How can the Insurance Ombudsman help you?

Whether your issue is with a short term or long term insurance provider, there is an Ombudsman that can step in and help you resolve your grievance.

Peter Nkhuna, senior assistant at the Ombudsman for Short Term Insurance (Osti), explained that it investigates facts, obtains all relevant information and evidence, and then makes an objective finding based on the available information.

“Where any financial loss has been suffered by the insured, the insurer would be required to compensate the insured for such a loss,” says Nkhuna.

“We rely on the law and, in exceptional circumstances, the principles of fairness and equity will also be invoked. Our investigations are conducted via written correspondence and the exchange of documents and records,” he added.

South Africans can approach either the Ombudsman for Long Term Insurance (Olti), or Osti. Short term insurance providers offer products like car insurance, homeowners’ insurance, home contents insurance, all risk, travel insurance, medical gap and hospital plans, personal accident, business and some commercial policies. Meanwhile, long term insurance providers offer things like funeral policies, credit life policies, policies providing benefits on death, disability and dread disease

Osti deals with short term policy related disputes.

Jennifer Preiss, deputy ombudsman for Olti highlights four different ways the Ombud can assist disgruntled customers in resolving their disputes:

• Mediation: where the two parties (insurer and complainant) try and resolve the complaint through an exchange of correspondence or in a meeting with the Ombud acting as mediator. “That means we give guidance but do not make suggestions or recommendations at that stage,” says Preiss.
• Conciliation: here we, either in correspondence telephonically or in person, try to or get the parties to an agreement by explaining their positions to them, asking questions and trying to get them to a settlement. We are more involved in the conciliation process. The process could also be a hybrid of mediation and conciliation.
• Recommendation: we make a non-binding recommendation to the parties giving our reasons for our suggestion.
• Determination: we make a decision which is binding on the insurer – the insurer cannot go to court and it has to abide by our decision. The complainant can still go to court if he/she does not agree with our determination.

How to complain

Complaints are typically made in writing, but they can also be made telephonically or through the Ombudsman’s walk-in service.

“We receive on average about 9, 800 written requests for assistance annually. Of these about 5, 200 are actual complaints,” says Preiss.

“When we receive a complaint we send it to the insurer in the first instance. If the complainant hasn’t complained to the insurer previously the insurer has six weeks to first try and resolve the complaint directly with the complainant. About 20% of our complaints are settled at this stage. If this fails we take up the complaint and follow the process of mediation, conciliation, recommendation, and determination,” she says.

Complainants can make use of the Ombud’s services free of charge, and once they have made contact with them they no longer have to address their insurer directly.

The Ombud receives funding from insurance companies who pay an annual levy, as well as a case fee for every case handled.