Imagine submitting a claim to your insurance company, only to have it rejected based on information you don’t understand. What should you do, when the insurer just does not understand your view?
Well, meet the insurance ombudsman – it is his job to care about your dispute!
An ombudsman is an official whose duty it is to represent the interests of the public, by investigating and addressing complaints of maladministration or a violation of rights; is usually appointed by the government or parliament; and is not supposed to be influenced by political parties or affiliations, but should be able to conduct an independent investigation into the complaint that was laid. In short, the ombudsman serves as a mediator.
South Africa has various ombudsmen available to its citizens, but today we will focus on the short-term and long-term insurance ombudsman and its roles and responsibilities; both of which are recognised in terms of the provisions of the Financial Services Ombud Schemes Act.
Every short-term insurer has agreed to abide by the decision of the Ombudsman and this can relate to any of the following personal lines of short-term insurance: motor; house owners (building insurance); householders (content insurance); cell phone; travel; disability; credit protection insurance; commercial insurance; claims disputes; etc.
The Ombudsman for Long-Term Insurance has the main duty of resolving complaints through mediation, recommendation and then, as a last resort, determination (or rulings). These determinations or rulings are legally binding on the contributing insurer, but not on the complainant, who has the option to go to court if unsatisfied with the ruling.
The essential characteristics of an ombudsman are important, as it determines its impartiality. The insurance ombudsman should be free from interference in the performance of its duties and it should be independent from influence. They must also produce decisions that are seen to be fair, by making decisions based on the information available and having pre-set criteria for reaching a decision. Accountability to the public is ensured by having its decisions published and made available to the public. Lastly, the ombudsman should work effectively by following informal and cost-effective procedures, supported by sufficient human, financial and operational resources.
So, what procedure should be followed once you realise you’ll need the ombudsman? Well, firstly, you should have tried to resolve the matter with the company concerned, by following their internal grievance procedure. If this did not solve your problem, you should contact the Ombudsman; who will require that you submit a complaint (preferably in writing) and provide them with the necessary information such as the insurance company’s name, policy number, contact details and a factual summary of your complaint. You should submit all relevant supporting documents available, including proof of your attempted resolution with the company. The ombudsman will then start its investigation and guide you through the rest of the process.
Isn’t it great to know that there is someone out there who can assist you when it seems you’ve run out of options?! Make sure you have the relevant contact details of the ombudsman you need to help you solve your problem as soon as possible!
