Insurance Claims Management Framework
The Company, as an authorised financial services provider, has a responsibility to conduct itself honestly, with integrity, fairness, dignity
and ethically wherever it operates, with due regard to the environment, the societies in which it operates and its other stakeholders.
The Claims Management Framework serves to meet the requirements of Section 62 of the ShortTerm Insurance act and Rule 17 of the
Policyholder Protection Rules. It needs to ensure fair treatment of policyholders and beneficiaries and must be reviewed regularly.
The Claims Management Framework must be maintained, operated adequately and effectively and ensure that:
2.1 It is proportionate to the nature, scale and complexity of the Insurer’s business and risks;
2.2 Is appropriate for the business model, policies, services and policyholders and beneficiaries of the Insurer;
2.3 Enables claims to be assessed after taking reasonable steps to gather and investigate all relevant and appropriate information and circumstances, with due regard to the fair treatment of claimants; and
2.4 Does not impose unreasonable barriers to claimants.
3. ALLOCATION OF DUTIES
The Financial Director of the Company is responsible to ensure that all claims lodged are treated in line with this framework. The Financial Director will ensure that adequate resources are allocated to claims handling and that any person dealing with claims are:
3.1 Adequately trained;
3.2 Experienced in claims handling and appropriately qualified;
3.3 Not be subject to a conflict of interest; and
3.4 Be adequately empowered to make impartial decisions or recommendations.
4. THE CLAIMS PROCESS
The process that a claim will follow at the Company:
4.1 Claim received from claimant
4.2 Lodging of claim by Company’s claims department on internal system
4.3 Communication to acknowledge receipt of claim sent to claimant contemporaneously when claim lodged
4.4 Claim notification and documents reviewed (one full working day)
4.5 Any outstanding or additional information and documentation requested by claims manager from claimant or relevant party
4.6 Assessment of claim, decision making and oversight (48-hour Assessment and Finalisation period)
4.7 Referral of recommendation to the Insurer (Part of 48-hour Assessment and Finalisation period)
4.8 Insurer response with claim outcome
4.9 Claim outcome communicated to the claimant (within 1 full working day of decision)
4.10 Escalation to follow where applicable time lines are exceeded to management and the Insurer or claimant is dissatisfied with the outcome.
5. CLAIM ESCALATION AND REVIEW PROCESS
Complex or unusual claims shall be escalated from the initial assessor to:
5.1 the Financial Director
5.2 the Insurer
5.3 the Reinsurer (where applicable)
6. RECORD KEEPING, MONITORING AND ANALYSIS
6.1 All claims received, assessed, and finalised will be kept for a minimum period of 5 years.
6.2 The documents are filled physically or electronic scanned copy on the internal network drives.
6.3 Trends, risks and remedial actions to review product design and disclosures in line with Treating Customers Fairly principles will be taken on a minimum half yearly basis.
7. REPUDIATION OR DISPUTES
The Insurer must communicate the following to the claimant:
7.1 The reason for the decision;
7.2 Include the facts that informed the decision;
7.3 That the claimant may within a period of not less than 90 days after the date of receipt of the notice make representations to the Insurer;
7.4 Have the right to lodge a complaint to the relevant Ombud and provide the contact details and time limitations of the applicable Ombud scheme.
8. CLAIM ESCALATION AND APPEALS PROCESS
Should a claimant or customer be dissatisfied with the outcome of the claim assessment, he/she may direct their dissatisfaction to the
Company, who will refer the matter to the Insurer for review of the decision. The Insurer must respond to the claimant within 15 working days. Should this result in a decision that is still unsatisfactory, the matter may be referred to the Internal Dispute Arbitrator at the Insurer, before referring it to an external body, such as the Ombud for Long Term Insurance.
The Insurer’s details are : Guardrisk Life Limited
Postal Address: PO Box 786015
Tel: (011) 669-1000
In addition, the claimant may send a formal complaint to the Company at the details below:
The Company will acknowledge the complaint within a minimum of 2 working days.
9. PROHIBITED CLAIMS PRACTICES
The Company and the Insurer may not:
9.1 Dissuade a claimant from obtaining the services of an attorney or adjustor;
9.2 Deny a claim without performing a reasonable investigation; or
9.3 Deny a claim based on the outcome of a polygraph, lie detector or truth verification or similar test.
10. VALID CLAIMS RECEIVED DURING PERIODS OF GRACE
If a claimant submits a claim in respect of an event that occurred during a grace period, the value of the claim may be reduced by the sum of the unpaid premium.
11. CLAIM SUBMISSION CONTACT DETAILS
All claims can be submitted to:
Postal address: PO Box 36562, CHEMPET 7442