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complaints

Long-term insurance complaints – What does the Ombud require from insurers?

The Ombudsman for Long-term insurance mediates in disputes between members of the long-term insurance industry and policyholders. As we await the release of the Ombud’s 2020 Annual Report to see the impact of the current “new normal” in the financial services industry, the Ombud has released guidelines for insurers with regards to their responses to the Ombud.

Following the receipt of a complaint from a policyholder, insurers are requested to send the Ombud a first response containing the following information:

Settlements

  • If the insurer decides to settle a matter after receipt of the complaint, the Ombud’s office, and not the complainant, must be notified of the decision.
  • If there is a payment to be made, the amount of the payment and any interest which is due, should be included in the letter to the Ombud. The Ombud’s office will then inform the complainant what to expect.
  • After payment, confirmation thereof, including the date, the amount and the bank account number should be sent to the Ombud’s office.
  • If a matter is settled on a so-called ex gratia basis, where the insurer contend that it is not in terms of the policy, the insurer should consider sending a settlement letter prior to payment.

Other responses

Where insurers are not settling a complaint in their first response to the office, they should provide a complete response raising all the defences on which they wish to rely. Insurers must provide supporting documentation, as well as the name and telephone number of the person with whom the Ombud can discuss the complaint, if necessary.

The following is a list of the minimum substantiating documents which must be attached to the insurer’s first response:

Nature of complaint Documents required from insurer
Poor communications/documents or information not supplied/poor service Policy and schedule
Endorsements – if applicable
Copies of correspondence exchanged
Claims declined (policy terms or conditions not recognised or met) Application form or telesale recording– if applicable
Policy and schedule
Letter declining claim
Medical evidence – if applicable
Any other claim documentation
Death certificate – if applicable
Copies of relevant correspondence
Claims declined (non-disclosure) Policy and schedule
Application form or telesale recording
Medical and other evidence
Letter declining claim
Schedule of total premiums less administration costs
Counter-offer – if applicable
Copies of relevant correspondence
Dissatisfaction with policy performance and maturity values Policy and schedule
Breakdown of policy performance
Actuarial certificate – if necessary
Copies of relevant correspondence
Dissatisfaction with surrender or paid-up values Policy and schedule
Calculation of costs and expenses
Breakdown of policy performance
Surrender Quotation – if applicable
Actuarial certificate – if necessary
Copies of relevant correspondence
Lapsing / non-payment of premiums Policy and schedule
Notification of non-payment
Premium reconciliation
Reinstatements – if any
Confirmation of lapse letter
Copies of relevant correspondence
Declined based on waiting period Policy and schedule
Membership certificate – if any
Application form or telesale recording
Record of premium payments – if relevant
Copies of relevant correspondence

Advisers may find the above of interest when assisting clients with such complaints.

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