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REDRESSAL OF PUBLIC GRIEVANCES RULES, 1998
Ministry of Finance (Deptt. of Economic Affairs) (Insurance Division), Noti. No. G.S.R. 670(E), dated November 11, 1998, published in the Gazette of India, Extra., Part II, Section 3(i), dated 11th November, 1998, pp. 4-7, No. 439 [F. No. 56/32/97-Ins. I] In exercise of the powers conferred by sub-section (1) of Section 114 of the Insurance Act, 1938 (4 of 1938) the Central Government hereby frames the following rules, namely :-
Rule 1 Short title
These rules may be called the Redressal of Public Grievances Rules, 1998.
Rule 2 Application
These rules shall apply to all the insurance companies operating in general insurance business and in life insurance business : Provided that the Central Government may exempt an insurance company from the provisions of these rules, if it is satisfied that an insurance company has already a grievance redressal machinery which fulfills the requirements of these rules.
Rule 3
The objects of these rules are to resolve all complaints relating to settlement of claim on the part of insurance companies in cost-effective, efficient and impartial manner.
Rule 4 Definition
In these rules unless the context otherwise requires :-
(a) "Act" means Insurance Act, 1938;
(b) "committee" means an advisory committee referred to in Rule 19;
(c) "financial year" means a period of twelve months commencing from the 1st day of April of any year and ending on 31st day of March of the succeeding year;
(d) "General Insurance Corporation of India" means agovernment company formed under sub-section (1) of S.9 of the General Insurance Business (Nationalisation) Act, 1972 and shall include a subsidiary company of such company;
(e) "governing body" means governing body of the Insurance Council constituted under sub-rule (1) of Rule 5;
1[1]Substituted for " (f) "Insurance Council" means the Life Insurance Council and the General Insurance Council referred to in Section 64-C of the Act ; ", vide " THE REDRESSAL OF PUBLIC GRIEVANCES RULES, 1998" Dt.December 18, 1998 Published in [37] Ministry of Finance (Deptt. of Economic Affairs) (Insurance Division), Noti. No. G.S.R. 752(E), dated December 18, 1998, published in the Gazette of India, Extra., Part II, Section 3(i), dated 18th December, 1998, p. I, No. 495 [F. No. S6/32/97-lns.] [L] (f) Insurance Council will consist of Life Insurance Corporation of India, General Insurance Corporation of India and its four subsidiaries and other Insurance Companies which will be permitted to do insurance business in future.
(g) "Insurance Regulatory Authority" means a body established by Government of India vide Resolution No. 17(2)/94 Ins. V dated 23-1-1996 to monitor the orderly growth of insurance industry;
(h) "Insurance Company" means the Life Insurance Corporation of India, the General Insurance Corporation of India and any other company which has been given a licence to carry on business of life insurance or of general insurance, as the case may be;
(i) "insured person" means an individual by whom or on whose behalf an insurance policy has been taken on personal lines:
(j) "Life Insurance Corporation of India" means the Life Insurance Corporation of India established under the Life Insurance Corporation Act, 1956;
(k) "Personal lines" means an insurance policy taken or given in an individual capacity.
Rule 5 Governing body of Insurance Council
(1) There shall be a Governing Body of the Insurance Council which shall consist of one representative from each of the insurance companies.
(2) The representatives of an insurance company shall ordinarily be Chairman or Managing Director or any one of the Directors of such company.
(3) The Governing Body shall formulate its own procedure for conducting its business including the election of the Chairman : Provided that the Chairman of the Life Insurance Corporation of India shall act as the first Chairman of the Governing Body,
Rule 6 Ombudsman
(1) The governing body shall appoint one or more persons as Ombudsman for the purpose of these rules.
(2) The Ombudsman selected may be drawn from a wider circle including those who have experience or have been exposed to the industry, civil service, administrative service, etc., in addition to those drawn from judicial service.
(3) An Ombudsman shall be appointed by the Governing Body from a panel prepared by the Committee consisting of-
(a) Chairman of Insurance Regulatory Authority -Chairman
(b) Two representatives of Insurance Council including one -Member each from the Life Insurance Business and from General Insurance Business respectively
(c) One representative of the Central Government –Member
Rule 7 Term of Office
An Ombudsman shall be appointed for a term of three years and shall be eligible for reappointment : Provided that no person shall hold office as such Ombudsman after he has attained the age of 65 years.
Rule 8 Removal from Office
(1) An Ombudsman may be removed from service for gross misconduct committed by him during his term of office.
(2) The Governing Body may appoint such person as it thinks fit to conduct enquiry in relation to misconduct of the Ombudsman.
(3) All enquiries on misconduct will be sent to Insurance Regulatory Authority which may take a decision as to the proposed action to be taken against the Ombudsman.
(4) On recommendations of the Insurance Regulatory Authority if the Governing Body is of opinion that the Ombudsman is guilty of misconduct, it may terminate his services.
Rule 9 Remuneration etc. of Ombudsman
(1) There shall be paid to the Ombudsman a salary which is equal to the salary of the Judge of a High Court.
(2) The other allowances and perquisites of the Ombudsman shall be such as may be specified by the Central Government.
Rule 10 Territorial Jurisdiction of Ombudsman
(1) The office of the Ombudsman shall be located at such place as may be specified by the Insurance Council from time to time.
(2) The Governing Body shall specify the territorial jurisdiction of each Ombudsman.
(3) The Ombudsman may hold sitting at various places within his area of jurisdiction in order to expedite disposal of complaints.
Rule 11 Staff
(1) The Ombudsman shall have such secretarial staff as may be provided to him by the Insurance Council after having consultation with the Ombudsman.
(2) The Ombudsman may engage the services of professional expert with a view to assist him in discharging his functions.
(3) The salary, allowances and perquisites payable to Ombudsman, the salary, allowances and other benefits payable to the staff of the secretariat and all expenses incurred for the purposes of these rules shall be borne by the Insurance Council.
(4) The Ombudsman shall prepare the budget indicating the requirement of funds before the beginning of every financial year.
(5) The budget of the office of Ombudsman will be sent to the Governing Body.
(6) The Governing Body will finalise the budget in consultation with the Ombudsman and shall allocate the funds to the office of Ombudsman.
(7) The total expenses on Ombudsman and his staff shall be incurred by the insurance companies who are members of the Insurance Council in such proportion as may be decided by the Governing Body from time to time : Provided that till a decision is taken by the Governing Body, the entire expenditure shall be shared equally between the insurance companies in the life insurance business and general insurance business in equal proportion.
(8) The share of expenditure which is to be incurred by each insurance company shall be in the ratio of premium income for the previous year of such company. Explanation.-For the purpose of this sub-rule "premium income" means the gross direct premium income of the insurer without taking into account from time to time income on reinsurance accepted by the insurance company,
Rule 12 Power of Ombudsman
(1) The Ombudsman may receive and consider :-
(a) Complaints under Rule 13;
(b) any partial or total repudiation of claims by an insurer;
(c) any dispute in regard to premium paid or payable in terms of the policy;
(d) any dispute on the legal construction of the policies in so far as such disputes relate to claims;
(e) delay in settlement of claims;
(f) non-issue of any insurance document to customers after receipt of premium.
(2) The Ombudsman shall act as counsellor and mediator in matters which are within his terms of reference and, if requested to do so in writing by mutual agreement by the insured person and insurance company.
(3) The Ombudsman's decision whether the complaint is fit and proper for being considered by it or not shall be final.
Rule 13 Manner in which complaint is to be made
(1) Any person who has a grievance against an insurer, may himself or through his legal heirs make a complaint in writing to the Ombudsman within whose jurisdiction the branch or office of the insurer complained against is located.
(2) The complaint shall be in writing duly signed by the complainant or through his legal heirs and shall state clearly the name and address of the complainant, the name of the branch or office of the insurer against which the complaint is made, the fact giving rise to complaint supported by documents, if any, relied on by the complainant, the nature and extent of the loss caused to the complainant and the relief sought from the Ombudsman.
(3) No complaint to the Ombudsman shall lie unless :-
(a) the complainants had before making a complaint to the Ombudsman made a written representation to the insurer named in the complaint and either insurer had rejected the complaint or the complainant had not received any reply within a period of one month after the insurer concerned received his representation or the complainant is not satisfied with the reply given to him by the insurer;
(b) the complaint is made not later than one year after the insurer had rejected the representation or sent his final reply on the representation of the complainant: and
(c) the complaint is not on the same subject-matter, for which any proceedings before any court, or Consumer Forum, or arbitrator is pending or were so earlier.
Rule 14 Ombudsman to act fairly and equitably
(1) The Ombudsman may, if he deems fit, adopt a procedure other than mentioned in sub-rules (1) and (2) of Rule 13 for dealing with a claim: Provided that the Ombudsman may ask the parties for necessary papers in support of their respective claims and where he considers necessary, he may collect factual information available with the insurance company.
(2) The Ombudsman shall dispose of a complaint fairly and equitably.
Rule 15 Recommendations made by the Ombudsman
(1) When a complaint is settled, through mediation of the Ombudsman, undertaken by him in pursuance of request made in writing by complainant and insurer through mutual agreement, the Ombudsman shall make a recommendation which he thinks fair in the circumstances of the case. The copies of the recommendation shall be sent to the complainant and the insurance company concerned. Such recommendation shall be made not later than one month from the date of the receipt of the complaint,
(2) If a complainant accepts the recommendation of the Ombudsman, he will send a communication in writing within 15 days of the date of receipt of the recommendation. He will confirm his acceptance to Ombudsman and state clearly that the settlement reached is acceptable to him, in totality, in terms of recommendations made by the Ombudsman in full and final settlement of complaint.
(3) The Ombudsman shall send to the insurance company a copy of the recommendation along with the acceptance letter received from the complainant. The insurer shall thereupon comply with the terms of the recommendations immediately not later than 15 days of the receipt of such recommendation and the insurer shall inform the Ombudsman of its compliance,
Rule 16 Award
(1) Where the complaint is not settled by agreement under Rule 15, the Ombudsman shall pass an award which he thinks fair in the facts and circumstances of a claim.
(2) An award shall be in writing and shall state the amount awarded to the complainant : Provided that Ombudsman shall not award any compensation in excess of which is necessary to cover the loss suffered by the complainant as a direct consequence of the insured peril, or for an amount not exceeding rupees twenty lakhs (including ex gratia and other expenses), whichever is lower.
(3) The Ombudsman shall pass an award within a period of three months from the receipt of the complaint.
(4) A copy of the award shall be sent to the complainant and the insurer named in the complaint.
(5) The complainant shall furnish to the insurer within a period of one month from the date of receipt of the award, a letter of acceptance that the award is in full and final settlement of his claim.
(6) The insurer shall comply with the award within 15 days of the receipt of the acceptance letter under sub-rule (5) and it shall intimate the compliance to the Ombudsman.
Rule 17 Consequences of non-acceptance of award
If the complainant does not intimate the acceptance under sub-rule (5) of Rule 16, the award may not be implemented by the insurance company.
Rule 18 Power to make ex gratia payment
If the Ombudsman deems fit, he may award an ex gratia payment.
Rule 19 Advisory Committee
An Advisory Committee not exceeding five eminent persons shall be notified by the Government to assist the Insurance Regulatory Authority to review the performance of the Ombudsman from time to time. The Insurance Regulatory Authority shall decide the time, venue and quorum of such meeting. The authority, after discussing the matter with the Governing Body, may recommend to Government appropriate proposals for effecting improvements in the functioning of Ombudsman. In the light of recommendations made by the Insurance Regulatory Authority, the Government may carry out such amendments to these rules as they may deem fit,
Rule 20
The Ombudsman shall furnish a report every year containing a general review of the activities of the office of the Ombudsman during preceding financial year to the Central Government and such other information as may be considered necessary by it. In the Annual Report, the Ombudsman will make an annual review of the quality of services rendered by the insurer and make recommendations to improve these services.
Rule 21 Recommendation of the Insurance Council
The Insurance Council may suggest to the Ombudsman such recommendations as it deems fit and which in its opinion will enhance the utility of the Annual Report and also so that the objectives of the rules are clearly analysed in terms of the activities in the year under review. Suggestion for long-term improvement of insurance sector will be incorporated by the Ombudsman in his report.
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