Insurance claim rejection may not be the end of the road — Ways to appeal against denial

In a recent case, Nainital's district consumer redressal commission has ordered an insurance firm to pay a compensation of Rs 15 lakh within 45 days to the kin of a man, who died in a road accident in 2021. The firm had earlier rejected the claim saying the documents were submitted 37 days late which was in violation of their policy, according to a Times of India report.

However, the redressal commission reportedly observed that the kin had no sound educational background and that's why she couldn't submit documents on time. Also, the vehicle had a valid permit to run on the roads.

While this may be one of the many cases, policyholders should know their rights as a claimant. As per the rules, policyholders have avenues to raise complaints and make their voices heard in case their claim is rejected by the insurance firms.

The policyholder can approach the grievance officer of the insurance company to understand the reasons why the claim was rejected. He/she can raise a complaint in writing along with the necessary supporting documentation and then take a written acknowledgement of the complaint with the date.

If not satisfied with the answer of the grievance offer, the policyholder can approach the Insurance Regulatory and Development Authority of India (IRDAI) and take up the complaint with the IRDAI Grievance Call Centre. A complaint can also be filed with IRDAI’s consumer education website or Integrated Grievance Management System where one can monitor the status of the complaint.

Policyholders can also go to the insurance ombudsman or seek legal action if the insurer's responses don’t satisfy the policyholder.

According to IRDAI's consumer education website, the insurance ombudsman scheme was created by the government of India for individual policyholders to have their complaints settled out of the court system in a cost-effective, efficient and impartial way. There are at present 17 insurance ombudsman in different locations and any person who has a grievance against an insurer, may himself/herself or through legal heirs, nominee or assignee, make a complaint in writing to the insurance ombudsman within whose territorial jurisdiction the branch or office of the insurer complained against or the residential address or place of residence of the complainant is located.

The complaint can be made in writing on a plain, duly signed by the complainant and shall state clearly the name and address of the complainant, the name of the branch or office of the insurer against whom the complaint is made, the facts giving rise to the complaint, supported documents if any, the nature and extent of the loss caused to the complainant and the relief sought from the insurance ombudsman.