9 things you should know about the Insurance Ombudsman

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By Bongisisa Sikunyana  

If you have movable and/or immovable property insured, you are probably familiar with the anxiety associated with lodging a claim. Some insurance companies often give every reason under the sun to avoid paying out a claim. In instances where a company is refusing to pay out a claim for one or more reasons, approaching the ombudsman is often one’s last resort. There is the Ombudsman for Long term insurance, which focuses on aspects related to insurance cover in the event of death, funeral, disability, or critical illness, and there is the Ombudsman for Short term insurance, whose main focus is dealing with insurance cover for vehicles, property, home contents, medical/gap, travel, business or personal liability among others. This article will particularly focus on the Ombudsman for Short-term Insurance.

Here are the 10 things you should know about the insurance ombudsman.

 

1.    Who/what is the insurance Ombudsman?

This is a public body that investigates complaints against organisations and businesses, specifically those related to any type of insurance. The ombudsmanassists the consumer and insurer in the event of a conflict arising from an insurance claim by providing an efficient and fair dispute resolution mechanism through an alternative dispute resolution process by applying the law and principles of fairness and equity.

2.    When can you take your matter to the Ombudsman?

The Ombudsman for Short Term Insurance (OSTI) states that it is not compulsory for one to complain first to their insurance company before submitting a complaint to OSTI. This means that OSTI will consider your complaint even if you have not yet complained to your insurer. However, its suggested that, before submitting a complaint to OSTI you first try to resolve your issue with your insurer.

3.    How do I lodge a complaint with the Ombudsman?

It is fairly simple to lodge a complaint with the Ombudsman. All you need to do is to fill in an online application for assistance form and submit immediately, together with all relevant documentation. Alternatively, you can download and print the form, available in any of the 12 official languages, complete it and send it back using any of these two forms: E-mail: info@osti.co.za Fax: 011 726 5501

4.    How much does it cost to lodge the complaint?

 

This service is completely free of charge to consumers.

 

5.    Am I guaranteed to receive help from the ombudsman?

The ombudsman will help you based on a consideration of the following factors:

·         Whether the insurer you are complaining against is a member of OSTI (ombudsman for short term insurance),

·         Whether the matter falls within OSTIs monetary jurisdiction

·         Whether the type of claim under your complaint is classified as short-term insurance, and

·         Whether or not you have been to court or issued summons against the insurer, OSTI will not be able to help in instances where you’ve been to court or issued summons.

6.    How often does the ombudsman find in favour of the consumer?


The ombudsman is not only impartial, they are also open and transparent about the work they do. They do not report the outcome of each individual case, but they do publish annual reports detailing complaints referred to them on an annual basis and the number of complaints decided in favour of the consumer. Their annual reports can be found at
www.osti.co.za/news-room/#reports

7.    Does the ombudsman fine/punish the insurance companies it decides against?


No. The ombudsman’s aim is to rectify errors and mistakes between an insured and the insurer. This may mean that they tell an insurer to pay a claim or remove an excess fee or amount that has been charged to the consumer, because Insurers enter into a contractual agreement with OSTI promising to abide by OSTI’s rulings, but they do not make rules for insurers.

8.    What happens in an instance where I am not happy with OSTI’s decision/ruling?

In such an instanceyou may ask for the matter to be “escalated” to a senior assistant ombudsman for review. However, a matter will not be suitable for review simply because you are unhappy with the result and wish that it had been decided in your favour. Instead your reason for asking for a review should be based on your belief that OSTI made the wrong decision and that someone else considering your matter may make a different decision.

Should you still be unhappy after the review, you are free to look for other ways to continue to challenge the insurer’s decision. You can seek legal advice, issue summons against insurer or pursue other forms of dispute resolution such as arbitration.

 

It is also possible to appeal against a decision by the ombudsman, but only if the ombudsman has made a formal ruling against you and has granted you leave to appeal against that ruling.

9.    What is the difference between a review and an appeal?


A review concerns only the lawfulness of the process by which a decision was arrived at by a statutory body (OSTI), this body can set the decision aside only if that process was flawed in certain defined and limited respects, not merely because of a belief that the decision was wrong on the merits.

 

An appeal on the other hand, the statutory body makes a finding on the merits of the case before it; if it decides that the previous/initial decision was wrong, then it sets that decision aside and hands down what it believes to be the correct judgment.

The discussion above makes clear the importance of familiarising oneself with insurance industry practices, their different bodies and being meticulous when entering into a contract dealing with any form of insurance.
For further information regarding insurance claim complaints visit the insurance ombudsman on
www.osti.co.za

 

 

DISCLAIMER: THIS ARTICLE IS WRITTEN PURELY FOR PURPOSES OF INFORMATION TO THE PUBLIC AND SHOULD NOT BE SUBSTITUTED FOR LEGAL ADVICE. READERS ARE ENCOURAGED TO SEEK PERSONAL LEGAL ADVICE BEFORE IMPLEMENTING ANY ACTIONS DISCUSSED HEREIN.