निःशुल्क बीमा शिकायत पत्र टेम्पलेट (भारत)

To: The Grievance Redressal Officer, [INSURER NAME]
Subject: Grievance regarding [rejection / delay / short settlement] of claim [CLAIM NUMBER] under policy [POLICY NUMBER]

Dear Sir/Madam,

I hold policy no. [POLICY NUMBER] issued by [INSURER NAME], valid from [START DATE] to [END DATE]. On [DATE OF CLAIM], I filed claim no. [CLAIM NUMBER] for [BRIEF DESCRIPTION, e.g. hospitalisation for cataract surgery] amounting to ₹[AMOUNT].

On [DATE], the claim was [rejected / partly settled / not responded to]. The stated reason was: "[QUOTE THE EXACT REASON FROM THE REJECTION LETTER]".

I dispute this because [STATE YOUR REASON — e.g. the condition was disclosed / the exclusion does not apply / the treatment is covered under clause [X] of the policy]. I enclose: the policy document, the rejection letter, the hospital/claim documents, and [OTHER EVIDENCE].

I request that you reconsider and settle the claim in full within the 14-day grievance-resolution timeline prescribed by IRDAI, and provide a written, reasoned reply. Please treat this as a formal grievance and share the complaint reference number.

Yours faithfully,
[FULL NAME]
[ADDRESS] · [PHONE] · [EMAIL]
Date: [DATE]

I, [FULL NAME], hold policy no. [POLICY NUMBER] with [INSURER NAME]. I filed claim no. [CLAIM NUMBER] on [DATE] for ₹[AMOUNT] towards [BRIEF DESCRIPTION].

The claim was [rejected / delayed / short-paid] on [DATE] citing "[EXACT REASON]". I raised a written grievance with the insurer's Grievance Redressal Officer on [DATE] (reference [GRO COMPLAINT REF, if any]), but it has not been resolved within the prescribed timeline / the reply was unsatisfactory.

I request IRDAI to take up the matter with the insurer. I believe the [rejection / delay / short payment] is not justified because [ONE-LINE REASON]. Supporting documents (policy, rejection letter, claim papers, grievance correspondence) are available and can be uploaded.

[FULL NAME] · [PHONE] · [EMAIL] · [CITY]

To,
The Insurance Ombudsman,
[YOUR OMBUDSMAN OFFICE — see the jurisdiction lookup]

Re: Complaint against: [INSURER NAME]
Branch / Division: [BRANCH / DIVISION]
Policy No.: [POLICY NUMBER]
Name of Complainant: [FULL NAME]
**********
Being aggrieved, I am lodging a complaint against the above-referred Insurance Company. Details are as under:

1. Complainant's full name and address
   Name: [FULL NAME]
   Address: [ADDRESS]
   Mobile: [MOBILE]   Landline: [LANDLINE]   Email: [EMAIL]
   Relationship to the insured person: [SELF / SPOUSE / PARENT / NOMINEE / ...]

2. Name of the Insurance Company: [INSURER NAME]
   Office address: [INSURER OFFICE ADDRESS]
   Division / Branch: [BRANCH]

3. Policy number: [POLICY NUMBER]

4. Subject matter of complaint and brief details of the case:
   [What was claimed (claim/policy no.), when filed, and how it was rejected / delayed / short-paid — quote the exact reason the insurer gave.]

5. Date of preferring your claim / complaint to the insurer (enclose a copy): [DATE]

6. Date of the insurance company's reply (enclose a copy): [DATE — or "no reply received"]

7. Are any proceedings before any Court / Consumer Forum / Arbitrator on the same subject matter pending, or were so earlier? [NO — or give details]

8. Grounds of complaint (why the insurer's decision is wrong):
   [e.g. the condition was disclosed / the exclusion does not apply / the treatment is covered under clause [X] of the policy.]

9. Relief sought: I request that [INSURER NAME] be directed to settle the claim in full — ₹[AMOUNT] — with applicable interest. (The amount is within ₹50 lakh.)

10. Declaration:
   a) The statements above are true to the best of my knowledge.
   b) I made a written representation to the insurer, which rejected it / did not reply within one month / replied on [DATE] but the reply is not acceptable to me.
   c) One year has not elapsed from the date of the insurer's rejection or final reply.
   d) The complaint is not on the same subject matter for which any proceedings before a court / consumer forum / arbitrator are pending, settled, or were so earlier.
   e) The subject matter has not been decided earlier by any office of the Insurance Ombudsman.

11. Enclosures:
   1) Copy of the complaint letter written to the insurer
   2) Copy of the reply received from the insurer
   3) Copy of the reminder, if any

For mediclaim / health policies — is the policy Fresh or Ported? [FRESH / PORTED]
   If ported: Date of porting [DATE] · Previous insurer [NAME] · Previous policy no. [NO.] · Commencement date of previous policy [DATE] · Sum insured ₹[AMOUNT]

Yours faithfully,
[FULL NAME]      Signature: __________      Date: [DATE]

--- Consent to mediation (Annexure VI-B) ---
To the Insurance Ombudsman: With reference to your letter dated [DATE], I hereby give my unconditional and irrevocable consent for the Insurance Ombudsman to act as mediator between the Insurance Company and myself and to give recommendations for the resolution of the complaint. I [consent / do not consent] to an audio and/or video hearing.
[FULL NAME]      Signature: __________