Handling of Health Insurance Grievance

Handling of Health Insurance Grievance

What are the options available to an insurance policy holder in case there is a grievance against the services provided by an insurance company as per the terms of the contract or in case of any dispute?

Let us see the modes to raise a complaint and steps to seek grievance redressal.

The Insurance Company:

1.     In case you are not getting satisfactory solution from Claims department take up the matter with Branch Manager.

2.     In case the matter is not resolved at this level then you should

File a complaint to the Grievance Redressal Office (GRO) of the insurance company. Every insurance company has a designated department for grievance redressal. The relevant documents must be submitted along with the written complaint. The insurer is liable to give an acknowledgement with reference number and date of complaint submission to the policy holder.

The GRO must revert to the complainant within a reasonable time frame, generally 15 days.

IRDA:

In case the insurer doesn’t revert within stipulated time or complainant is not satisfied with the resolution, matter can be escalated to the IRDA.

Policyholder needs to approach the Grievance Redressal Cell of the Consumer Affairs Department of IRDAI in one of the following ways:

·        Call on the Toll Free Number or send an email.

·        After the complaint has been lodged, one can register and monitor your complaint through IRDAI’s online portal - Integrated Grievance Management System (IGMS)

·        Complaint can also be filed through a written letter. Policy holder can fill and send the Complaint Registration Form along with any letter or enclosures and send it by courier or post.

The Turn Around Time (TAT) for each category of complaint is pre-defined, it is usually 10-15 days, maximum 30 days for majority of requests and grievances, other than death claims that require investigation, where the TAT is longer.

IGMS is a grievance redressal and complaint repository tool for IRDAI. If for any reason a policyholder is unable to contact the insurance company directly to lodge complaint, he/she can utilise IGMS channel to register complaints with insurance company also.IGMS serves as a common channel and platform for all insurance companies to resolve complaints and a way for IRDA to monitor the insurer’s resolution process as a whole.

InsuranceOmbudsman:

Govt.has set up Insurance Ombudsman to provide quick, cost effective and fair out of court resolution of complaints lodged by policy holders. Most of the times Insurance Ombudsman is retired Chairman of the Insurance Company, who understands Insurance industry very well.

Policyholder can approach Insurance Ombudsman when the insurance company has rejected the complaint, the policyholder is not satisfied with the resolution provided by the insurance company or there is no response from them for more than 30 days. The complaint must be lodged in writingwithin one year of the dispute or grievance being rejected by Insurance Company.

The complaint to Ombudsman can be lodged directly without needing a lawyer for representation. There are no fees or charged required to be paid.

The complaint should not be pending under any court or consumer forum when it is lodged to Ombudsman.

In case both parties agree for mediation, the Ombudsman gives his recommendation within 1 month; otherwise, he passes an award within 3 months from the date of receipt of all requirements from complainant.

The Insurer needs to comply with the award within 30 days from the date of receipt of the award and communicate award compliance to the Insurance Ombudsman.

Consumer Forum:

In case the complaint is not redressed through Insurance Ombudsman, the next step is to file the complaint with consumer forum personally or through a consumer redressal lawyer. There are three levels of consumer forums in India:

• District Forum: Complaints with total insurance claim value of less than Rs 20 lakhs can be filed here. The fee payable is nominal, maximum upto Rs 500. 

• State Commission: Complaints with total claim value of more than Rs 20 lakhs but less than Rs 1 crore can be filed and orders of the district forum can be challenged here within 30 days of the order being passed.The court fee for cases above Rs 20 lakh and up to Rs 50 lakh is Rs 2,000 while the court fee for cases up to Rs 1 crore is Rs 4,000. 

• National Commission: For complaints with total claim value of more than Rs 1 crore can be filed or the orders of state commission can be challenged here within 30 days of order being passed. The court fee is Rs 5,000.

There are instances where the case has been at different levels for 6 to 9 years so you have to have the patience.

If the judgement is in your favour you will get interest +legal charges+ harassment charges .

Feel free to reach us for any advice sksethi@riainsurance.com

If you are persistent you will win

If you are persistent you will win

The health insurance claim of Sanjay (name changed) was rejected by the insurance company. Repeated attempts by the insured with insurance company at various levels were not successful. We as Insurance Brokerage Firm advised him to take up the matter with Insurance Ombudsman. The matter took some time as the office of Insurance Ombudsman is having large number of complaints or cases coming up every day. After processing the date were fixed, the case was taken up and finally the insurance company was ordered to pay the claim. We appreciate the persistence effort put in by the insured, which has brought success to him.

Outlook magazine of November 3, 2011 has carried the case of Dr Kunal Saha, a medical doctor working and residing in USA. His wife had died in Kolkatta in 1998 while undergoing treatment. Kunal was convinced that Dr. Sukumar Mukherjee, the top Kolkatta physician who first treated Anuradha, had inflicted on her a massive overdose of Depomedrol, a long acting corticosteroids that went on to play havoc with her immune system; and that the treatment that followed, involving other doctors and the Advanced Medicare Research Institute (AMRI) a reputed private hospital, had been appallingly negligent .Armed with both certainty and rage, Saha, himself, a Kolkatta trained doctor put his peers in the dock.

Saha had too traveled 50 times over 13 years to India to fight the legal battle. I admire this gentleman.

The claim of Saha was for Rs 77 crores but Supreme Court of India delivered a ruling in 2009 which vindicated his struggle. By finding the Kolkatta doctors negligent, it opened the door for compensation order to be passed.

In October 2011, National Consumer Redressal commission has ordered that three Kolkatta doctors who treated Anuradha and AMFI will have to pay Rs 1.73 crores. Net payment after deductions to Saha will be Rs 1.34 crores. According to Dr Kunal Saha the amount spent by him on legal battle has been of the order of Rs 5 crores.

The points coming up before us are;

1. We should be persistent in follow up of our case whether it is Health insurance claim against an Insurance Company or liability claim against someone, who has not performed his duty.

2. Were 3 doctors or AMFI having professional liability cover in 1998 from Insurance Company? If yes will the Insurance Company pay it?

Let us wait and watch.

Are they supporting each other Or are they fighting with each other?

Recently we came across a news item that 64% of the cases which came up before Insurance Ombudsman (located all over the India) was pertaining to health insurance portfolio. Let us look at the facts;

Health Insurance as % of non life insurance portfolio = 32%
Group policies issued under Health Insurance portfolio = 50%
Policies issued to Individual/ Families = 50%

It means policies being issued to Individuals/ Families are only 16% of total non life insurance portfolio.

General impression is that claims arising from group policy get paid because they have the bargaining /negotiating power .It means that Individuals/ Families are the worst sufferers as this is the group which is having claims being disallowed.

The question before us is how many of the dissatisfied customers are able to reach the office of Insurance Ombudsman?

64% figure is really a very high figure .Let us try to look at the reasons for this scenario or why it is so?

There are 3 players.

Role of every player is to provide good service to the customer. When the insured has to go in for hospitalization then each one ( Insurance Company /TPA/Health care Provider ) is trying to pass on the buck to other player as if the objective or job description of each one is who can harass the customer most so that he runs away and forgets about claim .
Health care provider says that this insurance company is blacklisted or this TPA is black listed

TPA says that this health care provider is black listed.

Insurance Company says that they are ready to consider the payment of the claim but it will not be on cashless but on reimbursement basis. This defeats the basic assumption of the client that when the need arises he will be able to have payment coming from insurance company.

We need the change in thinking at all levels.