for grievance redressal

Definition of grievance /complaint

A “grievance” can be defined as any communication that express dissatisfaction about an action or lack of action ,about the standard of service / deficiency of an isurance company and/or any intermediary or asks for remedial action.

INQUIRY AND REQUEST

INQUIRY :- any communication for the

purpose of requesting information

about a company.

REQUEST :-any communication for

soliciting a service.

GRIEVANCEE REDRESSAL POLICYEvery insurer shall have a board approved Grievance Redressal Policy which shall be filed with IRDA.GRIEVACE OFFICERS

Every insurer shall have a Designated Grievance Officer of a senior management level. It includes:-CEO /COMPLIANCE OFFICER

Grievance Redressal System

An insurer send a written acknowledgement to a complainant within 3 working days of the receipt of grievance.

Acknowledgement shall contain the name and designation of the officer. It contains the details of insurer’s grievance redressal procedure the time taken for resolution of disputes.

If the insurer resolves the grievance within 3 days it may communicate the resolution along with acknowledgement.

If the grievance is not resolved within 3 days, an insurer resolve the grievance within 2 weeks of its receipts and send a letter of resolution.

The company sends the written response which offers redress or rejects the complaints and gives reasons for doing so.

Turnaround times

Service level turnaround

TA involved for the grievance redressal

Closure of grievance

a) The company has acceded to the request of the complainant fully.

b) Where the complaint has indicated in writing ,acceptance of the response of the insurer.

c) Where the complaint has not responded to the insurer within 8 weeks of the company’s written response.

d) Grievance redressal officer has certified that the company has discharge its contractual,statutory and regulatory obligations.

Categorisation of complaints

a)Categorisation of complaints

shall be adopted by insurers

and incorporated in their

system from time to time.

b)The present classification

prescribed by authority is

placed at annexure A .

Minimum software requirements

It is necessary for insurers to have automated systems that will enable online registration ,tracking of status of grievance by complainants and periodical reports as prescribed by IRDA .

The objective is to create the required industry level database and that would enable speedy and effective redressal of complaints .

Call relating to grievance

Publicizing grievance redressal procedure

Policyholder protection committee

Every insurer shall ensure that Policyholder Protection committee, is receiving and analyzing the required reports from the management and is carrying out all other requisite monitoring activities.

PROCESS OF GRIEVANCE REDRESSALPolicyholder complaints

IIRDS Grievance Call Centre

GR Channel of the insurer

IGMS Portal

Insurer

Does not respond responds

Not satisfactory satisfactory Not satisfactory

closed OCFCCIRDA

INSURANCE OMBUDSMANRedressal of public grievances

Rules,came into force w.e.f. 11th November ,1998. institution of Insurance ombudsman was created to implement the above rule.Purpose :- 1. quick disposal of

grievances 2. mitigate their problems 3. Protection of the interest of the policyholder.

Appointment of insurance ombudsman

Insurance ombudsman can be appointed on the recommendation of the committee consisting: *Chairman of IRDA*Chairman of LIC*Chairman of GIC*Representative of central government

Eligibility of ombudsmanTerms of officeTerritorial jurisdiction of ombudsmanThere are 17 Ombudsman across the country as on 1st January, 2015 these are:-Ahmadabad Ernakulum Bangalore Kolkata Bhopal lucknowBhubaneswar MumbaiChandigarh Noida Delhi PatnaGuwahati PuneHyderabadJaipur

Office managementRemoval of officer

Powers of ombudsman

Conciliation Award making

The complaint may relate to any grievance against insurer i.e.

Any partial or total repudiation of claims by insurance companies Dispute with regard to premium paid or payable in terms of the policy.Delay in settlements of claims.Non issuance of any document to the customer after receipt of premium.

Manner of lodging ComplaintComplaint must be in writing and addressed to the INSURANCE OMBUDSMAN.Before lodging a complaint :The complainant should have made a representation to the insurer.The insurer either should have rejected the complaint or complainant have not received any reply within a period of one year.The complaint is not made later than one year after the insurer had replied.The same complaint should not be pending with before any court,consumer forum or arbitrator.

Recommendations of the Ombudsman Ombudsman shall make recommendation not later than one month and copies of the same sent to the complainant and the insurance company concerned.

Complainant will send a communication in writing within 15 days of the date of receipt accepting the settlement.

Award

Ombudsman shall pass an award within the period of 3 Months from the receipt of the complaint.

If the policy holder is not satisfied , he can approach to other venues like

Consumer Forums and courts of law.