Ombudsman & Consumer Court

Covid-19 claim rejected? Here’s how to lodge complaint with insurer, Ombudsman & consumer court

Health insurance companies have received a total of 23.06 lakh claims worth Rs 29,341 crore as on August 6, 2021.

Ombudsman & Consumer Court While they have settled Rs 17,813 crore involving 18.99 lakh claims so far.

Ombudsman & Consumer Court

Coronavirus is not out of the woods yet and the threat of the third wave is doing the rounds.

While maintaining all Covid-19 protocols is the need of the hour.

One also needs to ensure there is adequate health insurance coverage to fall back upon in times of hospitalization.

But, of late, there have been apprehensions about the Covid-19 relate insurance claims not being accept by insurers.

Claims getting delay or partially pay to the policyholders.

Health insurance companies have receive a total of 23.06 lakh claims worth Rs 29,341 crore as on August 6, 2021.

According to figures compile by the General Insurance Council.

However, insurance firms have settle Rs 17,813 crore involving 18.99 lakh claims so far.

In order to clear the air around insurance claims and the mechanism for the policyholders to raise a grievance.

FE Online in an email interview sought the answers around settlement of claims Excerpts:

What is the course of action if a claim is denied? What is the process and timeline before lodging a complaint with the insurer, Ombudsman and consumer court?

If the claim is denied, the policyholder must inquire about the reasons.

Often rejection on the grounds such as inadequate bills.

Documents can be resolve by submitting the relevant documents.

Against the rejection of a claim, the first recourse is to the grievance committee of the insurer.

Although no timeline has been specified for the same.

It will be ideal to avail this remedy within 3 years of rejection of the claim to avoid the claim becoming time bar under laws of limitation.

Against the grievance committee’s decision, the Ombudsman can be approach.

The communication from the insurer should specify the details of the Ombudsman to be approach.

Ombudsman must be approach within one year from the date of rejection of the complaint by the insurer’s grievance committee.

If the consumer is dissatisfy with the Ombudsman’s determination.

(S)he can approach the consumer courts within 2 (two) years.

It is pertinent to note that IRDAI has establish an online complaints registering system call.

The Integrated Grievance Management System (IGMS) where the form with the complaint can be fill and submit.

Complaints submitted on IGMS are forward to the insurer as well as IRDAI.

IRDAI monitors the disposal of the complaint submit on IGMS portal.

Ombudsman & Consumer Court

In case a claim is partially settle, should one accept & later on approach court etc to settle full dues?

It is common for the insurance companies to seek a letter or undertaking from the insured releasing the insurer of any further claim.

It is advisable to avoid giving such undertakings.

Where such undertakings are force, a protest is lodge immediately with the insurer.

Partially settle claims can, thus, be accept under protest.

The courts may be approach for the settlement of the remaining claim.

Courts may have to be convince, in such cases, that the release.

If any, execute by the consumer was execute under duress and should be disregard.

What is the general trend in terms of Covid-19 claims being settle by the insurance companies?

Claim settlement turnaround time has been reduce by most insurers following IRDAI’s directive.

However, some concerns around settlement remain.

According to the industry data, as on July 19, 2021, of the total reported claims of Rs 27,640 crore.

Claims worth Rs 16,396 crore were settled. Settlement amounts range between 55 per cent and 65 per cent of the claim.

In the first Covid19 wave (up to February 22, 2021), insurers report claims worth Rs 13,736 crore.

Which claims worth Rs 7,125 were settle.

In the second wave – from February 23 to July 19, 2021 – of total health insurance claims of Rs 13,905 crore, claims worth Rs 9,271 crore were settle.

Ombudsman & Consumer Court

As per IRDAI, within how many days should insurers make reimbursement to the policyholder?

According to the guidelines issued by the IRDAI, insurers are required to settle or reject the claim.

As the case may be, within 30 days from the date of receipt of the last necessary document.

Where investigation is warranted, the insurer is required to complete the investigation within 30 days.

Accept or reject the claim within 45 days of receipt of the last necessary document.

If there’s a delay in the payment of the claim.

The insurer is required to interest at a rate 2% above the bank rate.

From the date the reimbursement is payable.

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