Introduction
Insurance is an essential component of contemporary society, encompassing both long-term and non-life cover, and serves as a safeguard against financial loss. However, insurance claims may be repudiated or rejected. In the event that a claimant is dissatisfied with such a decision, they have the right to refer the matter to the Insurance Ombudsman. The Ombudsman functions as an independent and impartial authority, tasked with objectively assessing the fairness and reasonableness of the dispute.
Guidance to determine whether one has a justifiable complaint to be submitted to the Ombudsman.
Start by perusing one’s contract entered into with the insurance company (Insurer) and looking at the basic requirements to determine if a valid contract existed at the time of the occurrence of the event. These include Capacity, Certainty of performance, Possibility of performance, Lawfulness, Formalities, and Essentialia. If all six have been met, then there is a valid contract.
It is advisable to review one’s insurance contract alongside the insurer’s policy wording to conduct a thorough assessment and determine, based on one’s own understanding, whether the disputed claim constitutes a legitimate basis for repudiation or rejection. Consulting the contract before challenging a repudiation or rejection is beneficial, as it ensures that one is well-informed and fully aware of the terms and conditions governing the policy.
Approaching the Insurer.
Moving on to the next step, query your rejection of one’s claim by contacting the insurer through whom one is insured and attempting to resolve the dispute internally before considering external sources. This will result in an easy and time-efficient solution. Suppose the insurer refuses to consult with you to justify the repudiation or rejection of the claim. In that case, it’s preferable to launch a formal complaint to the Financial Sector Conduct Authority (FSCA) due to unethical practices, should the insurer provide a complete justifiable explanation for the rejection or repudiation – but you, as the client, are still unhappy and not satisfied with the rejection and not in agreement with the insurer for the rejection then one approach an ombudsman.
Approaching the Ombudsman.
It is essential to be professional despite being agitated when approaching an Ombudsman. An Ombudsman can be approached in multiple ways, such as through an online application, telephone complaint, or walk-in services. To submit a formal complaint, one will need to submit one’s personal information, one’s insurance account number, and a factual summary of the occurrences, including all relevant correspondence and supporting documents. [1]
Furthermore, the Ombudsman will give the respondent a chance to respond to the complaint within 21 days of the formal complaint being lodged. Once a response has been submitted, you, as the complainant, will have a chance to comment on it. Once both parties have responded and the Ombudsman’s investigation has been completed, a ruling or recommendation will be made.
Regarding the costs of the Ombudsman service, is free to any complainants. [2]
Conclusion
When an Ombudsman is approached, it is not guaranteed that the rejection or repudiation of the claim will be overturned in your favour—it is merely a separate party investigating the merits of the claim and grounds for rejection.
If you need any assistance or advice regarding the content and implications of specific insurance policies, contact an attorney at Schoemanlaw.
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