How effective is complaining to the Insurance Ombudsman and the Insurance Regulatory and Development Authority of India (IRDAI)?
Index of Health Checkup Claim Repudiation Lawsuit CC-354–2022. (Link)
I degraded my Optima Restore health insurance policy with HDFC ERGO from 10 lakhs to 5 lakhs. 2000 INR is reimbursed for a full body health checkup every year for the policy of 10 lakhs after the first renewal. Similarly, 1500 is reimbursed for a full body health checkup every two years for the policy of 5 lakhs after the 2nd renewal. I was degrading my policy from 10 lakhs to 5 lakhs. So I decided to take written permission to receive reimbursement of 2000 INR after the degradation and renewal of the 5 lakhs policy to avoid any confusion. HDFC ERGO provided me written permission stating that because I’ve paid the premium for a 10 lakhs policy for one year, after the degradation and renewal of the policy to 5 lakhs, I’ll still be entitled to receive the reimbursement of 2000 INR for the yearly health checkup. Guess what, when I applied for the claim after taking the health checkup in the stipulated time as mentioned in the authorization letter, HDFC ERGO repudiated my claim citing the terms and conditions of the 5 lakhs policy that states every 2 years the insuree will be entitled to claim 1500 INR. This turned the matter into a case of mis-selling. Here the Insurance Company HDFC ERGO has made a false promise to the insuree to sell/renew the policy.
HDFC ERGO Authorized Me for Claiming Reimbursement of 2000 Rupees for a Yearly Health Checkup
Dear Mr. Aich
Greetings from HDFC ERGO General Insurance.
A warm welcome to the HDFC ERGO General Family, a brand trusted by 1.5 Cr customers. We’re pleased to announce the merger of HDFC ERGO Health (erstwhile Apollo Munich) with HDFC ERGO General. Our name has changed but not the passion to serve our customers. Assure you of our Best services, as always.
We acknowledge receipt of your below email dated November 16, 2020 regarding your concern regarding the Policy number:-AA01265980 / 2805203553540500000
This is in regards to the concern highlighted from your end, we would further like to inform you that in case you decrease the sum insured to Rs. 5 Lac from this renewal i.e November 2020 in that case below will be the eligibility.
Nov. 2019-Nov 2020 None
Nov. 2020-Nov 2021 2000 Rs. as per the Sum insured of Year Nov 2019-Nov 2020
Nov. 2021-Nov 2022 None
Nov. 2022-Nov 2023 1500 Rs. As per Rs. 5 Lac plan
Nov. 2023-Nov 2024 None
Nov. 2024-Nov 2025 1500 Rs. As per Rs. 5 Lac plan
Approaching Insurance Ombudsman
So, I discuss the matter with the HDFC ERGO grievance redressal office and then moved to the Insurance Ombudsman. I clearly state everything to the Insurance Ombudsman with evidence of written permission received from HDFC ERGO. All the necessary documents have been submitted to the Insurance Ombudsman. The Insurance Ombudsman Judge even reconfirm from me during the 15 min face to face online hearing about the existence of necessary evidence. Guess what, the verdict was pronounced and I lost the case. On reviewing the detailed verdict, I found out that HDFC ERGO lied to the Insurance Ombudsman.
HDFC ERGO Lied to the Insurance Ombudsman
The complainant vide his email dated 10/11/2020 sought clarification on whether the reduction of sum insured to Rs.5 lacs during the renewal on 29/11/2020 would entitle him to a claim of Rs.2,000/- or Rs.1,500/- on 30/11/2020 per insured person for comprehensive health check-up and against such email, it was clarified on the same day that if sum insured was decreased to Rs.5 lacs at renewal, then he would be eligible for Rs.1,500/- for health check-up only once at the end of block of continuous 2 policy years.
Perjury and Forgery Offense by HDFC ERGO for Lying to the Insurance Ombudsman
I informed the Insurance Ombudsman Office that the wrong information had been given to Insurance Ombudsman by the Insurance Company HDFC ERGO (Insurer). In the verdict, HDFC ERGO referred to the email sent to the insuree on 10 November 2020. Whereas a successive email was sent by HDFC ERGO on 17th November 2020 authorizing the insuree to reimburse 2000 INR after degrading and renewing the 5 lakhs policy has not been mentioned anywhere in the verdict even after providing all the necessary documents to the Insurance Ombudsman right at the beginning of the case by the insuree. HDFC ERGO authorization has influenced the decision of the insuree to degrade the health insurance policy to 5 lakhs and renew.
The Insurance Ombudsman is a Central Government Administrative Law Body. Insurance Company lying and misleading the Insurance Ombudsman is a perjury and forgery criminal case that is considered to be harmful to society and the state.
I requested the Insurance Ombudsman to take appropriate action and keep me informed. Instead, the Insurance Ombudsman incompetently replied.
Dear Sir,
This has reference to your trailing mail regarding the Award issued by the Hon’ble Ombudsman vide Award No. IO/KOL/A/HI/0036/2022–2023 dated 17.05.2022 against your Complaint registered in this office under Complaint No.KOL-H-018–2122–0878.
It may be mentioned that the Award has been issued taking into account the facts & circumstances of the case and submission made by both the parties during the course of hearing and going through the documents on record.
If the decision is not acceptable to you, you are at liberty to approach any other Forum/Court as per Law of the Land against the Respondent Insurer.
Regard,
A.O.
Office of the Insurance Ombudsman Hindustan Building Annexe, (7th Floor),4 C.R. Avenue, Kolkata-700 072
Approaching The Insurance Regulatory and Development Authority of India (IRDAI)
So, I decided to approach the Insurance Regulatory and Development Authority of India (IRDAI) and send an application to Honourable Insurance Ombudsman Escalation Committee to evaluate the Insurance Ombudsman Judge’s competence.
The Insurance terms and conditions HDFC ERGO as the respondent has referred to defend its position are the same terms and conditions that must have been referred by the HDFC ERGO officer for allowing the 2000/- HDFC ERGO health checkup. Therefore, it is beyond my comprehension that citing the same terms and conditions the HDFC ERGO officer referred to allow 2000/- Health Checkup and that HDFC ERGO is responsible and accountable for allowing, yet the judgment isn’t in my favor.
The IRDAI register my complaint and forwarded it back to the HDFC ERGO grievance redressal office. I don’t know why they did it!
- Why did the Insurance Regulatory and Development Authority of India (IRDAI) forward the complaint to evaluate the Honorable Insurance Ombudsman Judge’s competence to the Grievance Redressal Office (GRO) of the insurance company?
- How does the Grievance Redressal Office (GRO) of the insurance company have the authority to investigate the Honorable Insurance Ombudsman Judge’s competence to take appropriate action?
Image of HDFC ERGO reply to Insuree for a complaint made to the Insurance Regulatory and Development Authority of India (IRDAI) against the Insurance Ombudsman.
Dear Sir/Madam,
This is with reference to your complaint received by the company on 18 Aug 2022 vide reference number 57153289.
With reference to claim number RR-FC21–12734614, as per the policy terms and conditions — Health check up expenses (wherein Sum Insured is Rs. 5,00,000/-) up to a maximum of Rs.1,500/- per insured person, only once at the end of a block of every continuous 2 Policy Years. However, the block of two years would end on November 29, 2021 and claim intimated prior to end of such block. Thus, you are not entitled for the health check up claim. Since you had not completed the required step count, you are not eligible for the discount under the policy. Further would like to state that you are eligible for 0% discount. As you completed the Step of 3433, whereas he required to complete the step count of as mentioned in table. Since you have s not completed the required step count, he is not eligible for the discount under the policy.
Trust your complaint has been adequately resolved.
Incase you are not satisfied with our response, you may approach the Office of Insurance Ombudsman who is empowered to consider complaints relating to insurance policies purchased in individual capacity.
As per your address recorded with us, the address of nearest Ombudsman office is mentioned below.
Office of the Insurance Ombudsman, Hindustan Bldg. Annexe, 4th Floor, 4, C.R. Avenue,KOLKATA — 700 072. Tel.: 033–22124339 / 22124340
Why is the insurance company asking me to approach the Insurance Ombudsman for redressal of a complaint made against evaluating the Insurance Ombudsman Judge’s competence to the Insurance Regulatory and Development Authority of India (IRDAI)?
I am still circling and following up. If the Evaluation of the Insurance Ombudsman Judge’s Competence is taken up by IRDAI, I’ll keep everyone informed in the link here.
Appearing at District Consumer Forum
Demanding 5000 Crore INR from HDFC ERGO as a relief on behalf of District Consumer Forum.
The capping on maximum relief amount under the district consumer court’s jurisdiction has been exploited by Insurance companies and other companies (healthcare, fintech). Everyone knows that visiting the court for a thrifty amount dispute is a hassle because of lengthy procedures, followed by submitting a heap of hard copies, followed by multiple times appearances. The huge number of thrifty amount disputes w.r.t. the few complaints been made in consumer court w.r.t. the fewer complainants actually following through till the end to receive relief from the court decreases considerably in each step. In my opinion, this has been statistically calculated by the Insurance companies and other companies (healthcare, fintech). The capping on the maximum relief amount that could be disbursed by the district consumer forum (a Quasi-judicial body) is working like protection by the Government of India for the Insurance companies by applied statistics. It means the Insurance companies are booking huge profits by deliberately creating thrifty amount disputes in a very large volume only to reimburse the district consumer court capped relief amount to the very few complainants that could actually make it to the end. This is the reason I often witness thrifty amount’s complaints but the relief amount is not checking the wrongdoing of the Insurance companies once and for all. Thus I’ll request the Government of India to bring in the provision of a class action lawsuit and amend the capping on maximum relief that could be disbursed by the District Consumer Court and demand relief for 5000 Crore INR instead of 50,000 INR for consumer court reference number A22080005770 case no CC/354/2022 that could send a positive message loud and clear to the Insurance, Fintech, & Healthcare Sector. (Twitter thread timeline link)
Meanwhile Requested Council of Insurance Ombudsman take Action against Kolkata Insurance Ombudsman
I’ll list an extract from the email which I’ve sent to the Council of Insurance Ombudsman.
Without any further scope of the resolution, I had to move to the consumer court where both cases are going on. Although I’ve requested the IRDAI in ‘Application to Hournarable Insurance Ombudsman Escalation Committee to evaluate the Insurance Ombudsman Judge’s competence’, given the nature of the black and white case. I assume the Insurance Ombudsman is at fault and exploiting the system for vested interest. IRDAI has not taken any satisfactory steps until now and forwarded the case to the HDFC ERGO grievance department which doesn’t have the authority under its jurisdiction to bring justice to the nature of the complaint so the complaint is tossing around between IRDAI and HDFC ERGO. I’d request the Council of Insurance Ombudsman to initiate the right investigation and processes to take regulatory departmental action against the Kolkata Insurance Ombudsman Judge and the overall Ombudsman System to check on similar issues and restore the faith of the public in the justice system.
The matter has also been sent through speed post, EW147300439IN to the Council of Insurance Ombudsman Office.
To my astonishment, I received the following reply from the Council of Insurance Ombudsman on Wed, 25 Jan 2023, at 6:14 PM.
Sir,
This has reference to your trailing mail addressed to Council for Insurance Ombudsmen on the above subject.
In this regard kindly note that, as specified by Office of Insurance Ombudsman( OIO), Kolkata vide their mail dated 29.07.2022, the Award is issued taking into consideration the facts & circumstances of the case & submission made by both the parties during the hearing.
Hence the procedure followed by OIO Kolkata is as per the provision stipulated in Insurance Ombudsman Rules, 2017( amended till date).
Thanks and regards
Assistant Secretary
Office of the Council for Insurance Ombudsmen,
(Formerly Office of the Executive Council of Insurers/
Governing Body of Insurance Council)
3rd Floor, Jeevan Seva Annexe Bldg., S.V. Road,
Santa Cruz (West)
Mumbai — 400 054.
Phone.: 91 22–69038800/69038812
I don’t see any choice other than moving to court if such is the understanding of rationale and reasoning characterized by Quasi-Judicial and Regulatory Institutional bodies.
I think this will be my final reply on 21 Feb 2023 to all the government departments and ministries involved in this litigation.
Hello Everyone,
I’ve received the above reply from the Council of Insurance Ombudsman and I’ll request anyone in the email chain capable of taking suo-moto action to do so, for grave negligence of quasi-judicial and regulatory institutional duties in the best interest of Financial and Civil safety and security of citizen of India.
The statement of the verdict has been pronounced (in writing) in absence of rationale (in writing) and sound reasoning. The format of judgment is questionable.
The false data provided by OP HDFC ERGO in their defense has been ignored even though it has been brought to the notice of the Kolkata Insurance Ombudsman, IRDAI, and Council of Insurance Ombudsman which should be viewed as grave negligence of Quasi-judicial and Regulatory bodies' institutional duties.
I’m considering moving to court against the functioning and format of the judgment of the Quasi-Judicial and Regulatory bodies.
I’m thinking of converting the case into a PIL, The State vs HDFC ERGO.
A detailed copy of the litigation for public review
HDFC ERGO Health Insurance full body health checkup Claim Number RR-FC21–12734614. HDFC ERGO Optima Restore Health Insurance Policy number 2805203553540501. Insurance Ombudsman Complaint Number — KOL-H-018–2122–0878 and Insurance Ombudsman Award Number — IO/KOL/A/HI/0036/2022–2023. IRDAI complain no 08–22–008408. GRO HDFC ERGO Ref 57153289. District Consumer Dispute Redressal Forum, Barasat, North 24 Parganas, India, eDaakhil reference number A22080005770 and case number CC/354/2022.
Tweet Thread, Timeline of the Events. (Link)
The District Consumer Disputes Redressal Commission Complaint Petition CC-354-2022. (Link)
I’ve been fined 5000/- (Five Thousand INR) by GoI’s Quasi-Judicial body Consumer Disputes Redressal Commission. The ground realities of social justice (class action lawsuits) in India are very different from anything we pitch in the Tech and UX Conferences.
Salient Contemplation of Verdict Pronounced by District Consumer Disputes Redressal Commission. (Link)
The District Consumer Disputes Redressal Commission, Barasat, North 24 Parganas, West Bengal, Collection of Ratul Aich vs HDFC ERGO Proceedings and Orders CC-354-2022. Final proceedings page number 41 onwards. (Link)
Index of Health Checkup Claim Repudiation Lawsuit CC-354–2022. (Link)
Next in the series is Quasi Judicial Patients, & Victims of Insurance Companies Institutional Exploitation. (Link)
You may also like to check out a similar post, Judicial Investigation Friendly Digital Systems, Judibility. (Link)
Last edited on 17 September 2024.
