How To Lodge Health Insurance Complaint?

Many people buy a health insurance policy policy to take care of their medical expenses in the event of an emergency. It acts as a shield to your savings and allows you to get the best medical care without worrying about the cost.Often, people face issues with their claim settlement or getting compensation for the expenses incurred from the insurance company. In some cases, the insurer does not provide the services they promised initially or do not resolve a grievance within the stipulated time. If you have faced any such problems with the insurer or if you are dissatisfied with the services you receive from the insurer, you can lodge a complaint against them.But, before we look at the process to file a health insurance complaint, let us understand the common reasons to complain against the insurer:

• The payout is unsatisfactory
• Negligence in services
• The policy renewal process is denied without any valid reason
• Rejecting the claim request
• Increasing the premium cost without any prior notice
• Charging unnecessary fees for the services not rendered

The first step in filing a health insurance complaint is to approach the Grievance Redressal Officer of the branch and give a written complaint along with the necessary documentation and proofs (as required).Generally, the insurance companies take about 15 days to respond to your complaint and resolve the issue. However, if the insurer fails to do so, you can escalate the matter to the insurance governing body, the Insurance Regulatory and Development Authority of India (IRDA).To file a complaint against the insurance company with IRDA, you must get in touch with the Grievance Redressal Cell of the Consumer Affairs Department through email or customer care helpline number. You can also contact the IRDA through fax. Once you report the issue, you can use the IGMS (Integrated Grievance Management System) offered by the IRDA to monitor and track the complaint status.The IRDA has a specific maximum TAT (Turn Around Time) for different issues before responding to your complaint.What are the channels to file a health insurance complaint? You can lodge a health insurance complaint through three main channels – Insurance Ombudsman, IGMS, and the Consumer Court.

Insurance Ombudsman

An ombudsman is a government-appointed official who investigates the citizens' complaints against government departments, financial institutions, business organisations, etc. You can seek help from the insurance ombudsman to find a solution to the issue that has not been resolved by the insurance company. You can file a complaint with the insurance ombudsman under the following circumstances:

• Your claim is wholly or partially rejected
• You did not receive the policy even after paying the premium
• There is an unexplained in claim settlement
• There is a dispute regarding the premium paid or premium amount payable
• There is a dispute regarding the policy terms and conditions

IGMS – Integrated Grievance Management System

IGMS is an online platform introduced by the IRDA, where the policyholders can file a complaint against their insurance provider. Through this system, you can file a complaint and keep track of the progress. The IGMS helps the IRDA provide centralised access to the policyholder and classify the complaints based on specific pre-defined norms.Under the system, when you file a complaint, you are assigned a unique complaint ID, and the same is assigned to the relevant department for a quick resolution. The system also assigns a TAT for all complaints registered and ensures an efficient complaint resolution.

Consumer Court

Even after filing a complaint with the IRDA, if your issue is not resolved, you can approach the consumer court and file a litigation against the insurance company. The consumer court has a special division to handle health insurance complaints.

If you feel you are exploited by the insurance company, it is well within your right to file a complaint against them. Use the right channels and comply with the above-mentioned complaint procedures and get your issue resolved.

Health insurance has recently experienced rapid market expansion. However, scam in this area has also risen.These frauds can be committed by the insured and the insurer and take many forms. In case you were unaware, the government also gives you the option of complaining to the health insurer. To know about the prevalent frauds, see the list below:

Application Fraud:

It is a fraud type frequently seen in the health insurance sector. The policyholder gives misleading information about the sickness. Additionally, the insured may choose to remain silent or withhold any information in order to extend the term of the policy for health insurance.

Internal/External Fraud:

Frauds committed by the policyholder, beneficiary, medical vendor, and other external parties are referred to as external frauds. The insider commits internal fraud against the insured. Any employee of the business, from an executive to a manager, could be an insider.

You only need to register a complaint with the IRDAI against the health insurance provider if you are dissatisfied with the service and have proof that the firm is at fault and not you.You can immediately seek the governing body for an immediate resolution if the insurance firm does not respond within the TAT stipulated by the IRDAI. The IRDAI doesn't hold up the procedure and will speak with the company as soon as possible. The insured must file a formal complaint in the consumer court in case of any other inquiry.

Ombudsman for Insurance:

To escalate a problem that the insurance company hasn't fixed, you can ask the Insurance Ombudsman for help. Under the following circumstances, you may contact the Insurance.

Ombudsman with a complaint:

Your claim has either been rejected entirely or in part.After paying the premium, you still have not received your health insurance coverage .
The payment of the suit has been delayed.Regarding the payment due/premium paid, there is a disagreement.
The terms and conditions listed in the Policy Schedule are in question.

Integrated Grievance Management System:

IRDA created the Integrated Grievance Management System as an online forum for policyholders to escalate complaints or disputes they may have with insurance companies. You can use this system to file a complaint and follow its development. These monitoring and grievance redressal technologies aid the IRDA in centralising policyholder access and classifying complaints in accordance with predetermined standards.A unique complaint ID is assigned to each complaint under this system and transmitted to the relevant departments for resolution. This aids in keeping an eye on problems with market behaviour. Additionally, this establishes warnings for unfinished jobs and assigns turnaround times for any complaints registered. The system's rule-based procedures and thorough reports guarantee effective complaint resolution.

Consumer Court:

You can lodge a complaint with the consumer court if it hasn't been settled. Health insurance complaints are handled by a separate division of the consumer court, particularly those involving unethical business activities, negligence, and service problems.

The information contained herein is generic in nature and is meant for educational purposes only. Nothing here is to be construed as an investment or financial or taxation advice nor to be considered as an invitation or solicitation or advertisement for any financial product. Readers are advised to exercise discretion and should seek independent professional advice prior to making any investment decision in relation to any financial product. Aditya Birla Capital Group is not liable for any decision arising out of the use of this information.