How to Lodge a Complaint Against Health Insurance Company?

Any person gets insurance for the family or for himself or herself as a safeguard against tough times but there could be instances when one is not content with the performance of the insurer. If any customer feels that there was a lapse or negligence on the part of their insurance company in processing a proposal, servicing a policy or processing Insurance Claims, there are various ways to file a complaint against your Health Insurance Company.

The IRDAI can be approached in such cases for a solution. The IRDAI has a turnaround time or TAT for all the services rendered by an insurance company to the insured person and it has come into effect under the IRDA Protection of Policyholders’ Interests PPHI Regulations, 2002.

The maximum turnaround time or TAT, has also been set for life insurance companies as well as general insurance companies and it is based on the kind of service offered by it. The insurance provider has to resolve the grievance within the stipulated date and when it does not, the policyholder may take up the matter with the IRDA and approach them for a solution. The process is definitely escalated when they intervene and if an inquiry is required, the policyholder may next approach the Consumer Court.

How to file a complaint against Health Insurance Company:

There is a process to file a complaint against your health insurance company. Before making the complaint, the Grievance Redressal Office of the branch has to be approached whereby the complaint has to be written and submitted with proper documentation. An acknowledgement of receiving the complaint would be provided and it is expected the matter would be resolved in 15 days, after which it can be taken up with the IRDA.

In case the matter is taken up to the IRDA, the policyholder would have to approach the Grievance Redressal Cell of the Consumer Affairs Department through the customer support helpline or by email. After the complaint has been lodged, the Integrated Grievance Management System offered by the IRDA may be used to monitor the complaint and its progress. The Insurance Regulatory or the Development Authority may also be contacted via fax or through a formal letter. The TAT on requests and grievances related to some of the services vary. For example, obtaining a copy of policy proposal be require 30 days time while the issue or cancellation of policy may require 15 days only. Issues pertaining to survival benefit, maturity claim or penal interest would also take around 15 days.

There are various channels for lodging a complaint as well. Apart from the above mentioned Consumer Court or approaching the Integrated Grievance Management System, one may also approach the Insurance Ombudsman.

To take up the matter with the Ombudsman, one of many of the incidents should have occurred:

• The claim of the policyholder has been rejected completely.
• The policyholder has not received the policy benefits even after paying premiums.
• There are delays in claim settlement.
• A dispute has arisen regarding premium paid and or payable.
• Disputes regarding the terms or conditions that have been specified in the policy schedule.

On the other hand, the Integrated Grievance Management System is an online platform where the policyholders can escalate their case. The monitoring tools of the system help the IRDA to track the matter and provide them with centralized access to the policyholder as well as classify the complaints based on their type for quicker resolution. The policyholder is provided with a unique ID pertaining to the complaint.

The matter can also be taken up with the Consumer Court, which has a separate department to deal with the health insurance grievances and looks into matters especially arising out of malpractices in health insurance companies, service issues and unfair trade practices.

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