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Ombudsman for Short Term Insurance

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 Ė 

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 Ė 

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 Ombudsmanís 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 Ė 

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    In the event that the complaint is withdrawn from the Ombudsman or the Ombudsman decides that he cannot make a ruling in favour of the complainant, then the complainant shall have thirty days or the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 Ombudsmanís 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 / Complainantís rights 

The Policyholder / complainantís 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 Ombudsmanís 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.

 

 

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