How to address grievances related to health insurance for senior citizens

Grievance redressal through the insurer

A senior citizen’s first option is to contact their insurer with their complaint. Every insurer should have a dedicated helpdesk for senior citizens as mandated by the IRDAI (Insurance Regulatory and Development Authority)

The process

• Make a complaint at your insurer’s grievance redressal cell through post, email or online
• The complaint must have relevant documents and data, such as policy number and supporting documents, including medical reports, discharge summaries, consultation notes, etc., which can add credence to your complaint
• The insurer must acknowledge your complaint and address it within 30 days
• If your grievance has been satisfactorily addressed, the complaint will be closed at this level. But if you are not satisfied or your issue has not been resolved, you can now approach the ombudsman

Grievance redressal through the insurance ombudsman

You can approach the ombudsman if:

• There’s been a delay with claims settlement
• Your claim has been rejected 
• Your insurer has not addressed your grievance within 30 days
• Your claim and claim expenses are not above INR 50 lakhs
• Your policy has not been issued after you have paid your premium 
• Any issue related to premium payment
• Your insurer has misrepresented or not followed the terms and conditions of the health insurance policy
• The insurance policy issued to the policyholder does not match the proposal form from the insurer
• The insurer is not following the rules laid down by the IRDAI or violating the provisions of the Insurance Act, 1938

How to lodge your complaint

• You can visit the ombudsman’s official website: https://cioins.co.in/Complaint/Online and file an online complaint
• Alternatively, you can email, use postal mail or visit the regional office of the ombudsman to file your complaint 

Pointers to keep in mind while filing your complaint

• You have to file your complaint within one year of your grievance being rejected by the insurer, or if your insurer doesn’t address your grievance within 30 days from the date of filing
• Every region has its ombudsman, so make sure to file your complaint with the relevant one
• As per the IRDAI, the documentation process for grievance redressal should be simple for seniors 

Mediation

• Once the complaint is received, the ombudsman will try to mediate between the insurer and the policyholder
• If a settlement is reached between both parties, it is put down in writing and signed off by both
• The insurer has 15 days to implement the terms of the settlement 

Award

• If the mediation falls through, the ombudsman will call for a hearing
• After receiving all the relevant documents from the complainant, the ombudsman will pass an award within 3 months
• This award is binding on the insurer, and they will have to comply with it within 30 days if the complainant accepts the award
• The award is not binding on the complainant. They can escalate it further if dissatisfied and involve the judicial system by filing a court complaint