How do I prepare for an Insurance Ombudsman hearing?

Prepare a one-page chronology, a numbered set of the documents that matter, and a short statement that answers the insurer's stated reason and says what relief you want. The Ombudsman decides on the pleadings and the evidence on record after giving both sides a reasonable opportunity to be heard, in person or by video-conference. Preparation helps you be heard clearly; it cannot predict or secure the result.

The Insurance Ombudsman Rules require the Ombudsman to give both sides a reasonable opportunity of being heard, and to base an award on the pleadings and the evidence brought on record. So the hearing is your chance to make the written record easy to follow, not to introduce a new case.^[1]

What to prepare

1. 1

   A one-page chronology

   Dates only, in order: when the policy started or was renewed, the event, the claim, the insurer's decision, your complaint, the insurer's reply, and the date you filed with the Ombudsman. Each line should point to a document.^[1]

2. 2

   Your documents, numbered

   The Rules ask for the facts to be supported by documents. Put them in date order, number them, and use the numbers whenever you speak ('document 7, the discharge summary').^[1]

3. 3

   The insurer's reason, and your answer

   Write down the insurer's stated reason and the clause it relies on, exactly as written. For a health claim, IRDAI requires a rejection or partial disallowance to refer to the specific policy terms; if yours does not, say so. Then answer the reason point by point, each with a document number.^[2]

4. 4

   The relief you want

   State it plainly: the amount and what it is for, or the action you want. The Ombudsman cannot award more than the loss directly suffered or ₹50 lakh including expenses, and cannot award ex-gratia payments.^{[1, 3]}

5. 5

   A short statement

   Two or three minutes, spoken: who you are, what happened, why the reason does not apply, and what you are asking for. Practise it aloud once.

6. 6

   Answers to the hard questions

   Think about the weakest points in your case — a late intimation, a condition not mentioned on the proposal form, a missing bill — and prepare an honest, short answer to each, with any document that helps.

On the day

• In person or by video: The Rules let the Ombudsman hear a matter by video-conference, on its own or at your request, if satisfied that the circumstances require it, and the Council says hearings are held in person or by video where considered necessary. If you need a video hearing, ask the office early.^{[1, 3]}
• You speak for yourself: The Council says the Rules make no provision for engaging a lawyer. The complainant may be you, or your legal heir, nominee or assignee. Do I need a lawyer? covers this.^{[3, 1]}
• Stay with the record: The award is based on the pleadings and the evidence on record. If the Ombudsman needs more, it can ask either side for additional documents.^[1]
• If mediation is offered: Mediation needs both sides' written consent. If a recommendation follows, you have 15 days from receiving it to accept it in writing, so you need not decide in the room.^[1]
• Be accurate: Say 'I don't know' rather than guess, and correct a mistake as soon as you notice it.

What preparation cannot do

No checklist decides a complaint. The Ombudsman weighs the facts, the policy wording and the evidence, and may also obtain the opinion of professional experts where a case warrants it. Be wary of anyone who claims to know how an Ombudsman will rule.^[1]

ClaimAssure is an independent private platform. It is not an insurer, IRDAI, Bima Bharosa or the Insurance Ombudsman, it never files anything on your behalf, and it cannot promise any outcome. What it does is read your documents and show you what they say.

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