How to file an Insurance Ombudsman complaint about a health insurance claim

What does the Insurance Ombudsman do?

The Insurance Ombudsman settles disputes between policyholders and insurers without a court case, and its award binds the insurer. It works under the Insurance Ombudsman Rules, 2017, made by the Central Government, and the Council for Insurance Ombudsmen sets the guidelines for how its offices are administered. Under rule 13, it can hear complaints about:

• delay in settling a claim beyond the time set in IRDAI’s regulations;
• partial or total repudiation of a claim;
• disputes over premium;
• misrepresentation of policy terms, or a policy that doesn’t match your proposal form;
• how the policy should be read, where the dispute relates to a claim;
• policy servicing, and non-issue of a policy after premium was paid.

It covers individual policies and group policies, so a dispute over an employer’s group health cover can go to the Ombudsman too.

Who can complain, and when?

The policyholder can complain, or their legal heirs, nominee or assignee, but only after a written complaint to the insurer. The guide to what to do when a claim is rejected has an outline for that first complaint. Under rule 14 you can go to the Ombudsman if, after you complained to the insurer in writing, by email or online:

• the insurer rejected your complaint;
• it didn’t reply within one month of receiving it; or
• you aren’t satisfied with its reply.

The complaint must be filed within one year of the insurer’s rejection or reply, or within one year of the end of that one-month period if it never replied. The Ombudsman can condone a delay after hearing the insurer, but don’t count on it. Insurers must resolve grievances within 14 days, and their reply must include the Ombudsman’s contact details.

The Ombudsman can’t hear a complaint on a matter already pending before, or decided by, a court, consumer commission or arbitrator. Choose this route before going to a consumer commission, not after.

How much can the Ombudsman award?

Up to ₹50 lakh, including relevant expenses, and never more than the loss you actually suffered. The award states the amount after deducting anything the insurer has already paid.

Example. Your hospital bill was ₹4,20,000 and the insurer paid ₹2,95,000, deducting ₹1,25,000. Of that, ₹15,000 is for non-payable items such as gloves and an admission kit, which your policy clearly excludes. The other ₹1,10,000 is a proportionate deduction applied to medicines and diagnostics, which your policy’s definition of “associated medical expenses” leaves out. You ask the Ombudsman for ₹1,10,000 plus interest for the delay. That is well within the ₹50 lakh limit, and narrowing the claim to the deductions your wording doesn’t support makes it easier to decide.

A draft amendment published in November 2025 would replace the ₹50 lakh cap and add an appeal route, but as of October 2026 it hadn’t been notified, so the ₹50 lakh limit still applies.

How to file an online complaint at cioins.co.in

File online through the “Register Complaint” page on cioins.co.in, with your documents ready as PDFs or photos. The steps are:

1. Confirm eligibility. The form asks you to confirm that you complained to the insurer, that it rejected you or didn’t reply within one month, that you are within one year, and that the compensation sought is no more than ₹50 lakh.
2. Verify your mobile number. An OTP is sent to your phone and is valid for 90 seconds.
3. Fill in your details. Name, relation to the insured, address, policy number, date of the event and a short description of the dispute.
4. Add the complaint you made to the insurer. The date you complained, whether it replied, and the insurer’s name.
5. Choose the office. You can file with the Ombudsman covering the insurer’s branch or office, or where you live. If that office is busy, you may be asked to consent to a transfer and an online hearing.
6. Upload documents. PDF or JPG, under 10 MB each.
7. Review, declare and submit. Note the complaint number. The complaint is checked before it is registered, and you can follow it on the “Track Complaint” page.

You can also send a signed written complaint by post or email to the right Ombudsman office. A specimen complaint form is on cioins.co.in.

Documents you need

Keep these ready before you start, as the Council for Insurance Ombudsmen asks for them:

• the complaint you sent to the insurer, and any reply;
• the insurer’s repudiation, rejection or partial settlement letter;
• a full copy of the policy, all pages;
• copies of all earlier policies for the 48 months before this one, if the claim was rejected over a pre-existing disease or waiting period;
• ID and address proof, and a photograph for online complaints;
• all other letters and emails with the insurer or TPA.

Add the discharge summary, the final bill and the itemised deduction sheet, as these are what the Ombudsman will compare with your policy wording. The guide to why a claim is paid less explains how to read that sheet.

What happens after you file?

The Ombudsman first tries mediation if both sides agree, and otherwise hears both sides and passes an award.

• Insurer’s response. Under an IRDAI circular of 23 July 2026, insurers must file their written response within 7 days of notice. If they don’t, the Ombudsman can go ahead without it.
• Mediation. If both sides consent, the Ombudsman makes a recommendation within one month. If you accept it in writing within 15 days, the insurer must comply within 15 days.
• Hearing. Hearings can be in person or by video conference, and you don’t need a lawyer.
• Award. The Ombudsman must pass a reasoned award within three months of receiving all requirements from you, so send everything at the start.
• Compliance. The award binds the insurer, which must comply within 30 days and pay interest for the delay in settling. Under IRDAI’s 2024 Master Circular, an insurer that doesn’t comply in time, and hasn’t appealed, pays you ₹5,000 a day. Ten days late would mean ₹50,000.

The award doesn’t bind you. If you aren’t satisfied, the Council for Insurance Ombudsmen says you can still pursue your normal legal remedies.

How many complaints does the Ombudsman handle?

Tens of thousands a year, and most are about health insurance. The Council for Insurance Ombudsmen’s annual report for 2024-25, as reported by Insurance Business, shows 53,184 complaints received across the offices, with health insurance disputes about 64% of the total.

What to check in your policy

1. Grievance redressal section: the grievance cell email and the Grievance Redressal Officer’s contact. Many wordings also list Ombudsman office addresses.
2. The clause the insurer cited: quote it exactly in your complaint.
3. Definitions: the terms your dispute turns on, such as “pre-existing disease” or “associated medical expenses”.
4. Schedule: the date of continuous coverage, if waiting periods or the moratorium are in dispute.

Where people get caught out

• Not complaining to the insurer first. Without a written complaint to the insurer, the Ombudsman can’t take the case.
• Filing too late. The one-year clock runs from the insurer’s reply, or from one month after your complaint if it didn’t reply.
• Going to a consumer commission first. The Ombudsman can’t then hear the same dispute.
• Sending documents in instalments. The three-month award clock starts only when the Ombudsman has everything it needs.
• Asking for more than the loss. The award can’t exceed your actual loss, so a precise, itemised claim is stronger.