Insurance Query: How to resolve disputes with insurers over claim settlements

I have a dispute with my insurance company regarding mediclaim payment. Whom should I contact first, the insurance ombudsman or Consumer Disputes Redressal Commission? In case the verdict of the first authority is not to my satisfaction can I go to the next level? What is the priority order to approach the authority?

Thomas

In recent years, health insurance has emerged as a necessity rather than an essential aspect of financial planning. The Covid-19 pandemic was a wake-up call for the general public to invest in health insurance with adequate coverage. For policyholders, health insurance acts as an assurance during an emergency. However, when faced with the harsh reality of claim rejections or delays in settlement, this safety net can seem more like a web of confusion and frustration.

Despite regular premium payments and a need for financial support, many find themselves embroiled in disputes with insurers over claim settlements. As a policyholder, if you find yourself facing such a situation, you must know how to claim the amount that rightfully belongs to you.

Why do mediclaims get rejected by insurance companies?

The rejection of mediclaim policies often starts from breaches in policy terms and conditions. At the time of purchasing a policy, individuals must declare all pre-existing ailments. The responsibility lies with the insured to provide comprehensive information, even if it means higher premiums. Failure to disclose pertinent medical history can lead to claim denials, leaving policyholders in an unwanted position.

Mediclaim policies typically offer two modes of settlement — cashless treatments and reimbursement of expenses. While cashless facilities provide immediate relief by settling bills directly with the hospital, reimbursement requires policyholders to bear the expenses initially, submitting claims for repayment later.

What to do when mediclaims get rejected? Whom should one approach?

If your mediclaim gets rejected, you must study the reason behind the rejection and understand the course of action suggested in the policy. You can then raise a complaint with your insurance company. If you don’t receive a response from your insurance company, you can escalate the matter to the grievance team.

Grievance Officer: The First Option

Every insurance company has a Grievance Redressal Officer (GRO) who can be approached if you are not satisfied with the claim amount or decision. You can approach the GRO either by visiting the branch office or via email, the latter being a convenient option in today’s digital age. Filing a complaint with GRO comes with no charges or fees.

According to the Insurance Regulatory and Development Authority of India (IRDAI) guidelines, the GRO is mandated to address your grievance within 15 days of receiving it. However, if you fail to receive a response within this timeframe or are dissatisfied with the resolution provided, you have the option to escalate the matter further by approaching the Grievance Redressal Cell of the Consumer Affairs Department of IRDAI, where steps can be taken to ensure your complaint is adequately addressed and resolved.

Role of Insurance Ombudsman

The Insurance Ombudsman scheme, an initiative by the Government of India, serves as a beacon of hope for dissatisfied policyholders. With 22 offices across 17 cities, the ombudsman provides an alternative dispute resolution system, aiming for a fair, swift, and impartial resolution. This process is available to the insured, their legal heirs, nominees, or assignees under specific conditions.

You can approach the ombudsman only when your insurance company has rejected the claim or not resolved it to your satisfaction or has not responded to it at all for 30 days. Moreover, the quantum of loss payable under the insurance policy doesn’t exceed ₹50 lakh. Importantly, this process is entirely free of charge, ensuring accessibility to all policyholders seeking solutions to mediclaim disputes.

Consumer Disputes Redressal Commission: The Last Resort

For unresolved grievances, the Consumer Disputes Redressal Commission stands as the final bastion of justice. Despite its efficacy, the judicial route is often protracted, entailing prolonged legal battles and associated expenses. Hence, while the Commission offers a definitive verdict, it should be approached as thelast resort after exploring all other avenues. It is important for you to pay certain fees if you file a complaint with the Commission.

The Preferred Option: Insurance Ombudsman

The Insurance Ombudsman is considered the preferred option due to its expeditious process and non-binding recommendations. With most cases resolved within a week of hearing, the ombudsman offers a swift and cost-effective resolution mechanism, sparing individuals the ordeal of lengthy legal battles. If the ombudsman issues a directive for the insurance company to make the payment, the company has to comply with it. However, if there is dissatisfaction with the ombudsman’s decision, the insured has the option to approach the Consumer Disputes Redressal Commission .

While insurance companies serve as the first point of contact, escalation to the ombudsman or Consumer Disputes Redressal Commission becomes imperative for unresolved grievances. For justice and financial stability, informed decision-making and timely action are mandatory, ensuring that individuals receive the healthcare security they rightfully deserve.

The writer is COO, InsuranceDekho

Send your queries to insurancequeries@thehindu.co.in