1. Presented By : AMANDEEP THAKUR
ASSISTANT PROF. DAV COLLEGE HOSHIARPUR
2. INTRINSIC CHARACTERISTICS OF
INSURANCE CONTRACTS DIFFER
FROM OTHER CONTRACTS
INSURANCE IS STILL SOLD AND NOT
BOUGHT
PRODUCTS – NOT TANGIBLE – ONLY
PROMISES
AFTER SALES SERVICE
3. INTRINSIC CHARACTERISTICS OF
INSURANCE CONTRACTS DIFFER
FROM OTHER CONTRACTS
LEVEL OF KNOWLEDGE OF
INSURED/NOMINEE
LAWS OF LAND
LAWS OF CONTRACT
LAWS OF INSURANCE
4. INTRINSIC CHARACTERISTICS OF
INSURANCE CONTRACTS DIFFER FROM
OTHER CONTRACTS
CRUCIAL ROLE PLAYED BY
INTERMEDIARIES
AGENTS INCLUDING BROKERS/CORPORATE
AGENTS
SALES TEAM
MEDICAL EXAMINERS
TPAs
5. NEED FOR A STRONG REGULATOR AND INSTITUTION
LIKE OMBUDSMAN
Pre-1956 Lessons
Experiences in nationalised era
Scenario – Post 1998
Level of consumerism
Global context
Scenario of present legal system
(i) delay / right to appeal
(ii) Cost
No single solution to the problem of satisfying
customer
6. WHY AN UMPIRE IS
REQUIRED FOR
RESOLVING INSURANCE
DISPUTES ?
INSURER INSURED/NOMINEE
STRONG DATA WEAK
AND DOCUMENTATION
WELL TECHNICAL TERMS NO
VERSED EXPERIENCE
ONLY AS PRE-PROPOSAL FAIRLY WELL
ON PAPER DATA EQUIPPED OF
(TRUE OR FALSE) ALL DETAILS
7. WHY AN UMPIRE IS
REQUIRED FOR
RESOLVING INSURANCE
DISPUTES ?
OMBUDSMAN
INSURER INSURED/
NOMINEE
1. FRONT OFFICE
2. BACK OFFICE
3. GRIEVANCE OFFICE
8.
9. GOVERNING BODY OF INSURANCE COUNCIL
Consist of one representative from each of the
insurance companies.
Representatives shall be Chairman or Managing
Director or any one of the Directors of the
company
Shall formulate its own procedure for conducting
its business including the election of the
Chairman.
10. APPOINTMENT OF OMBUDSMAN
The governing body shall appoint one
or more persons as ombudsman from a
panel prepared by the committee
consisting of Chairman of IRDA, Two
representatives of the Insurance Council
(one from life and one from non-life),
one representative of the Central
Government.
11. APPOINTMENT OF OMBUDSMAN
The Ombudsman selected may be
drawn from a wider circle including
those who have experience in industry,
civil service, administrative service,
judicial service etc.
12. Term of Office
An Ombudsman shall be appointed
for a term of three years or till the
incumbent attains the age of 65
years, whichever is earlier. Re-
appointment is not permitted.
13. Territorial Jurisdiction
The Office of the Ombudsman shall be located at such place as may be
specified by the Insurance Council
The Governing Body shall specify the territorial jurisdiction of each
Ombudsman.
At present there are 12 centres in India
The Ombudsman may hold sitting at various places within his area of
jurisdiction in order to expedite disposal of complaints
14. Staff
Secretarial staff to be provided by the Insurance
Council after consultation with the Ombudsman
The Ombudsman may engage the services of
professional expert with a view to assist him in
discharging his functions.
The salary, allowances and perquisites payable to
Ombudsman and staff and all expenses incurred
shall be borne by the Insurance Council. Personnel
deputed for a term of 2/3 years from Public Sector
Life and non-life insurance companies to assist the
Ombudsman.
15. Staff
The Ombudsman shall prepare the budget indicating the requirement of
funds and will be sent to the Governing Body.
The Governing Body will finalise the budget in consultation with the
Ombudsman and allocate funds to the Office of the Ombudsman.
The total expenses on Ombudsman and his staff shall be incurred by the
Insurance companies who are members of the insurance council in such
proportion as may be decided by the Governing Body from time to time.
The share of expenditure which is to incurred by each insurance company
shall be in the ratio of premium income of the previous year.
16.
17. REDRESSAL OF PUBLIC
GRIEVANCES RULES, 1998
(RPG RULES) NOTIFICATION
DATED 11.11.1998 AMENDED
ON 18.12.1998 AND
21.06.1999.
18. These Rules shall apply to all the
insurance companies operating
in general insurance business
and in life insurance business in
India
Objective - Cost effective,
efficient and impartial manner
19. ENTERTAINABLE COMPLAINTS
The Ombudsman may receive and consider
complaints on
a. any partial or total repudiation of claims
b. any dispute in regard to premium paid or payable
c. any dispute on the legal construction of the policies in so far as such
disputes relate to claims
d. delay in settlement of claims
e. non-issue of any insurance documents
20. Recommendations made by the Ombudsman
Ombudsman to give recommendation
there is Mutual agreement.
Complainant to communicate his
for the recommendation
The Insurer to comply with the
recommendation within 15 days of the
receipt of the consent from the complainant
and report to the Ombudsman of the
compliance.
21. Award made by the Ombudsman
Where the complaint is not settled by
agreement, the Ombudsman shall conduct
hearing and pass a speaking award.
Power to make ex-gratia payment
If the Ombudsman deems fit he may award an
ex-gratia payment under Rule 18.
Complainant to give consent on receipt of the
award within 1 month to the insurer
The Insurer to comply within 15 days
22. Consequences of non-acceptance of
award
The award may not be
implemented by the insurer if the
consent from the complainant is
not received within the timeframe
specified.
The complainant has the right to
approach other forums.
23. OMBUDSMAN –
REAL TEST WHEN SITS ON JUDGEMENT
Effective listening
Allow steam to let out
Extract more and more data
Counsellor / Mediator
Finally to say Yes/No
No pushing paper vertical/horizontal
24. SOME STATISTICAL DATA
2007-08 – 1200 complaints received
2008-09 - Complaints received till December
Life: 568; Non-life:527= Total 1095
No. of awards given = Life:35; Non-life:77
Decisions in favour of the company
Life: 17; Non- Life 33
Decisions in favour of the complainant
Life: 18; Non-life 44
