Filing a Complaint Against Health Insurance Company

How to Lodge a Complaint Against Health Insurance Company?

The following are the steps to lodge complaints against a health insurance company: 

Turn Around Time (TAT) on Complaints:

The maximum TAT (Turn Around Time) on complaints/ requests/ grievances related to some of the services offered by health insurance companies are as follows:

First, contact the grievance cell or helpdesk of your health insurance company regarding your issue. If it's not resolved within the TAT listed, you can escalate the issue to IRDA. Following are the contact details of some of the leading .

What Could Be the Reasons? 

There could be certain doubts in your mind while purchasing a health insurance plan. Given below are certain factors which you need to consider before purchasing a health insurance policy: 

1. Scope :  While paying a premium of your health insurance plan, it is advisable to go through each and every aspect of the insurance policy. Do not always opt for the health insurance plans that charge low premium. Opt for the health insurance plan which provides you a maximum coverage at a reasonable premium amount.  
2. Size of the Family : The number of family members differs from family to family. Thus, you should ensure whether the health insurance company provides health insurance coverage to all the family members or not.  
3. Claim Settlement : It is extremely important to look the claim settlement ratio of a health insurance provider. If the claim settlement ratio is low, then you might face issues at the time of insurance claim processing.  
4. Sub Limits : In every insurance policy, you will find an entry point as sub limits. If your insurance policy states the same, this means that the insurance company is going to bear all the expenses. 

Types of Insurance Frauds:

Let us have a look at different types of insurance frauds: 

1. Application Frauds : Application fraud is one of the most common fraud types that are witnessed by the health insurance companies. In this case, the policyholders mention fake details regarding their health conditions. In some cases, the policyholders may not describe their health conditions and are likely to provide information in order to get more time in the policy.   
2. Opportunity Frauds : Opportunity frauds are shown as the natural occurrence, but it is actually calculated and presented such that the intended claim is covered by the policy.  
3. Eligibility Fraud : In case of eligibility frauds, the insured presents the false information before the insurance company. The information includes existing illness, salary, age, dependents, etc.  
4. Internal or External Fraud : The frauds which occurred due to the external factors are the external frauds such as the medical vendor, the beneficiary, etc. On the other hand, the frauds which are carried by the inside person against the policyholder is the internal fraud.

Channels for Lodging a Complaint:

These are the main channels for lodging a complaint - the Insurance Ombudsman, the Integrated Grievance Management System and the Consumer Court. These are explained below:

1. Insurance Ombudsman:

You can seek the assistance of the Insurance Ombudsman in order to escalate an issue which has not been resolved by the insurance provider. You can file a complaint with the Insurance Ombudsman under the following conditions:

1. Your claim has been partially or wholly rejected.
2. You have not received your policy after payment of premium.
3. There is delay in claim settlement
4. There is a dispute regarding premium payable/ premium paid.
5. There is a dispute regarding the terms and conditions specified in the Policy Schedule.

2. Integrated Grievance Management System:

IRDA had introduced the Integrated Grievance Management System as an online platform where the policyholders having a grievance or dispute with an insurance provider can escalate the same. You can register a complaint as well as track its progress using this system. This grievance redressal and monitoring tools helps the IRDA to provide a centralized access to the policyholder and to classify complaints based on predefined norms.

Under this system, complaints are assigned a unique complaint ID and is assigned to concerned departments for resolution. This helps to monitor market conduct issues as well. This also assigns Turnaround Times (TATs) for all complaints registered and sets up alerts for pending tasks. The system ensures efficient complaint resolution with rule based workflows and detailed reports.

3. Consumer Court:

If the complaint has still not been resolved, you can register the same with the consumer court. The consumer court has a separate department to handle health insurance grievances, especially those arising out of Unfair Trade Practice/ malpractice/ service issues.

Contact Details of Grievance Cell of Health Insurers:

Contact Details for Grievance Redressal Cell:

GST rate of 18% applicable for all financial services effective July 1, 2017.

Disclaimer: Premiums may vary depending upon factors like age, location and prevailing taxes/GST.