Also at https://www.box.com/s/8ce7e60e3e02ca045335
COMPLAINT
PETITION
BEFORE HON’BLE INSURANCE OMBUDSMAN AT __________
Address
of Office of Insurance Ombudsman:
_______________________________________________________________
Date: _________ By
Registered Post AD
Being aggrieved by no
decision/ full or part repudiation of claim, I submit this complaint for kind decision.
01. Name and address
of complainant with mobile No. and email ID [if any] :
Mention your details
02. Name and address
of Insurance Company with fax/phone/email ID:
03. Details of policy:
Type
of Policy _________
No.
of policy: __________
Validity
from _______ to ________
Policy
since: _______ [mention date of commencement of first policy]
04. Details of Claim:
Claim Amount: Rs.__________
[Rs. ___________________________only]
Claim submission date
________
Claim relating to:
________
Claim No. [Allotted by
insurance co] if any
05. Cause of Complaint:
[Mention here how claim
has been rejected]
06.
Submission of Complainant:
[Mention
why you think claim should have been paid]
07. Prayers and Relief:
a.
Claim of Rs. ________[ in words Rs. __________] be kindly ordered to be paid to
complainant with interest at ____ p.a. from
date of lodging claim to date of payment.
b.
Compensation of Rs. _____ towards expenses and mental agony be ordered to be
paid.
c.
Insurance Company be imposed exemplary penalty for improper repudiation, non-conveying
decision, delay in conveying decision on claim, violating IRDA directives and not
honoring averments of higher judiciary on the matter of such claims.
d.
The Hon’ble Insurance Ombudsman be pleased to pass such other orders as deemed
fit in the interest of justice, fair play and equity.
08.
Declaration:
Complainant
hereby states that the information and particulars given above are true to the
best of his knowledge and belief. He also declares that this matter is not
previously filed with any commission or Court or tribunal or authority.
09.
Attachments:
Self
attested photocopies of: a] Policy, b] Claim form with its enclosures, c] All letters of Insurance Co or TPA d] Complaint
made to insurance company/TPA by complainant giving 30 days minimum time to
settle claim.
X
Signature
of Complainant
Copy
to [without attachments, since same are with it] by Regd AD post:
Branch
Office of Insurance Company which issued policy
________________________________________________________________
Guidelines:
1. Please visit http://www.gbic.co.in/notifications.html
specially clauses 13 to 18. For address etc please visit www.gbic.co.in
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