How does the IRDAI grievance process work for group health insurance?

What is a grievance in group health insurance?

A grievance, in insurance terms, is a written complaint that an insurer, broker, or Third Party Administrator (TPA) hasn't handled a policyholder's or insured member's claim, service request, or policy matter properly, fairly, or within a reasonable time. It's a formal channel for flagging that something went wrong in how a request was handled, not a request in itself.

• A service request is a routine ask, such as updating a dependent's details, requesting a duplicate health card, or asking a general question about coverage. There's no dispute involved.
• A claim is a formal request for the insurer to pay for a covered medical expense, whether cashless or reimbursement.
• A grievance is what happens when a service request or claim isn't handled the way it should have been, a claim gets rejected without adequate reason, a cashless request is denied, a settlement is delayed well beyond normal timelines, or a deduction from a claim payout looks incorrect.

Common grievances under group health insurance for employees include claim rejection, part-payment or short settlement of a claim, cashless authorisation denial at a hospital, unexplained or incorrect deductions from a claim amount, delays in issuing a health card or policy document, and disputes over policy terms such as waiting periods or exclusions.

Who can raise a grievance under a group health insurance policy?

• The insured employee, as the person the claim or service request was actually about, is generally the primary party expected to raise a grievance.
• The employer, as the policyholder of the master group policy, can raise grievances related to the policy itself, and, as covered further below, has a specific standing to approach the Insurance Ombudsman on an employee's behalf.
• A nominee, legal heir, or assignee can raise a grievance in situations where the insured employee themselves isn't able to, consistent with how the Insurance Ombudsman Rules, 2017 define who may file a complaint.

What are the three levels of escalation?

1. The insurer's Grievance Redressal Officer (GRO): every IRDAI-licensed insurer maintains a GRO, whose contact details are published on the insurer's website and policy documents, and on IRDAI's own list of GROs.
2. Bima Bharosa, IRDAI's grievance portal: if the insurer's response is inadequate or doesn't come within the expected timeline, the complaint can be escalated through Bima Bharosa, which registers the complaint against the insurer and monitors its resolution.
3. The Insurance Ombudsman: if the matter still isn't resolved, or the resolution isn't satisfactory, the complaint can go to the Insurance Ombudsman, a quasi-judicial body set up under the Insurance Ombudsman Rules, 2017.

What is the IRDAI grievance redressal process?

• Step 1: Raise the complaint with the insurer's GRO: Submit the complaint in writing, by email or letter, to the insurer's grievance redressal officer. IRDAI expects the insurer to address the complaint within roughly two weeks.
• Step 2: Escalate to Bima Bharosa if unresolved: If the insurer hasn't resolved it within that window, or the response is unsatisfactory, register the complaint on Bima Bharosa at bimabharosa.irdai.gov.in. Bima Bharosa is the successor to the earlier Integrated Grievance Management System (IGMS), and it centralises and tracks grievances against IRDAI-licensed insurers across the industry.
• Step 3: Contact IRDAI's Grievance Redressal Cell directly, if needed: Alongside Bima Bharosa, complaints can also be sent to IRDAI's Policyholders' Protection and Grievance Redressal Department by email at complaints@irdai.gov.in, by calling the toll-free number 155255, or by post to IRDAI's office in Hyderabad.
• Step 4: Approach the Insurance Ombudsman if still unresolved: If the complaint remains unresolved, or the resolution isn't acceptable, the next step is a written complaint to the Insurance Ombudsman with jurisdiction over the insurer's branch or the complainant's residence. Under the Insurance Ombudsman Rules, 2017, this complaint must generally be filed within one year of the insurer either rejecting the representation, replying unsatisfactorily, or failing to reply within one month.
• Step 5: The Ombudsman reviews and, if needed, passes an award: The Ombudsman may first attempt mediation between both parties. If that doesn't resolve it, the Ombudsman passes a written award, which cannot exceed the actual loss suffered or ₹50 lakh, whichever is lower. The insurer must comply with the award within thirty days.

How to file a group health insurance complaint with IRDAI

• Confirm you've first approached the insurer's GRO: Give them a reasonable window, generally around two weeks, to respond, since IRDAI expects this first step before a formal escalation.
• Register the complaint on Bima Bharosa: At bimabharosa.irdai.gov.in, providing the policy details, the nature of the complaint, and any correspondence already exchanged with the insurer.
• Alternatively, email or call IRDAI directly: At complaints@irdai.gov.in or the toll-free number 155255, or send a written complaint using IRDAI's Complaint Registration Form to its Hyderabad office.
• Keep the complaint focused on facts: Includes dates, claim or policy reference numbers, and what resolution is being sought, since a clear, well-documented complaint moves faster through the system.

What are the most common group health insurance grievances?

• Claim rejection: Without what the employee considers adequate justification, often citing a policy exclusion or a documentation gap.
• Short settlement: Where a claim is approved but paid at a lower amount than expected, sometimes due to sub-limits or deductions the employee wasn't aware of.
• Cashless denial at the hospital: Where pre-authorisation is refused or delayed, forcing the employee to pay upfront and file for reimbursement instead.
• Delayed claim settlement: Well beyond the insurer's or TPA's stated turnaround time.
• Incorrect deductions: Where the amount paid doesn't match what the employee expected based on the sum insured and the treatment received.
• Policy-related disputes: Such as disagreements over what a waiting period, exclusion, or benefit actually covers.
• TPA service issues: Including unresponsive support or documentation requests that go back and forth without resolution.

What documents should you keep before raising a grievance?

How can HR help employees with group health insurance grievances?

• Maintain a clear internal process: So employees know exactly who to contact first when a claim is rejected or delayed, rather than each employee having to figure out the insurer's GRO contact independently.
• Keep policy documents and TPA contacts easily accessible: So employees aren't stuck trying to locate their certificate of insurance or claim helpline during an already stressful situation.
• Step in with the insurer or TPA directly: When an individual escalation stalls, since HR, as the policyholder's representative, often gets a faster response from an insurer than an individual employee does.
• Track recurring issues across the group: Since a pattern of similar grievances, repeated cashless denials at a particular hospital network, for instance, is useful leverage in renewal negotiations with the insurer.
• Use the employer's standing with the Insurance Ombudsman when needed: Since the Insurance Ombudsman Rules, 2017 explicitly allow an employer to file a complaint on behalf of an employee covered under a group policy, HR can step in formally at this final stage in a way it generally can't at IRDAI's own Grievance Redressal Cell, which is intended for the insured or claimant themselves.

What happens after you raise a grievance?

How Pazcare helps

Most grievances don't need to reach IRDAI at all if they're caught and handled early, which is where having a dedicated point of contact for the policy makes a real difference.

• A single point of escalation for stuck claims: Pazcare's claims support team steps in when a claim, cashless request, or TPA response stalls, working directly with the insurer rather than leaving HR or the employee to chase it alone.
• 24/7 support, including WhatsApp-based assistance: employees and HR can raise an issue and get a direct response without waiting on a generic insurer helpline.
• Visibility into recurring issues: Pazcare helps HR track patterns across claims and grievances, which strengthens the conversation at renewal if a particular type of issue keeps coming up.
• Renewal negotiation informed by actual claims experience: where grievances point to a genuine gap in the policy or TPA service, Pazcare factors that into how the plan is negotiated the following year.

If a claim or grievance on your policy has stalled, talk to a Pazcare group health insurance expert. Our claims support team will step in with the insurer directly, so it's not just you or your employee chasing a resolution alone.