Complaint to the Insurance Ombudsman

To, The Insurance Ombudsman [ombudsman_office] Date: [complaint_date] Subject: Complaint under the Insurance Ombudsman Rules, 2017 Sir/Madam, 1. COMPLAINANT Name : [complainant_name] Address : [complainant_address] Contact : [contact_number] 2. THE INSURER COMPLAINED AGAINST Insurer : [insurer_name] Policy number : [policy_number] Claim number : [claim_number] Claim made on : [claim_date] Amount claimed: Rs. [amount_claimed] 3. THE CLAIM [claim_details] 4. THE INSURER'S DECISION The claim was rejected, or last replied to, on [rejection_date]. The reason given was: [insurer_reason] 5. WHY THAT DECISION IS WRONG [why_wrong] 6. That I first made a written representation to the insurer's grievance redressal officer, and the insurer has either rejected it, or failed to resolve it to my satisfaction, or not replied within one month. 7. DECLARATIONS 7.1 The subject matter of this complaint is not pending before, and has not been settled or dealt with on merits by, any court, consumer forum or arbitrator. 7.2 The complaint is made within the period prescribed under the Insurance Ombudsman Rules, 2017. 7.3 The information given above is true to the best of my knowledge and belief. RELIEF SOUGHT That the insurer be directed to settle the claim in the sum of Rs. [amount_claimed], together with interest and compensation for the loss and inconvenience caused. Yours faithfully, [complainant_name] ENCLOSURES 1. Copy of the policy document 2. Copy of the claim form and all documents submitted 3. Copy of the rejection or repudiation letter 4. Copy of the representation to the grievance redressal officer, and any reply 5. Medical, repair or loss documents relied upon ──────────────────────────────────────────────────────────────── IT IS FREE, IT IS FAST, AND MOST PEOPLE NEVER USE IT The Insurance Ombudsman is among the most underused remedies in India. There is NO FEE, you do NOT need a lawyer, and the Ombudsman's award is BINDING ON THE INSURER — while you remain free to pursue other remedies if the award does not satisfy you. Very few forums are asymmetric in the consumer's favour like that. TWO PRECONDITIONS, BOTH OF WHICH TRIP PEOPLE UP: 1. YOU MUST COMPLAIN TO THE INSURER FIRST, in writing, to its grievance redressal officer. Every insurer is required to have one and to publish the details. Only after it rejects your representation, or fails to reply within a month, can you approach the Ombudsman. 2. YOU MUST COMPLAIN WITHIN THE PRESCRIBED PERIOD of that rejection or of the expiry of that month. Do not let it drift; a complaint made too late is not entertained however good it is. THERE IS A MONETARY CEILING on what the Ombudsman can award. Where your claim exceeds it, a Consumer Commission or a civil suit is the route instead. CHOOSE ONE FORUM. If the same dispute is already before a consumer commission or a court, the Ombudsman will not entertain it. Running two proceedings on one claim wastes the stronger of them. WHAT WINS THESE COMPLAINTS: the policy wording itself. Insurers repudiate on exclusions, on non-disclosure, and on delayed intimation. Read the exact clause relied upon in the rejection letter and answer it specifically — "the exclusion does not cover this because..." is far stronger than a general account of the hardship caused. IF THE REJECTION WAS ORAL OR BY TELEPHONE, write and demand it in writing with reasons. You cannot answer a reason you have not been given, and an insurer that will not put its reason in writing is already in difficulty.