Insurance Ombudsman शिकायत

To,
The Insurance Ombudsman
Office of the Insurance Ombudsman,

Date:

Subject: Complaint under the Insurance Ombudsman Rules, 2017 — against , Policy No. , Claim No. 

Respected Sir/Madam,

I am the policyholder of the above health insurance policy. I submit this complaint against for partial settlement of my hospitalisation claim.

Facts in brief:

1. was hospitalised at from to for .
2. The total hospital bill was Rs. . The claim was settled at Rs.  on , leaving Rs.  paid by me out of pocket.
3. On , I filed a written grievance with the insurer's Grievance Redressal Officer disputing specific deductions totalling Rs.  (copy enclosed). The grievance disputed items deducted as “non-payable”. It disputed amounts cut as above “reasonable and customary” charges. It disputed cuts made citing room-rent or category sub-limits. It disputed deductions for which no reason was given. It disputed a proportionate deduction applied across the bill. It also disputed further deductions described in the grievance. No satisfactory reply was received within 30 days as required under the IRDAI's grievance redressal norms.
4. The insurer rejected my grievance without adequate reasons (copy enclosed).
5. This complaint is filed within one year of the insurer’s final reply, as required.

I have not filed any complaint on the same matter before any court, consumer commission, or arbitrator, and it is not pending in any such forum.

Relief sought:

1. Payment of the wrongly deducted amount of Rs. .
2. Interest on the delayed amount as per the applicable IRDAI norms.
3. Any other relief the Hon'ble Ombudsman deems fit.

Enclosures:

1. Policy document / policy schedule
2. Claim form and claim correspondence
3. Itemised hospital bill and discharge summary
4. Insurer's settlement letter / deduction sheet
5. My grievance letter to the insurer, with proof of delivery
6. Insurer's reply, if any
7. Payment receipts for the out-of-pocket amount
8. Copy of my ID and address proof

I declare that the facts stated above are true to the best of my knowledge.

Thank you,