1) With whom is a complaint to be lodged?
Insurance Policy holders who wish to apply to the Insurance Ombudsman for relief are advised to consult the website, which has been prepared by the Ombudsman’s office for the benefit of the public. It contains useful information to those wishing to complain or apply to the Ombudsman and also sets out general information about the Ombudsman scheme. The Insurance Ombudsman’s website is www.insuranceombudsman.lk.
There are two main steps you have to consider when seeking any relief from the Insurance Ombudsman.
Step 1
Ask yourself whether you have contacted the insurance company that sold you the policy about your complaint. For example, your car has met with an accident and the insurance company is refusing or not paying the entire repair bill claimed by you. Have you written or spoken to a responsible officer of the insurer about it? Has the insurer failed to respond or failed to attend to your complaint to your satisfaction? It is only at this stage that you should complain to the Insurance Ombudsman. You must not complain to the Insurance Ombudsman without first attempting to resolve your dispute with the insurer.
Step 2
Let us assume you have tried to contact the insurance company but; (i) you either had no response or (ii) the insurance company was unwilling or unable to satisfy your complaint and you still feel that you have a grievance that needs to be redressed, then you can apply to the Insurance Ombudsman.
2) Does Insurance Ombudsman operate in any territorial jurisdiction?
Territorial Jurisdiction of the Insurance Ombudsman depends on the type of policy taken. For example, a motor insurance policy will usually cover any accident occurring within Sri Lanka. A travel insurance policy applies in the case of an eventuality covered, occurring overseas.
3) Who can approach Ombudsman?
Any Insurance policyholder who has a grievance against the Insurance Company issuing the policy can approach the Ombudsman.
4) What are the complaints that are entertained by the Ombudsman?
A complaint on any one of the following grounds alleging deficiency in respect of general insurance or long – term insurance service, may be lodged with the Ombudsman.
(i) Non-settlement or delay in the settlement of claims.
(ii) Inequitable interpretation or application of the terms and conditions of the insurance policy with regard to the following:
(a) Claims including maturities of long-term insurance policies and (b) Premium payable and premium refunds,
(iii) Unpaid benefits payable in terms of the insurance policy.
(iv) Any matter referred to the Ombudsman by the Consumer Affairs Authority of Sri Lanka (CAA)
5) How is the complaint to be lodged?
Applying to the Insurance Ombudsman is simple. There are no special forms to fill up. All that you have to do is to write out your complaint briefly in any language of your choice.(English, Sinhalese or Tamil) and post /deliver it to the Ombudsman's Office or you can e-mail it. The Ombudsman will not however, entertain telephone complaints and/or unsigned complaints. Signed complaints are required to prevent bogus or vexatious complaints.
Address
No.143A, Vajira Road, Colombo 5.
Telephone
94 11 2505542
Email Address
Website
Insurance Ombudsman
Dr. Ranjith Ranaraja, Secretary/ Administrative
Officer to the Ombudsman
Ms. Sabina Ekanayake
6) Is there any time limit to approach the Ombudsman?
Your complaint to the Ombudsman must normally be made within twelve months/one year after the cause of action or ground for the complaint had arisen. The one year period will be counted to the date of your first complaint to the insurance institution. This requirement of complaining to the Ombudsman within one year is to prevent belated/stale complaints being made. If the facts justify, exceptions can be made and the one year rule will not be enforced.
7) Is there any maximum limit for the amount under dispute that can be entertained by the Ombudsman?
The jurisdiction of the Insurance Ombudsman is limited to claims below Rs. 2.5 million
8) Can a complainant who has already approached Consumer Forum/Court on the same subject, approach the Ombudsman?
You cannot make a complaint to the Ombudsman if:
(a) You have previously made a complaint and the matter was investigated by the Ombudsman and a decision given.
(b) Your complaint is already the subject matter of proceedings before any Court of Law/Tribunal/Arbitration etc. – unless both the insurer and you agree to the Ombudsman’s intervention.
9) What are the pre-requisite conditions in short, for lodging a complaint?
When the Ombudsman's Office receives a written complaint, it first satisfies itself that the complaint is within the Ombudsman's Terms of Reference. For example (i) whether the complaint is signed (ii) whether the complaint is belated or relates to a matter that arose several years ago (iii) whether the complainant has gone for Arbitration or Litigation, in which case the Ombudsman has no power to inquire into it or (iv) the complaint relates to a matter which is clearly outside the Ombudsman's jurisdiction, as for example where an employee or agent of an insurance company is complaining of wrongful dismissal or termination of service etc.
The particulars that should be given when complaining to the Ombudsman
There are no formal/special application forms to fill up. All that one need do is to briefly write out the complaint in any language (English / Sinhala / Tamil) of your choice but giving your name / address / Telephone number and also stating the name of the insurance company and the insurance policy number. If the complaint refers to a motor vehicle, the vehicle registration number should be given. Only written/signed complaints will be entertained. Do not send any documents. The Ombudsman's office will only call for documents if necessary. The Ombudsman normally, gets the insurance company to supply the required documents and provide details of the claim and why it was rejected or not settled etc.
10) Should a complainant approach the Ombudsman through a lawyer?
You do not need to get the assistance of lawyers to come before the Ombudsman. You are not prohibited from getting a lawyer to draft your complaint. But the general practice in Ombudsman Schemes is that no lawyers are permitted to appear before the Ombudsman. Nor is the Ombudsman bound by legal rules and procedures which apply to Courts of Law.
11) Within what time shall the Ombudsman dispose off the complaint?
Usually a complaint is inquired into and disposed of within 30-45 days.
12) Can the Ombudsman award ex-gratia payment?
An ex-gratia payment to the insured can be made to the insured, after discussion with and consent of the insurer.
13) Are there any fees / charges payable for lodging a complaint?
Since its establishment, the Ombudsman has made the Ombudsman Scheme a very simple/user friendly one, where insurance policyholders are not expected or required to spend any money or incur expenses in seeking relief. The Insurance Ombudsman Scheme is free and there are no fees/charges of any kind payable when making a complaint.
14) Does the Ombudsman conduct hearings of the parties?
The Insurance Ombudsman’s Office is a transparent friendly and hassle free service. It is a forum which affords complainants an opportunity to air their grievances personally. The Insurance Ombudsman brings the insurer’s staff to the Ombudsman’s Office and the insured will not be at the mercy of the insurer’s office!
Most claims have been mediated and settlements arrived at and some relief granted. Even a small increase of payment to the amount earlier agreed to by the insurer is gratifying, because unlike in litigation, there is no financial cost to the Complainant.
15) If so, can the hearings be conducted outside headquarters?
There are no facilities to conduct hearings into disputes regarding claims outside the premises of the Insurance Ombudsman’s office.
16) Can a complaint be lodged against a Private Insurer?
In terms of Section 13 of the RII Act, a company interested in commencing an Insurance business in Sri Lanka must incorporate a public company under the Companies Act No 7 of 2007 and obtain registration (a licence) from the IRCSL as an insurer under the Act, after having fulfilled other statutory requirements.The Insurance Ombudsman has jurisdiction over only those companies which have fulfilled the above conditions and are members of the IASL
17) Can Partnership Firms/Corporate Clients/Co-operative Societies/ Associations/Trusts approach Ombudsman?
Yes, if they are Insurance Policyholders. See answer to question 3.
18) Is there any appeal against a decision given by the Ombudsman?
The Insurance Ombudsman does not give a decision but makes an Award/Recommendation, from which there is no right of appeal.
19) Are copies of complaints or queries and correspondence related thereto required to be forwarded to the Office of the Governing Body of Insurance Council?
There is no provision to forward any documents referred to, to the IRCSL.
Most of the answers given above were prepared based on the text of Dr. Wicrema Weerasooria’s work on the subject titled Law Governing Insurance Negligence Damages and Third Party Moto Claims.
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