Rules and Procedures
General Rules
The Insurance Ombudsman, Sri Lanka is an independent person. He will act impartially and do his best and inquire into your complaint and try to settle it. He is also assisted by an able and qualified Advisory Panel of Experts on Insurance Law and Practice. The Ombudsman will discuss your complaint with the insurance company (insurer), concerned with a view to settlement. The Ombudsman will also obtain all the relevant documentation (such as the insurance policy etc.) from the insurer and the complainant need not worry about submitting these documents or spending money on photocopying documents for use by the Ombudsman.
The Insurance Ombudsman is not bound to observe any legal procedure or rules relating to evidence etc. like a Judge in a court of law. The Ombudsman is entitled to follow any procedure considered appropriate. The Ombudsman will be guided by the evidence placed before him, principles of Insurance Law and Practice, Directives issued by the Insurance Board of Sri Lanka (IBSL)and the Codes of Conduct and Manual of Procedures used by the insurance institution in question. The Ombudsman is more concerned with what is just and equitable and will always act in the interest of justice in each case.
The Ombudsman will decide on each complaint on its merits and will not consider the decision in one case as a binding precedent in another complaint of a similar nature. It has been agreed by the insurance institutions that are participating in this scheme that the principle of "binding precedent" which normally applies to courts of law (judges) will not apply to the Insurance Ombudsman scheme.
What type of Complaints are Excluded
Your complaint to the Ombudsman must 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.
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. Where a similar matter/complaint was investigated by the ombudsman and a decision given.
c. Your complaint is already the subject matter of proceedings before any Court of Law/Tribunal/Arbitration etc.
The Ombudsman also has the right to reject and/or not proceed to require into any complaint if in the Ombudsman's opinion:
a. The complaint is frivolous/vexatious or was made in bad faith or without sufficient cause.
b. That the complainant has not pursued the complaint with reasonable diligence.
c. There was no real loss or damage or inconvenience caused to the complainant.
d. The complaint is of a complicated nature which requires consideration of elaborate documents/oral evidence or involves complicated legal issues which are not appropriate for an inquuiry or decision by a person such as the Ombudsman. In such an event the Ombudsman may give a written opinion as to what steps he recommends and why and a certified copy of such written opinion shall be admissible in any other proceedings without objection by the complainant and/or the insurer.
General Procedures
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 for 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 terminatioin of service etc.
Generally speaking if the complaint is one which the Ombudsman can and should inquire into, the Ombudsman's Office will open a file and give the complaint an Office Reference Number. It will next. (i) inform the complainant of the receipt of the complaint (ii) fax and post a copy of the complaint to the insurance company concerned for a quick reply/response.
Sometimes the reply sent by the insurance company (insurer) is sufficient to settle the dispute and for the Ombudsman to come to a decision on the matter. If not, after the insurer's response is received, the matter(complaint) is fixed for inquiry at the Ombudsman's office. Sometime only the relevant officials of the insurance company (insurer) are asked to come for the inquiry. This is because it may be possible to find out what has happened and try to settle the dispute by speaking to the insurer independently. The Ombudsman's office is not anxious to trouble the complainant to attend inquiries unless it is absolutely essential. Another reason is that all relevant documents are with the insurer.
However, if it is not possible to settle the dispute at an inquiry only by contacting or speaking to the officials of the insurance company, the Ombudsman will fix an inquiry where the complainant also can be present. At such an inquiry, the Ombudsman can question both the complainant (insured) and the insurance company(the insurer) in the presence of each other. In some instances this meeting with both parties has helped to settle disputes.
Finality about complaints to Ombudsman
The Insurance Ombudsman's objective is as far as possible to settle complaints (disputes) to the satisfaction of the complaining policy holder. Where this is not possible because, in the Ombudsman's view, the insurance company (the insurer) has not been at fault, the Ombudsman informs the complainant that he is unable to help him/her and closes the file. In some cases, the Ombudsman calls the complainant to his office and explains to the complainant why he is unable to grant any relief.
Once the above steps are taken, the file on the matter is closed. The Insurance Ombudsman is keen to ensure that no complaint is kept pending without a decision for more than three to six months.
Insurance Ombudsman's Office
The Insurance Ombudsman's Office is situated at No. 143 A, Vajira Road , Colombo 5 (This is the same road on which the well-known Girls school – Visakha Vidyalaya – is situated). The Insurance Ombudsman's Office is housed in the same building as the Financial Ombudsman's office.
The contact details of the Insurance Ombudsman's Office are as follows.
| Address: |
No. 143 A, Vajira Road, Colombo 5 |
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| Telephone: |
+ 94 11 4528671 |
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+ 94 11 2505542 |
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| Fax: |
+ 94 11 4528670 |
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+ 94 11 2595625 |
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| Email Address: |
info@insuranceombudsman.lk |
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| Web Address: |
www.insuranceombudsman.lk |
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| Insurance Ombudsman: |
Dr. Wickrema Weerasooria |
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| Secretary/Administrative
Officer to Ombudsman: |
Ms. Sabina Ekanayake |
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When and How to apply to the Ombudsman
Normally, when there is an insurance claim, the insurance company (insurer) will examine the claim and take steps to settle it to the satisfaction of the policy holder(insured). In exceptional circumstances, this may not happen and an insurance claim may remain unsettled or settlement is being inordinately delayed to the dissatisfaction of the policy holder. In such a case, the policy holder(the insured) can apply to the Insurance Ombudsman for relief and request the Ombudsman to ensure that the insurer settles the insurance claim.
No policy holder need pay any money to obtain the Ombudsman's services. He or she need only communicate with the Ombudsman's office by letter or by fax or personally call at the office which is situated at 143 A, Vajira Road, Colombo 5 (This is the same road on which the well-known Girl's School, Visakha Vidyalaya is situated). The Insurance Ombudsman functions in the same building at 143 a, Vajira Road Colombo 5 where the Financial Ombudsman Sri Lanka also has his office.
Steps to be taken before contacting the Ombudsman
Before applying to or complaining to the Insurance Ombudsman, it is expected that the policy holder/complainant would have contacted the insurance company in question about his or her claim. Complaints should be made to the Insurance Ombudsman only if the insurer is refusing to pay the claim or there is a long delay in attending to a claim.
What particulars you should give when complaining to the Ombudsman
There are no formal/special application forms to fill up. All that you need do is to briefly write out your complaint in any language (English/Sinhala/Tamil) of your choice but please give your name/address/Telephone/Fax No. (if available) and also state the name of the insurance company and the insurance policy number. If the complaint refers to a motor vehicle please give the vehicle registration number.Only written/signed complaints will be entertained.
Do not forget to write
(a)
Name of Insurer
(b)
Insurance Policy No.
(c)
In case of a vehicle, the vehicle number
(d) Give a brief description of why you are making a claim
Do not send any documents. The Ombudsman's office will only call for documents if necessary. We normally get the insurance company to supply the required documents
