Did the insurance company trick you by denying your health claim? Here’s what to do

Most people purchase the Mediclaim insurance policy by paying exorbitant premium rates, thinking it would be helpful in a hospital emergency. The amazing promises in the policy may have lured you, but the insurance companies may show their true colours when you are admitted to the hospital. In some cases, they reject cashless transactions and give only the reimbursement. Even if we submit the bills after getting discharged from the hospital for reimbursement, the company will reject them citing many reasons. Meanwhile, in other cases, the entire claim is rejected.

If you think you have been tricked by the insurance companies and intend to seek legal remedies, then note the following steps.
1. If you have a complaint, then the first step is to approach the grievance redressal officer at the concerned branch of the insurance company.
2. A detailed written compliant should be given along with supporting documents. Do not forget to get the receipt in which the date of filing the complaint is noted.

3. The insurance company will solve the complaint within fifteen days or they will at least give a reply. If the company fails to respond or if you are not satisfied with their reply, then you could file a complaint with the grievance redressal cell at the consumer affairs department of the Insurance Regulatory and Development Authority. The specified proforma for this is available on the IRDA website or can be downloaded from this link . This should be printed out, filled and send to the address: Insurance Regulatory and Development Authority of India (IRDAI), Policy Holders’ Protection and Grievance Redressal Department – Grievance Redressal Cell, Sy. No. 115/1, Financial District, Nanakramguda, Gachibowli, Hyderabad – 500 032. You could also email the complaint at complaints@irdai.gov.in.
To file your complaint on phone, dial the toll-free number 155255 or 1800 4254 732
Log into this website to submit the complaint.

4. If your grievance isn’t addressed even a month after filing the complaint, then you could approach the insurance ombudsman.
5. There are 17 insurance ombudsman around the country to solve the cases related to insurance fraud.
6. You could submit the complaints either in person or via post.
7. It is better to file the complaint with the insurance company first and then approach the ombudsman if they fail to respond or you are unsatisfied with their reply. Approach the ombudsman if the insurance company doesn’t reply or solve the grievance within 30 days of filing the complaint.

8. The complaint should be related to the policy that you have purchased as an individual. Besides, the compensation that you have demanded shouldn’t exceed Rs 20 lakh. Anyone could approach the ombudsman if the above guidelines are met.
9. You could seek remedies if the insurance company rejects the claim, allows the claim only partially or if there are any delays in allowing the claim, disputes regarding the premium rates and refuses to give the insurance documents.
10. If a complaint has been filed, then the ombudsman acts like a counsellor or a mediator. He/ she would summon both parties to listen to their sides, understand the facts and suggest remedies. If you are willing to accept the remedy, the ombudsman would inform this to the insurance company. The insurance company should then execute it within 15 days.

11. If the insurance company refuses to obey the instructions, the ombudsman would issue a decree of his/her own, within three months after receiving the complaint. The insurance company is bound to obey this and should execute it within 15 days.
The address of the insurance ombudsman in Kerala:
Insurance Ombudsman
Office of the Insurance Ombudsman
10th Floor, Jeevan Prakash, LIC Building
Opposite to Maharaja’s College Ground, MG Road
Kochi – 682 011
Tel – 0484 2358759
Email – bimalokpal.ernakulam@cioins.co.in
(Mail your doubts in this matter to nv190nv@gmail.com)