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Insurance Ombudsman Complaint
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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 my hospitalisation claim.
Facts in brief:
- was hospitalised at from to for .
- The total hospital bill was Rs. . The claim was settled at Rs. on , leaving Rs. paid by me out of pocket.
- 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.
- This complaint is filed within one year of , 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:
- Payment of the wrongly deducted amount of Rs. .
- Interest on the delayed amount as per the applicable IRDAI norms.
- Any other relief the Hon'ble Ombudsman deems fit.
Enclosures:
- Policy document / policy schedule
- Claim form and claim correspondence
- Itemised hospital bill and discharge summary
- Insurer's settlement letter / deduction sheet
- My grievance letter to the insurer, with proof of delivery
- Insurer's reply, if any
- Payment receipts for the out-of-pocket amount
- Copy of my ID and address proof
I declare that the facts stated above are true to the best of my knowledge.
Thank you,
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How to use this letter
What this letter does
It files a formal complaint with the Insurance Ombudsman — a free statutory forum under the Insurance Ombudsman Rules, 2017, for disputes up to ₹50 lakh. The Ombudsman decides largely on the documents you enclose, so the paper trail matters more than the argument.
What to do with it
- Find your Ombudsman office on cioins.co.in — jurisdiction is decided by your postal address, not the hospital's or the insurer's.
- File within one year of the insurer's final reply, or one year from the day the 30-day response window expired.
- File online through the same portal, or send the printed complaint by registered post with AD to the office address. Keep the acknowledgement.
- Enclose the full paper trail — policy, claim correspondence, itemised bill, settlement letter, your grievance letter with proof of delivery, and the insurer's reply (or proof of silence).
- If the insurer rejected your grievance on a specific date and you have the reply, you can add that date into point 4 using “Edit letter wording” before you print.
Questions you may be asked
- “Did you complain to the insurer first?”
- “Yes — my grievance letter and either the insurer's reply or proof that 30 days passed are enclosed.”
- “Is any court or consumer case pending on the same matter?”
- “No — the declaration in the complaint is true. Nothing is pending in any other forum.”
- “Why is your Ombudsman office the right one?”
- “Jurisdiction is decided by my postal address, and my address falls within this office's territory.”
- “Is the amount within our limit?”
- “Yes — the disputed amount is within the ₹50 lakh limit under the Insurance Ombudsman Rules, 2017.”
Keep calm, keep records
- Hearings are rare — most complaints are decided on the documents. A clean, chronological file does more than a strong argument.
- The declaration that no court or consumer case is pending on the same matter must be true — file with the Ombudsman first, or with the consumer commission, not both at once.
- Keep the acknowledgement number (portal) or the registered post AD receipt — it is your proof of filing date if any deadline is questioned.
Attach: your policy document and claim correspondence, the itemised hospital bill and discharge summary, the insurer's settlement letter, your grievance letter to the insurer with proof of delivery, the insurer's reply (or proof that 30 days passed), payment receipts for the out-of-pocket amount, and copies of your ID and address proof.
How to send: file online at cioins.co.in — the portal accepts uploads and issues a numbered acknowledgement — or send by registered post with AD to the office covering your address (list on the same portal). Either route is free and no lawyer is needed.