Mumbai: One of my friends -- let's call him Atul -- had a health insurance (mediclaim) plan with a nationalised general insurance company since 2002.
Atul started with a sum assured of Rs 3 lakh and unfortunately, had a claim in the second year (2004) itself related to heart disease. This was duly paid (though not without some extensive follow-up from his side), which motivated Atul to hike the sum assured to Rs 5 lakh at the next renewal.
The insurance company agreed, on condition that if any claim arose due to the heart disease, then the sum assured would be treated only as Rs 3 lakh and not Rs 5 lakh. He was also assured that as per the policy wordings, if he did not make any claim for four continuous policy years, then in the fifth policy year (2009), even this restrictive condition would be removed.
Fortunately, Atul did not need to make any claims on the policy for four years. So when he went in for the renewal in 2009, he was expecting the restrictive condition would be removed.
But it was not to be. The policy came back with the same restrictive clause. When his verbal and written complaints to the branch office elicited no response, he decided to use the grievance redressal mechanism provided by Irda, the insurance regulator. Here is his experience:
Atul went to the insurance company's website to file an online grievance. However, the online grievance form was not working.
He then wrote to the email mentioned in the grievance section of the insurance company. Within a few hours, he received a response asking some very relevant questions about the grievance. His reply was then promptly directed to another official within the same insurance company by the pro-active grievance redressal officer.
Here onwards, the promptness was replaced by the typical tardy responses of PSUs. Not being one of those to give up, Atul continued to remind the official every 7-10 days and finally got a response after around 45 days, again asking for some more details.
After supplying these details, he was pleasantly surprised to receive a rather prompt response from the erstwhile lax official, who agreed to his contention and confirmed that the clause restricting his claim for heart disease to Rs 3 lakh would not apply.
The official also wrote to the concerned divisional office to provide Atul this confirmation in writing.
Now, the real trouble began. The divisional office just did not respond to any emails or even letters personally delivered to them to provide this written confirmation. Even emails to the grievance redressal officer to get the branch office to issue the written confirmation did not elicit any response.
Atul came to me for help. I advised him to file a complaint to the insurance ombudsman, as more than 2 months had passed since the order issued by the senior official of the company had not been complied with. Even emails to the grievance redressal officer in this regard had not elicited any response for more than a month.
To Atul's shock, he received a letter from the insurance ombudsman saying that "We have to inform you that administrative matters relating to underwriting/ acceptance of risk/ renewal, change in policy, cancellation of policy, passing of endorsement to the policy, deficiency of service, etc. is not within the purview of the Insurance Ombudsman's adjudication."
One wonders then, what does the ombudsman actually adjudicate on?
At his wits end, Atul again consulted me. I laid out his options:
Use the alternative grievance redressal machinery that Irda provides, independent of the insurance ombudsman
File a complaint with the consumer forum
Write to major newspapers mentioning the name of the insurance company and see whether that might shame the company into carrying out the orders of its own top officials
If none of the above worked, then, as a last resort, he could also file a complaint with the vigilance officer of the nationalised insurance company
Atul finally decided to file an online complaint with the alternative grievance redressal mechanism provided by Irda. This worked like magic.
The insurance company responded within two days of the complaint being filed, and Atul got the necessary written confirmation within a week of having filed the complaint with the alternative grievance redressal mechanism.
The moral of the story is that if you are persistent, you will ultimately get what you should have got anyways. So, be persistent.
(Harsh Roongta is CEO, Apna Paisa, a search comparison engine for loans, insurance and investments)


