P N Ramesh, Assistant Manager,

Bangalore RO ITD
Policyholder Servicing Turnaround Times as
prescribed by IRDA

P N Ramesh, Assistant Manager, Bangalore RO ITD

Ombudsman
FORMATION The institution of insurance Ombudsman was created by a Government of
India Notification dated 11th November, 1998.

PURPOSE Quick disposal of the grievance of the insured customers and to mitigate their
problems involved in redressal of those grievances.

APPOINTMENT OF INSURANCE OMBUDSMAN The governing body of insurance council issues

orders of appointment of the insurance Ombudsman on the recommendations of the committee
comprising of Chairman - IRDA, Chairman - LIC, Chairman GIC and a representative of
the Central Government. Insurance council comprises of members of the Life Insurance
council and general insurance council formed under Section 40C of the Insurance Act, 1938. the
governing body of insurance council consists of representatives of insurance companies.

ELIGIBILITY Ombudsman are drawn from Insurance Industry, Civil Services and Judicial
Services.

TERMS OF OFFICE Three years or till the incumbent attains the age of sixty five years
whichever is earlier. Re-appointment is not permitted.

TERRITORIAL JURISDICTION OF OMBUDSMAN There are 17 Ombudsman across the

country
P N Ramesh, Assistant Manager, Bangalore RO ITD
Ombudsman
REMOVAL FROM OFFICE If the ombudsman is not discharging its duties he can be removed
from the office by conducting an inquiry against him by IRDA.

POWER OF OMBUDSMAN The area of complaint may relate to (1) any partial or total
repudiation of claims by Insurance Companies (2) dispute with regard to premium paid or
payable in terms of the policy (3) dispute on the legal construction of the policy wordings in case
such dispute relates to claims (4) delay in settlement of claims and (5) and non-issuance of any
insurance documents to customers after receipt of premium.

FINANCIAL POWER Ombudsmans power are restricted o insurance contract of value not
exceeding Rs.20 lacs. The insurance companies are required to honour the awards passed by
an Insurance Ombudsman within three months.

PROCEDURE OF LODGING COMPLAINT The complainant should lodge a complaint in writing

to Ombudsman office under whose jurisdiction the insurers office falls but before lodging
complaint, the complaint should ensure that (1) he should have filed a complaint against the insurer
and has not received satisfactory reply (2) the complaint is not made later than one year
after the insurer had replied. (3) the same complaint on the subject should not pending with before
any court, consumer form or arbitrator.

RECOMMENDATIONS OF THE OMBUDSMAN After deciding the case, the ombudsman shall
aware the insurer as well as P Ncomplainant
Ramesh, Assistant Manager,
about Bangalore RO ITD
his recommendation within one month(30
Ombudsman
AWARD After receiving acceptance from the complainant, the Ombudsman shall
pass an award within a period of three months from the receipt of the complaint.

CHALLENGING OF AWARD The insurance cannot challenge the award passed by

the Ombudsman, however, the complainant has the liberty to approach other venues
like Consumer Forums and Courts of law for redressal of his grievances.

DUTY OF INSURER As per the policy-holders protection regulations, every insurer

shall inform the policy holder alongwith the policy document in respect of the Insurance
Ombudsman in whose jurisdiction his office falls for the purpose of grievance redressal
arising if any subsequently.

WHO CAN LODGE A COMPLAINT An individual, complaint lodged by corporate

client does not come under the preview of the Ombudsman.

P N Ramesh, Assistant Manager, Bangalore RO ITD

Ombudsman

The Insurance Ombudsman scheme was created by Government of India for individual
policyholders to have their complaints settled out of the courts system in a cost-effective,
efficient and impartial way. There are 17 Insurance Ombudsman in different locations
and you can approach the one having jurisdiction over the location of the insurance
company office that you have a complaint against.

You can approach the Ombudsman with complaint if:

You have first approached your insurance company with the complaint and
They have not resolved it
Not resolved it to your satisfaction or
Not responded to it at all for 30 days
Your complaint pertains to any policy you have taken in your capacity as an individual and
The value of the claim including expenses claimed is not above Rs 20 lakh

Your complaint to the Ombudsman can be about:

Any partial or total repudiation of claims by an insurer
Any dispute about premium paid or payable in terms of the policy
Any dispute on the legal construction of the policies as far as it relates to claims
Delay in settlement of claims
Non-issue of any insurance document to youManager,
P N Ramesh, Assistant afterBangalore
you pay your premium
RO ITD
 dsman

budsman will act as counsellor and mediator and

at a fair recommendation based on the facts of the dispute

ccept this as a full and final settlement, the Ombudsman will
the company which should comply with the terms in 15 days

ement by recommendation does not work, the Ombudsman will:

award within 3 months of receiving the complaint and which will be
peaking award with the detailed reasoning
ding on the insurance company but
binding on the policyholder
mbudsman can also award an ex-gratia payment

he Award is passed
e to accept the award in writing and the insurance company has to be informed of it within 30 da
urance company has to comply with the award in 15 days after that.

P N Ramesh, Assistant Manager, Bangalore RO ITD

The silent features of the act :
A. It covers all the sectors - private, public or co-operative.
B. A three tier quasi judicial machinery to provide simple, speedy and in-expensive
redressal of consumer grievance.

Insurance has been defined as services for the purpose of the act. Every buyer of
insurance is a consumer.
In the past several decades, there has been a movement to safeguard the interest of the
consumer.

The following four consumer rights have been accepted as basic.

a. The right to safety. Goods which are hazardous to life and property violates this
right.
b. The right to be informed about all the relevant aspects of the product being sold.
c. The right to choose.
d. The right to be heard against unfair trade practice.

A consumer can approach the various forums prescribed under the act for redressal, in
case:
He is not satisfied with the goods or services.
A defect or deficiency, imperfection, short
P N Ramesh, coming
Assistant or inadequacy
Manager, Bangalore RO ITD in the quality, nature or
The majority of disputes relating to insurance arise out of repudiation and delay in claims
such delay occur often due to non-compliance with requirements or ambiguity in title.

Complaint may be filed before:-

A District Forum has jurisdiction to entertain a complaint if the value of the service and
compensation claimed, is up to Rs. 20 lacs.

A State Commission has original, appellate and supervisory jurisdiction. It would

entertain appeals from the district forum. It has original jurisdiction to entertain complaints
where the value of goods/services and compensations claims exceeds Rs. 20.00 lacs but
not to exceed Rs. 1.00 crore.

The NATIONAL COMMISSION is the final authority established under the act. It will have
the original appellate as well as supervisory jurisdiction. It would hear the appeals from the
order passed by the state commission and it has original jurisdiction to entertained
complaints where the value of goods/services and compensation claimed exceeds Rs.
1.00 crore.

An appeal shall lie within 30 days from the order of the National Commission to Supreme
Court. Cases must be decided within 3 months unless lab tests are required (then 5
months). Non compliance with the orders of the forum are liable to be penalized with fines
P N Ramesh, Assistant Manager, Bangalore RO ITD
upto Rs. 10,000 and jail upto 3 months.
IRDAI Grievance Mechanism

The Consumer Affairs Department of the Insurance Regulatory and Development

Authority (IRDA) has introduced the Integrated Grievance Management
System (IGMS) which is an online system for registration and tracking of
grievances.

You must register your grievance first with the insurance company and in
case you are not satisfied with its disposal by the company , you may escalate it
to IRDA through IGMS by accessing www .igms.irda.gov.in. In case you are
not able to access the insurers grievance system directly , IGMS also provides
you a gateway to register your grievance with the insurer .

Apart from registering your grievance through IGMS or simply call IRDAI Call
Centre at Toll Free 155255 through which IRDA shall, free of cost, register
your complaints against insurance companies as well as help track its status.

When a complaint is registered with IRDA, it facilitates resolution by taking it up

with the insurance company . The company is given 15 days time to resolve
the complaint. If required, IRDA carries out investigations and enquiries. Further ,
wherever applicable, IRDA P advises the Manager,
N Ramesh, Assistant complainant to approach the Insurance
Bangalore RO ITD
Who is an Agent?
An agent is a person who is licensed by the Authority to solicit and procure
insurance business including busines s relating to continuance, renewal or revival
of policies of insurance. An agent could be an Individual Agent or a Corporate
Agent. An Individual Agent, as the name suggests is an individual who in an
intermediary representing an insurance company while a corporate agent is an
intermediary other than an individual, representing an insurance company .

What does Designated Person of a Corporate Agent mean?

A Designated Person means an officer normally in charge of marketing operations, as
specified by an insurer , and authorized by the Authority to issue or renew
licences under the applicable regulations.

Who is a Composite Insurance Agent?

Composite Insurance Agent means an insurance agent who holds a licence to act as
an
insurance agent for a life insurer and a general insurer .

Who is an Insurance Broker?

An Insurance Broker means a person licensed by Insurance Regulatory and
P N Ramesh, Assistant Manager, Bangalore RO ITD
Development Authority who arranges insurance contracts with insurance companies
What is the difference between an Agent and a Broker ?
While an Agent represents only one insurance company ( one general, one life or both if he is a
composite agent, apart from a health insurance company), a Broker may dealt with more than one
life or general or both.

A r e Surveyors a n d Third Party Administrators also Intermediaries?

Surveyors and Third Party Administrators are also termed as Intermediaries but they are not
involved in marketing of insurance.

Are Agents and Brokers required to be licensed?

Yes. Agents and Brokers have to be licensed by the Insurance Regulatory and Development
Authority (IRDA) for life insurance or general insurance or both. They also are bound by a Code
of Conduct laid down in the respective regulations.

Can the Intermediary give me a discount on the premium I am supposed to pay?

No intermediary can offer any discount to you to induce you to take the policy . If any such
inducement is resorted to, it is in violation of Section 41 of the Insurance Act, 1938 and all
parties involved would be subject to rosecution as provided by the Law .

Any discount on premium you receive would be only in terms of what the policy allows and it is given
by the insurance company .
P N Ramesh, Assistant Manager, Bangalore RO ITD
Insurance Surveyors and Loss Assessors

Section 64 UM of the Insurance Act, 1938 stipulates requirements to act as Surveyor and Loss
Assessor. IRDAI (Insurance surveyors and Loss Accessors) regulations 2015 prescribe the
procedure for obtaining the license of Insurance Surveyor & Loss Accessors.

Regulation 12 of the IRDAI (Insurance Surveyors and Loss Accessors) Regulations, 2015
mandates appointment of Surveyors and Loss Assessors either by Insurance or Insurer to assess
loss under a policy of Insurance in respect of (a) Motor Insurance - above Rs. 50,000/- (b) other
than Motor Insurance above Rs. 1,00,000/-. Further the required qualification to become
surveyor has also laid down in Annexure-I of schedule I of the above said Regulation.

A surveyor & Loss Assessor shall assess losses of only those departments which are specified in
his/her license.

P N Ramesh, Assistant Manager, Bangalore RO ITD

Survey Report : Time Limit & Additional Survey report

In exceptional circumstances, there could be a delay in submission of survey report by a surveyor,

beyond 30 days from the date of his appointment, in which case he has to necessarily seek
extension of time from insurer under intimation to the insured.. However, in NO case, the time
limit for submission of report can exceed a period of 6 months from the date of his
appointment.

Yes. Wherever the insurer finds the surveyors report incomplete in any respect, he can ask the
surveyor to furnish additional report within 15 days of receipt of the original report. In such
a case, the surveyor shall furnish the additional report within 3 weeks of the receipt of such
communication.

Claim Settlement : Offer

Once an offer of claim settlement given by insurer is accepted by a policyholder in writing, claim
settlement amounts should be disbursed within 7 days from the date of acceptance by
policyholder. In case of any delay in disbursement of the claim amount, the insurer is liable to pay
interest @ 2% rate above the bank rate prevalent on 1st April of that financial year.

Celebration of Insurance Awareness Day

IRDAI is celebrating 19th April as Insurance Awareness Day at Hyderabad. On this occasion,
IRDAI is organizing Pan India Insurance Quiz Competition for Insurance Companies, which is one of
the activities to taken up as a part of these celebrations.
P N Ramesh, Assistant Manager, Bangalore RO ITD
Health : IRDAI

The Hospital Daily Cash Benefit policy , provides a fixed daily sum insured for each
day of hospitalization. There may also be coverage for a higher daily benefit in case of
ICU admissions or for specified illnesses or injuries.

A Critical Illness Benefit policy provides a fixed lumpsum amount to the insured in
case of diagnosis of a specified illness or on undergoing a specified procedure. This
amount is helpful in mitigating various direct and indirect financial consequences of
a critical illness. Usually , once this lump sum is paid, the plan ceases to remain in
force.

There are also other types of products, which offer lumpsum payment on undergoing
a specified surgery (Surgical Cash Benefit), and others catering to the needs of
specified target audience like senior citizens.

Waiting Period for claims under a policy :

Ans. Yes. When you get a new policy , generally , there will be a 30 days waiting period
starting from the policy inception date, during which period any hospitalization charges
will not be payable by the insurance companies. However , this is not applicable to any
emergency hospitalization occurring due to
P N Ramesh, Assistant an Bangalore
Manager, accident.
RO ITD This waiting period will not
Health : IRDAI (Tax Benefit)

Health insurance comes with attractive Tax Benefits as an added incentive. There
is an exclusive section of the Income Tax Act which provides tax benefits for health
insurance, which is Section 80D, and which is unlike the section 80C applicable to
Life Insurance wherein other form of investments/ expenditure also qualify for the
deduction.

Currently , purchasers of health insurance who have purchased the policy by any
payment mode other than cash can avail of an annual deduction of Rs.15,000 from their
taxable income for payment of Health Insurance premium for self, spouse and
dependent children. For senior citizens, this deduction is higher , and is Rs.20,000.

Further, since the financial year 2008-09, an additional Rs 15,000 is available as

deduction for health insurance premium paid on behalf of parents, which again is Rs
20,000 if the parents are senior citizens.

P N Ramesh, Assistant Manager, Bangalore RO ITD

Pre-existing Condition in Health Policy
It is a medical condition/disease that existed before you obtained health insurance
policy , and it is significant, because the insurance companies do not cover such pre-
existing conditions, within 48 months of prior to the 1st policy. It means, pre-
existing conditions can be considered for payment after completion of 48 months of
continuous insurance cover .

Grace Period : During Renewal The Policy will be renewable provided you pay the
premium within 15 days (called as Grace Period) of expiry date. However , coverage would
not be available for the period for which no premium is received by the insurance
company . The policy will lapse if the premium is not paid within the grace period.

Health Portability The Insurance Regulatory and Development Authority ( IRDA ) has
issued a circular making it effective from 1st July ,2011, which directs the insurance
companies to allow portability from one insurance company to another and from one
plan to another , without making the insured to lose the renewal credits for pre -
existing conditions, enjoyed in the previous policy .
However , this credit will be limited to the Sum Insured (including Bonus) under
previous policy .

'Any one illness' would mean P the continuous period of illness, including relapse
N Ramesh, Assistant Manager, Bangalore RO ITD
within a certain number of days as specified in(9655765560)
the policy . Usually this is 45 days
Free-Look Period
After receipt of your policy , go through it thoroughly and if you do not understand
certain terms contact your intermediary and get them explained. Remember, for life
insurance and for health insurance policies of a term of three years or more, there is a
free -look period within which you may return the policy if you do not agree with the
terms and conditions therein.

You can seek cancellation a Health Insurance insurance policy within 15 days (30 days if
sold by distance mode) from the date of receipt of the policy document if you disagree
with any of the terms or conditions in the policy.

For this, you should return the policy stating the reasons for objection.
You will be entitled to a refund of the premium paid.
A proportionate risk premium for the period on cover and the expenses incurred by the
insurer on medical examination and stamp duty charges will be deducted

Cumulative Bonus
Cumulative bonuses offered under policies, shall be stated explicitly in the prospectus
and the policy document.
If a claim is made in any particular year, the cumulative bonus accrued may be reduced
at the same rate at which it has accrued;
P N Ramesh, Assistant Manager, Bangalore RO ITD
Group Health Insurance
The Group shall have a minimum size of 7 members to be eligible for issuance of a
Group Insurance Policy.
No Group Health Insurance Policy shall be issued by any Insurer where a Group is formed
with the main purpose of availing itself of insurance

Entry and Exit Age

Except as provided for in regulation 17(i), all health insurance policies shall provide for
an entry age of at least up to 65 years
Except travel insurance products, personal accident products and Pilot Products, once a
proposal is accepted and a policy is issued which is thereafter renewed periodically
without any break, further renewal shall not be denied on grounds of the age of the
insured.

Cost of Pre-Insurance Health Checkup

The cost of pre-insurance medical examination in case of products with term of one year
and less, if such cost is to be incurred by the insured, not less than 50% of such cost shall
be borne by the insurer once the proposal is accepted, except in travel insurance policies.

Multiple Policies
If two or more policies are taken by an insured during a period from one or more insurers to
indemnify treatment costs, theP Ninsurer
Ramesh, Assistant Manager, Bangalore RO ITD
shall not apply the contribution clause, but the
Developments on IRDAI

Insurance Repository System

Hon'ble Finance Minister has launched the Insurance Repository System initiated by IRDA to
hold insurance policies in electronic form. The system was launched on 16th September,
2013

Policyholder Protection Committee

IRDA has put forth many measures to protect the policyholders interests. Insurers have
been told to strengthen their grievance redress procedures, consumer complaint resolving
procedures where they are found weak.

An important step taken by IRDA is that it has made it compulsory that each company
forms a Policyholder Protection Committee in the Board of Directors. This is part of the
Corporate Governance guidelines issued by IRDA and will have the effect of ensuring that
insurers internal systems are monitored effectively at the highest level of the company,
that is, the Board.

Distance Marketing
Insurance policies are sold over the phone or the internet as well as through bank ATMs and
so on. These other than face-to-face selling
P N Ramesh, Assistant methods
Manager, Bangalore have
RO ITD their own peculiarities and
Rejection of Claims
An insurer shall settle or reject a claim, as may be the case, within thirty days of the
receipt of the last necessary document.
TPA is not permitted to settle/or repudiate claims as per Sec 33(c)
Claims that are being settled shall be done through e-payments by the insurers.
The rejection letter should mention the specific grounds for denial of claim

Individuals covered under group policies have had their claims rejected on technical
grounds like slight delays in intimation of claims. IRDA has advised insurance companies
that contractual conditions should not prevent them from considering genuine claims. This
is especially if unavoidable circumstances prevented the consumer from following some of
the policy conditions like time-frame for intimation

e-Insurance Policies
The world is moving towards using less paper and to electronic records, especially financial
records. Shortly you too can get and maintain your insurance policies in electronic form.
IRDAI has issued guidelines relating to insurance repositories and electronic issuance of
insurance policies.
You can:
Maintain, store and retrieve your policies and the information in them easily
You can modify or revise your insurance policies with speed and accuracy
P N Ramesh, Assistant Manager, Bangalore RO ITD
It will help increase efficiency and transparency
IRDAI Latest Amendments

IRDAI Projects in Pipeline

Tying and Bundling

Tying of two products (or services) occurs when a seller sells one good (tying good) on the condition
that the buyer buys the other good (tied good) from that seller or imposes on the buyer the
requirement that s/he will not purchase the other good from another seller.

Bundling is a general term describing selling collections of goods as a package. In pure bundling, the
individual goods are not sold separately but only in combination, so it is essentially equivalent to
tying. In mixed bundling, the individual goods, as well as the package, are available

P N Ramesh, Assistant Manager, Bangalore RO ITD