Ombudsman for Long-term Insurance

Mission Statement

• he or she acts independently and objectively in resolving any complaint received and takes no instructions from anybody regarding the exercise of his or her authority;
• he or she follows informal, fair and cost-effective procedures;
• he or she keeps in balance the scale between complainants and subscribing members;
• he or she accords due weight to considerations of equity;
• he or she maintains confidentiality, in respect of every complaint received;
• he or she co-operates with the Council established in terms of the Financial Services Ombud Schemes Act, 2004, in promoting public awareness of the existence, function and functioning of the Ombudsman and the Ombudsman’s office and in informing potential complainants of available dispute resolution forums.
• subscribing members act with fairness and with due regard to both the letter and the spirit of the contract between the parties and render an efficient service to those with whom they contract.

What we do

Complaints about Long-term insurance policies

• The office for the Ombudsman for Long-term insurance was established in 1985. The function of the office is to mediate in disputes between subscribing members of the Long-term insurance industry and policyholders regarding insurance contracts.
• It is an independent office which is accountable to an independent Long-term Ombudsman Council for providing an efficient and independent service to policyholders and others in response to disputes arising from Long-term insurance policies.
• Policyholders who submit a complaint to the Ombudsman may still decide to follow the conventional civil justice process, although these two processes are not allowed to proceed simultaneously.
• The service is free to complainants.
• Industry subscribers are bound by the Ombudsman’s rulings. There is provision in the rules for an informal appeal process.
• a complainant may at any time terminate the Ombudsman’s investigation of the complaint and resort to litigation.

In achieving its mission the office strives towards:

• informality;
• ready access;
• cost effectiveness;
• speedy resolution of disputes;
• mediation rather than adjudication; and
• the right to afford due weight to equity.

Who can complain to us?

What can you complain about?

• marketing;
• entering into of Long-term insurance contracts; and
• their administration;

• communication/administration failures;
• mis-selling;
• lapsed policies; and
• alleged unfair rejection of claims.

What we do not do

• the conduct of independent brokers;
• purely administrative issues such as cancelling a policy, etc;
• short-term insurance; and
• unit trusts or other investments.

How to Complain

Requirements for complaints submitted to the Ombudsman

• The complaint must be in writing.
• Please provide us with the following information:
  • policy number/s;
  • insurance company;
  • policyholder contact details;
  • factual summary of your complaint; and
  • letter of mandate if you are writing on behalf of the policyholder or beneficiary.
• Keep the details of your complaint as short and factual as possible.
• Provide us with copies of supporting documents referred to in the complaint, including correspondence with the insurer.
• Please write neatly. Type if possible. Black ink should be used for faxed correspondence.

What happens next?

• Should the complaint fall within the ambit of our rules, we will write to the insurer concerned requesting an investigation of the matter.
• The insurer is requested to respond within six weeks. On receipt of a written response the complaint will either be decided and the complainant advised accordingly or further information or comment might be requested from either or both parties.

Costs

Fairness Checklist

The policyholder is entitled to the following:

• details of the intermediary and his/her relationship with the insurer. Insurers must mandate intermediaries for the products they sell;
• details of the transaction with reference to expenses, assumptions, values, benefits, premiums, loading, guarantees, exclusions, etc;
• information about the cooling-off period;
• the implication of replacing one policy with another;
• notification from the insurer that a policy has been cancelled; and
• written explanation for repudiation or non-payment of claims

Self-help guide

• The policyholder has a 30-day grace period during which a policy or an amendment to a policy can be cancelled.
• Always complete a proposal form for a policy yourself. Only in this way will you fully understand the nature of the information required.
• Information sought is never a formality and complete and accurate information is always required.
• If in doubt, disclose information.
• Always read any document before you sign it.
• Read through the policy contract to ensure that the documents conform to your expectations or what you understood the contract to be.
• Keep written proof of your correspondence and dealings with the insurer and your intermediary.Keep written proof of your correspondence and dealings with the insurer and your intermediary.