For a health, life, or general insurance claim that was rejected, delayed, or paid less than you expected -- or a cashless claim denied at the hospital.
Bima Bharosa (IRDAI Grievance Portal): https://bimabharosa.irdai.gov.in/
Helpline: 155255
Handled by: IRDAI (Insurance Regulatory and Development Authority of India)
Who can use this: The policyholder, or a complaint made through their legal heirs, nominee or assignee -- an assignee (for example a bank holding a policy as loan security) can complain while the insured is alive; a nominee or legal heir typically does so after a death. Complaints are also entertained from a sole proprietorship or a micro enterprise holding the policy, not only from individuals. Note that IRDAI's own Grievance Cell will not accept a complaint written on a policyholder's behalf by an advocate, agent or other third party.
This does not cover: Does not decide who is at fault in a motor accident, or fix the compensation payable to an accident victim -- third-party motor accident compensation goes to the Motor Accident Claims Tribunal instead. A dispute with your own motor insurer about your own policy -- an own-damage or theft claim that was rejected, underpaid or delayed -- is different, and is within the Ombudsman's scope. Does not decide which insurer a person should buy a policy from, but does cover a dispute over the premium paid or payable, misrepresentation of the policy's terms at any time (including mis-selling by an agent, intermediary or broker), a policy issued that does not match the proposal form, and non-issuance of a policy after the premium was taken -- a purely commercial underwriting or pricing decision on whether to offer cover at all is outside its scope, but the sale and issuance of a policy are not. Does not entertain a complaint on a matter that is already pending before, or has already been decided by, a court, a Consumer Commission or an arbitrator -- approaching one of those forums first closes off the Ombudsman route for the same dispute, so the choice of forum is effectively a one-time election.
Time limit: Complain to the Ombudsman within 1 year of the insurer's rejection, or of receiving a reply you are not satisfied with -- or, if the insurer never replies at all, within 1 year of the date one month after you sent your written complaint to it. (Rule 14(3), Insurance Ombudsman Rules, 2017)
Cost: Free at every stage -- the insurer's own GRO, Bima Bharosa, IRDAI's Grievance Cell, and the Ombudsman all charge nothing.
What happens after: The Ombudsman's decision is binding on the insurer (though the policyholder can still decline it and go to court instead). Below the Ombudsman stage, IRDAI's own Grievance Cell can direct the insurer to respond but does not itself award compensation.
These are the remedies Indian law provides for this kind of situation -- not a recommendation, and not every remedy will apply to your own facts.
It depends on the type of policy and how long it has been running -- life and health insurance are governed by different rules. For a life insurance policy, Section 45 of the Insurance Act, 1938 applies: within 3 years from the date the policy was issued, risk commenced, or the policy was last revived (whichever is latest), the insurer may question the policy on the ground of fraud, or of a misstatement or suppression of a fact material to the expectancy of life -- but it must communicate the specific grounds and the materials relied on to you in writing. After those 3 years, Section 45(1) bars the insurer from calling the policy in question 'on any ground whatsoever' -- since the 2015 amendment, that bar is absolute and covers fraud as well. For a health insurance policy, Section 45 does not apply. The equivalent protection is the moratorium period under IRDAI's Master Circular on Health Insurance Business dated 29 May 2024, which reduced the moratorium from 96 months to 60 months: after 60 months of continuous coverage, a health policy or claim cannot be contested on the ground of non-disclosure or misrepresentation, except on the ground of established fraud. The moratorium does not override a permanent exclusion written into the policy.
Yes. A life insurance (death) claim needs the claim form, nominee's ID, the original policy, and death-related proof (death certificate, and for accidental death, FIR and post-mortem) -- typically a one-time lump-sum payout. A health/mediclaim claim ties to actual hospitalisation, can be cashless at a network hospital or reimbursed after you pay, and needs hospital bills and discharge summaries rather than a death certificate.
Alongside the standard claim form, you'll typically need your own ID/address proof, the deceased's death certificate, the original policy document, and proof of your relationship to the deceased if not already recorded with the insurer. If there's ambiguity or multiple claimants, the insurer may ask for a legal heir or succession certificate.
No. You must first make a written complaint to the insurer's Grievance Redressal Officer, and can only approach the Ombudsman if the insurer fails to respond within 30 days or you're dissatisfied with the response.
The Ombudsman's award power is capped at Rs.50 lakh per complaint (raised from Rs.30 lakh in November 2023). If your genuine claim exceeds this, you'd need to pursue the consumer courts (District/State/National Commission by value) or a civil court instead, where there's no equivalent cap.
Yes. Under IRDAI's Master Circular on Health Insurance Business dated 29 May 2024, an insurer or its TPA must decide a cashless authorisation request within a fixed window, and must grant final authorisation within 3 hours of receiving the hospital's discharge request. If the insurer causes a delay beyond that, any additional hospital charges arising from the delay are to be borne by the insurer out of its own funds, not deducted from your sum insured. A cashless refusal is also not the end of the claim -- you can pay the hospital and file for reimbursement instead, and the refusal itself can still be taken through the grievance route above, since a partial or total repudiation by a health insurer is within the Insurance Ombudsman's jurisdiction.
Governing law: Insurance Act, 1938 (s.45); IRDA Act, 1999; Insurance Ombudsman Rules, 2017
Source: Insurance Act, 1938, s.45 (as substituted by the Insurance Laws (Amendment) Act, 2015); IRDA Act, 1999; Insurance Ombudsman Rules, 2017, Rules 13, 14 and 17, as amended by the Insurance Ombudsman (Amendment) Rules, 2021 and the Insurance Ombudsman (Amendment) Rules, 2023 (G.S.R. 828(E), 9 November 2023, raising the ceiling to Rs.50 lakh); IRDAI (Protection of Policyholders' Interests, Operations and Allied Matters of Insurers) Regulations, 2024 (20 March 2024) and its Master Circular; IRDAI Master Circular on Health Insurance Business, 29 May 2024 (60-month moratorium); Bima Bharosa (bimabharosa.irdai.gov.in).
Aadhrix does not decide which route applies to you. This describes the official process as published — consider an advocate for advice specific to your situation.
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