Complaint Form

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COMPLAINT FORM
Name:
________________________
Telephone No._________________
Res.Add:__________________________
Mobile No.
_________________
___________________________
Email I.D
_________________
To,
The Secretary/Dy.Secretary/Centre in-charge,
Office of Insurance Ombudsman
__________________________
Sir/Madam,
Re: Policy No._____________________________
Name of Insurance Co._______________________
Branch
______________________________
Extent of Loss__________________________________
Relief sought from Ombudsman _____________________
1.
Kindly mention gist of your complaint.
2.
Specify the photo copies of the documents being submitted alongwith Complaint letter for
consideration such as :
a) Policy copy ( all pages of policy under which complaint is lodged)
b) Copies of all old policies for covering of Insurance since last 48 months prior to this policy if claim
is rejected on grounds of pre-existing diseases/waiting period.
c) Repudiation/Denial letter/Partial settlement letter issued by the Insurance company.
d) Representation to the Grievance Redressal of Insurance Company.
e) Any other correspondence exchanged with Insurance Company & TPA.
f) Hospital Bills, Investigation reports claim form , Indoor Case papers etc.for mediclaim
g) RC Book, Driving Licence etc for Motor Complaint.
h) Annexure VI-A
click
here.
i.e Details of the complaint to be furnished to Ombudsman Office along
with consent for Ombudsman to act as mediator
Signature.

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