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OMBUDSMAN for
Short-term Insurance
Contact Details
Tel:
(011) 726 8900
Fax:
(011) 726 5501
1.
The Ombudsman provides, free of charge, an informal and speedy
dispute resolution process to Policyholders whose claims have been
rejected or partly admitted.
2. The
Ombudsman resolves disputes using the criteria of the law, proper
Insurance practice (which includes fair dealing and equity).
3.
Jurisdiction of the Ombudsman
The
Ombudsman
considers a complaint made to him if he is satisfied that-
i.
the complaint is not the subject of existing litigation –
ii.
the complaint does not involve a monetary claim in excess of
R800,000, but the Insurer may agree in writing that this limitation
be exceeded –
iii.
the complaint is made by a Policyholder or duly authorised
representative of the Policyholder to whom or from whom the
Insurance services in question were provided -
iv.
the complaint is being pursued reasonably by the complainant
and not in a frivolous, vexatious, offensive, threatening or abusive
manner, as the Ombudsman may decide in his or her sole discretion -
v.
the complaint has not become prescribed in terms of the
Prescription Act 68 of 1969 or any enforceable time-bar
provisions contained in the Policy -
vi.
a complainant may at any time terminate the Ombudsman’s
investigation of the complaint and resort to litigation.
4.
Limits on the jurisdiction of
the Ombudsman
Subject to the
Terms of Reference, the Ombudsman shall have the power to consider a
complaint made to him except –
i. where
the Ombudsman determines that it is more appropriate that the
complaint be dealt with by a Court of Law or through any other
dispute resolution process -
ii.
where a matter is already under the consideration by any
other appointed Ombud scheme.
5.
Time-barring provisions
Any enforceable
time-bar clauses in a policy shall not run against a complainant and
shall be interrupted during the period that the complaint is under
consideration before the Ombudsman. In the event
that the complaint is withdrawn from the Ombudsman or the Ombudsman
decides that he cannot make a ruling in favour of the complainant,
then the complainant shall have thirty days or the remaining period
of the time-bar provision of the relevant policy, whichever is the
longer within which to institute proceedings against the relevant
Insurer.
6.
Rulings
i.
When all the material facts are agreed or the facts have been
established to the Ombudsman’s satisfaction on a balance of
probabilities, the Ombudsman may make a ruling.
ii.
Rulings shall be based on the law and proper Insurance
practice (which includes without limiting the generality of the
foregoing, fair dealing and equity.
iii.
Any ruling made by the Ombudsman shall be binding on the
Insurer concerned.
7.
Policyholder / Complainant’s
rights
The Policyholder
/ complainant’s rights to institute proceedings in any competent
Court of Law against the Insurer shall not be affected by any of the
provisions of these Terms of Reference.
8.
Precedents
Rulings shall
not establish any precedent in the Ombudsman’s office.
9.
Confidentiality
i.
The Ombudsman shall, as far as possible, maintain secrecy
unless the parties expressly exempt him or her from that duty.
ii.
The Insurer and the complainant shall not be entitled to make
use of any information which comes to their knowledge as a result of
the intervention of the Ombudsman during the course of any
investigation.
iii.
A complaint will be regarded as confidential between
Policyholder, the Insurer and the Ombudsman and it is for the
Ombudsman to decide what should be disclosed to the Insurer and / or
the Policyholder.
iv.
Documents brought into being as a result of any approach to
the Ombudsman shall not be liable to disclosure or be the subject of
a discovery order or subpoena in the event of any legal proceedings
between the complainant and the Insurer.
v.
The Ombudsman will not be liable to be subpoenaed to give
evidence on the subject of a complaint in any proceedings.
Tel:
(011) 726 8900
Fax:
(011) 726 5501
0860
726 890
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