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Submitted by: Swati Singh

Submitted to: Dr. V. Shunmuga Sundaram Sir


1. Introduction.
2. Establishments & Purpose.
3. Appointment , eligibility and tenure.
4. Territorial jurisdiction of ombudsman.
5. Nature of complaints to ombudsman.
6. Manner in which complaints is to be made.
7. Functions of insurance ombudsman.
8. Settlement of cases.
9. Case Studies.
10. Discussion on doubts.
 The concept of Ombudsman began in Sweden where an
independent executive was appointed by the government to
look into the disputed matters of the citizens.

 ombudsman means representative (with ombud meaning


attorney).

 It is an official appointed by government who can represent


the interests of the insured by investigating & addressing the
complaints.

 Also known as chief vigilance officer, Lokpal or Lokayukta.


ESTABLISHMENT:
 The institution of insurance ombudsman was created
by a Government of India dated 11th november,1998.

PURPOSE:
 Free , fair and efficient dispute resolution mechanism.
APPOINTMENT:
 Governing body of insurance council issues orders of
appointment of ombudsman on the recommendation of
committee comprising of chairman of IRDA,LIC,GIC
and a representative of central government.

ELLIGIBILITY:
 Ombudsman is drawn from Insurance Industry, Civil
Services and Judicial Services.

TENURE:
 For a term of 3 years or until the age of 65 years,
whichever is earlier.
TERRITORIAL JURISDICTION OF OMBUDSMAN:

 The Executive council of Insurers specifies


the territorial jurisdiction of Ombudsman.

 Any person who has grievance against an insured may make


complaint to ombudsman within whose territorial
jurisdiction the office of insurer complained or the
residential address of the complainant is located.

 At present there are 17 insurance Ombudsmans located at :


 1.Ahmadabad 2.Bangalore 3.Bhopal 4. Bhubaneswar 5.
Chandigarh 6.Chennai 7.Delhi 8.Guwahati 9.Hyderabad
10.Jaipur 11. Ernakulum 12.Kolkata 13.Lucknow
14.Mumbai 15.Noida 16.Patna 17.Pune.
Nature Of Complaints To Ombudsman:

The complaint must be in respect of personal lines of


insurance and may relate to :

 Any partial or total repudiation of claims.

 Dispute with regard to premium paid or payable.

 Legal construction of the policy wordings.

 Delay in settlement of claims and

 Non-issuance of any insurance document.


When can a complaint be made to the Ombudsman?

1. If the insurer has rejected a written representation of


the complainant.

2. The complainant had not received any reply within 1


month after the insurer received his representation.

3. The complainant is not satisfied with the reply given


to him by the insurer.
 The complaint is made not later than 1 year after the
insurer had rejected the complaint.

 The complaint is not on the same subject matter, for


which any proceedings “before any court, or Consumer
Forum, or arbitrator” is pending.
Functions of insurance Ombudsman :
1. Conciliation

Complaint is settled
through mediation

Recommendation
within 1 month
accepted not accepted

Send in writing, within 15 Move to other avenues


days that he accepts the Courts, consumer forum
settlement as full & final or arbitrator

Notify the insurer to comply with Notify the


terms of recommendation within ombudsman of
15 days compliance
Functions of insurance Ombudsman(cont.)
2. Award Making

 Award means payment ,compensation or prize to


someone.

 Ombudsman conducts hearing of both the parties before


an award is passed.

 Theombudsman shall pass an award within a period of


3 months from the receipt of the complaint.
 The awards are binding upon the insurance companies.

 If the policy holder is not satisfied with the award of


the Ombudsman he can approach other venues.

 Ombudsman's powers are restricted to insurance


contracts of value not exceeding Rs. 30 lakh.
 Copies of the award shall be sent to the insurer and the
complainant.

 Complainant shall furnish to the insurer within one


month, a letter of acceptance.

 Insurer shall comply with the award within 15 days and


intimate compliance to the Ombudsman.

 If the complainant does not intimate acceptance within


one, the insurance company may not implement the
award.
SETTLEMENT OF CASES:

 During 2015-16, the Seventeen Ombudsmen centres spread


across India have received a total of 26,177 complaints.

 While 17,257 complaints (66 per cent) pertained to life


insurers, the remaining 8,920 complaints (34 per cent)
related to non-life insurers.

 This was in addition to 6,782 complaints pending with


various offices of Ombudsmen as at the end of March 2015.

 During 2015-16, Ombudsmen disposed of 30,266


complaints. Out of these complaints, Ombudsmen declared
49.56 per cent of the complaints as non-acceptable/not
entertainable.

 2,693 complaints were pending


as on 31st March, 2016.
ISO 9001:2015 (QMS) CERTIFICATION:

 The Office of the Insurance Ombudsman, Delhi has


been awarded ISO 9001:2015 certification.

 Certification is based on quality management


principles.

 On 28.02.2017 a total of 27926 complaints were


received out of which 24140 complaints were disposed
off.