Insurance Regulatory and Development Authority
LIFE INSURANCE
POLICY HOLDER COMPLAINTS REGISTRATION FORM
(Separate forms to be used for each complaint)
Annexure I
Please approach your Insurance Company first with the grievance. If you have not received a response or you are not satisfied with the response on your grievance, you may use this form to register the complaint with IRDA.
If the complaint is a dispute in regard to premium paid or payable, dispute on policy wording pertaining to claim payment, delay in settlement in claims or non-issue of insurance document the same may be lodged with Insurance Ombudsman. The addresses of the Ombudsmen are available on our website.
1. Name of the complainant: ___________________
2. Address of the complainant: _______________________
_______________________
_______________________
_______________________
3. E-mail/Telephone/Fax : _________________________
4. Whether Individual /Company:
(Please tick)
Individual Company/other entities
5. Name of the Insurance Company: ___________________________
6. Address of the servicing office/branch with office code (if available):
________________________________________
________________________________________
________________________________________
7. Policy number/Proposal deposit number: _______________
8. Claim number: __________________________________
9. Is your complaint related to (please tick the appropriate box)
Conventional Life Insurance Policy
Unit Linked Life Insurance Policy
Pension Policy
Health Insurance Policy
Insurance Regulatory and Development Authority
LIFE INSURANCE
POLICY HOLDER COMPLAINTS REGISTRATION FORM
(Separate forms to be used for each complaint)
Group Insurance Policy
Others
10. Nature of complaint: (Please tick the appropriate box)
a. Purchase of policy
Plan & Term of the policy differ from what is requested
Mis-sale/Mis-representation/Tampering in proposal
b. Issue of policy
Acceptance of proposal related complaints
Non-refund of excess proposal deposit
Communication of decision on proposals not done within 15 days of
receipt
Non-receipt of Policy Bond
Refund on Free-look
Error in Policy Schedule and Documents
c. Policy Servicing
Cancellation of policy other than Free-look
Response for recording Change of address is not sent within 10 days
from receipt of communication
Response for noting a new nomination or change of nomination is
not done within 10 days from receipt of communication
Response for noting an assignment is not sent within 10 days from
receipt of communication
Response for information of current status of policy is not sent
within 10 days from the receipt of communication
Response for issuance of an endorsement under the policy (noting a
change in sum assured etc.) is not sent within 10 days from the
receipt of communication
Response for issuance of duplicate policy is not sent within 10 days
from the receipt of the communication
Payment of premium (ECS, Online payment, non-acceptance by
company etc.)
Delay in adjustment of premium (causing policy lapse, loss of units
Insurance Regulatory and Development Authority
LIFE INSURANCE
POLICY HOLDER COMPLAINTS REGISTRATION FORM
(Separate forms to be used for each complaint)
etc.)
Complaints related to improper Allocation of Units
NAV related complaints
Charges deducted are not as per the policy provision
Non-receipt of Premium receipt
Non-receipt of Duplicate policy
Non-receipt of lapse intimation
Complaints related to Revival of lapsed policy
Complaint related to Assignment of Policy
Transfer of policy from one branch to another
Complaint on other benefits under the policy other than policy
payment (Automatic Premium loan/ premium redirection/conversion
option etc.)
Complaint on alteration in policy (Rider addition or deletion, change
in SA, Change in Premium, Change in mode of payment, change in
plan & term etc.)
Non-receipt of statement of accounts/ bonus etc.
d. Claim Servicing
Surrender Value not paid
Payment of less surrender value
Queries or requirement of additional document in respect of survival
benefit not received within 15 days of receipt of the claim request
Partial withdrawal benefit is not paid
Survival Benefit is not paid within 30 days from the date of receipt
of all relevant papers
Queries or requirement of additional document in respect of
Maturity Claim not received within 15 days of receipt of the claim
request
Maturity claim is not paid within 30 days from the date of receipt of
all relevant papers
Queries or requirement of additional document in respect of Death
Claim not received within 15 days of receipt of the claim request
Death claim is not paid within 30 days from the date of receipt of all
relevant papers
Death claim not paid since investigation is not completed within 6
months from the date of intimation
Repudiation of Claim
Insurance Regulatory and Development Authority
LIFE INSURANCE
POLICY HOLDER COMPLAINTS REGISTRATION FORM
(Separate forms to be used for each complaint)
Queries or requirement of additional document for any other claim
(Health, Accident Benefit, Disability Benefit or other Riders) is not
received within 15 days of the receipt of the claim request
Any other claim (Health, Accident Benefit, Disability Benefit or
other Riders) is not paid within 30 days from the date of receipt of
all relevant papers
Any other claim (Health, Accident Benefit, Disability Benefit or
other Riders) is not paid since investigation is not completed within
6 months from the date of intimation
Complaint related to Payment of Annuity installments
Response for processing and Payment of Policy Loan is not sent
within 10 days from receipt of the communication
The amount of claim is not correct (Bonus, Sum Assured etc. )
Non-payment of penal interest for delayed policy payments
e. Other issues
Advertisement related complaint
Complaint against Agent
Malpractices by the employees of the insurer
Repeated and unwanted tele-calls from the company - Do not Call
Register
Any other complaint related to Policy (Details of complaint is
compulsory)
10. Details of complaint (including details of document copies attached):
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
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SIGNATURE: ________________________
DATE: