Post-pandemic complaints against health insurers seen sharp rise

Most of the pending complaints at the Insurance Ombudsman's office in Mumbai are those filed in June 2021 or thereafter. "Still, average resolution time as of now is six months and therefore the imminent main challenge is to bring down the turnover time to three months," says Bharatkumar Pandya, Insurance Ombudsman, Mumbai in an exclusive interview with Bizz Buzz

Though we are mandated under the Insurance Ombudsman Rules, 2017 to dispose of the cases within 90 days of receipt, few complaints received even in May and June are still pending. The delay has occurred due to multiple factors of influx of large number of Covid cases, adverse impact of Covid on our own speed, and vacancy in the office of Ombudsman for five months. Most of the pending complaints are those filed in June 2021 or thereafter. Still, average resolution time as of now is six months and therefore the imminent main challenge is to bring down the turnover time to three months

The insurance Ombudsman's office is a forum where redressal is free, fast, final, less formal, least complex and where the complainant himself is heard without observance of any complex rules of procedure or of evidence

As you have recently joined as Insurance Ombudsman at Mumbai, how do you think you would best carry out your duties and what are your plans in this behalf?

I have joined my duties on October 14, 2021. Two months is a very short period to wholly grasp the depth and width of the task at hand though I have applied myself in getting acquainted with the magnitude, criticality and requirement of the task and components thereof and to experience, explore and engage in the work, and learn from industry and my senior colleagues so as quickly strategize for delivering the speediest possible outcomes as mandated under Insurance Ombudsman Rules, 2017. Possibly, the best way to get acquainted with the new role is to learn by doing. We have heard more than 150 complaints through GoToMeeting platform and have passed recommendation/awards in more than 120 cases. Fortunately, I have a team of highly motivated, committed, experienced and knowledgeable officers on deputation from Industry, who have made my challenging task of learning and delivering easy. Put simply, the mandate of this office under the Insurance Ombudsman Rules is to deliver resolution of the complaint after following due procedure, within 90 days of receipt of the complaint. However, as there is huge pendency (accumulated due to vacancy in Office of Ombudsman and influx of Covid complaints) of more than 1600 complaints as on date, with some April-May complaints still pending, our first endeavour is to focus on older complaints and bring down the turnaround time to below 90 days. The task is thus clearly defined.

Coming from a different background, how are you coping with the new role?

My income-tax (I-T) experience is primarily in quasi-judicial and investigative work, which in a layman's language, can be described as that of ascertaining facts by calling for and identifying relevant evidence and appreciating the same and then applying the law to the facts so ascertained and crystallized. The task in the present new role is no different. The only new things here are the insurance jurisprudence, the IRDAI guidelines and circulars, and a subjective and intuitive sense of "what is fair, just and reasonable in the circumstances" which comes only with experience in each field. Another new aspect is the fact that most of the complainants would not themselves be well-versed in insurance law to plead or bring out the most relevant facts or law or the policy contract terms or the applicable IRDAI guidelines/circulars which, consequently, the forum would need to bring on record and deal with. A further difference is the responsibility of ensuring amicable resolution by way of mediation and counselling. Overall, it is an interesting and exciting role and I think that as ably assisted and advised by my team of experienced and expert officers in the secretariate, I would be able to carry out the job efficiently with objectivity, fairness, speed, and purpose.

Have there been any increase in disputes relating to Covid claims?

Yes, there is such increase, as is to be expected. Presently, roughly 35-40 per cent of health insurance related complaints we receive pertain to Covid claims.

Have overall cases gone up?

Yes, compared to last year's nearly 3200 complaints, we may cross 5000 during the current financial year, though, many of the complaints out of those registered on our complaint management system portal need to be rejected at threshold being non-entertainable due to some deficiencies in the complaints within the meaning of Rule 13.

Which segment of Insurance, life or non-life, has seen increase in complaints?

It is non-life, primarily health insurance complaints, which has seen a larger portion of increase.

How many cases are pending as of now?

Overall there are 1623 pending cases of which claims related to life insurance, health insurance and general insurance stands at 191, 1365 and 67 respectively.

How much time normally you are taking to resolve the cases?

Though we are mandated under the Insurance Ombudsman Rules, 2017 to dispose of the cases within 90 days of receipt, few complaints received even in May and June are still pending. The delay has occurred due to multiple factors of influx of large number of Covid cases, adverse impact of Covid on our own speed, and vacancy in the office of Ombudsman for five months. Most of the pending complaints are those filed in June 2021 or thereafter. Still, average resolution time as of now is six months and therefore the imminent main challenge is to bring down the turnover time to three months.

The govt has increased the limit to Rs 30 lakh from Rs 20 lakh. Is it sufficient?

I think this is not the domain I would want to enter. However, it needs to be kept in mind by all concerned that ours is only an alternate dispute resolution mechanism which is supposed to provide free, fast, fair, and objective resolution with finality vis-à-vis the Insurer. The process of mediation involving persuasion and communicating pros and cons of "give and take" vis-à-vis the speed of resolution compared to other available forums is also a key differentiator. Further, even 30 lakh limit generates the number of complaints which already substantially stretches the human and other resources and infrastructure of this Forum. The speed of resolution is a critical requirement and if the time-limit of resolution is not maintained, I believe, the key objective and mandate of the forum gets diluted.

There was a proposal to bring cases of deficiency in service under the Jurisdiction of the Ombudsman. What happened to that?

The amendment to Rule 13 of the Insurance Ombudsman Rules, 2017, brought in vide notification no G.S.R. 147 (E), dated 2.3.2021.

Would you like to convey any specific message to our readers?

Yes, indeed. This is a forum where redressal is free, fast, final, less formal, least complex and where the complainant himself is heard without observance of any complex rules of procedure or of evidence. Only requirement for the complainant is to have real grievance and to be precise and specific as regards relief he is keen on and to submit copies all correspondence with the insurer till the date of filing the complaint along with copy of policy document.

Documents like duly signed complaint, settlement/repudiation letter from the insurer, further letter of representation to insurer after claim rejection/part-settlement, insurer's response thereto (or waiting for a month for response after the representation), photograph, Aadhar Card and policy document need to be ready for enclosing or uploading on the portal. The resolution normally is guaranteed within three months if all requisite documents and evidences are filed or uploaded online. Also, if he exhibits a spirit of 'give and take' and accepts an amicable offer from the insurer, or as suggested by the Ombudsman as a counsellor, the resolution can still be faster. To achieve the fastest possible resolution, however, the best course for the complainant is to file complaint on-line on portal of council for Insurance Ombudsmen, accessible at www.cioins.co.in and upload all requisite documents. The complaints, however, can also be filed by physical delivery at Ombudsman office or through e-mail at [email protected] or though registered or normal post or courier.