By: Karabo Kopeka, Head of Claims at MiWay Insurance
The need for insurance is becoming increasingly important, particularly in South Africa, where poor road conditions, high crime rates and extreme weather triggered by global warming remain persistent challenges. However, while many South Africans recognise the need for insurance, not everyone understands the complexities of their respective policies, which can result in claims being rejected from time to time.
As a policyholder, it’s important that you take time to read your policy to understand what you are and aren’t covered for. In many instances where claims are refuted, the decision is based on a specific exclusion noted in the policy, which is sent to the consumer. Over and above this, it’s vital that you understand both your rights and obligations prior to accepting cover to avoid a potential rejection of a claim.
So what rights do you as a policyholder have and, more importantly, how do you exercise them? Many turn to social media as a default course of action, hoping to elicit a response by public naming and shaming. Whilst the frustrations experienced by policyholders as a result of what can be a devastating decision are understandable, channels such and Facebook and Instagram rarely elicit the desired results.
If you are looking to ensure your grievance is heard, here are the recommended steps to follow:
Contact Dispute Resolution
Your insurer’s Dispute Resolution (DR) department is an independent department specifically tasked with investigating and addressing customer complaints escalated to them. Under South African law, your insurer is obligated to serve you to the best of its ability, and as such, the DR department is mandated with preserving your interests and keeping you updated regarding your specific case.
Escalate your claim to the Ombud
If your initial attempts are unsuccessful, you can then approach the Short-Term Insurance Ombud. This is an independent body established to deal with problems that cannot be resolved directly with your insurer. The Ombud acts as a neutral Arbitrator and is tasked with considering both sides of the case before making a ruling. If the insurer is found to have treated the customer unfairly, they can then be ordered to settle the claim.
In the interest of transparency, the Ombud releases a report each year, detailing the disputes dealt with and the outcomes thereof. This tends to act as a good gauge of service, as insurers with a low rate of complaints referred to the Ombud are generally considered to be more fair in their dealings with clients.
Before escalating your grievances, it’s important to understand both your rights and obligations as a policyholder. Essentially, an insurance policy is a legally binding agreement between two parties and is enforceable by our legal system should either party fail to honour their side of the agreement.
As a consumer, you have the right to get what you pay for, and to be treated fairly. Essentially, your insurance provider is obliged to provide you with the best possible service, and to recommend a policy best suited to your actual needs and budget.
Further to this, you have the right to be supplied with all the relevant information pertaining to your policy. It is vitally important that you, as the Policyholder, ask as many questions as possible to ensure that you fully understand the various clauses contained in your policy, as once you accept the policy it becomes a legally binding agreement.
As a policyholder, you are also obliged to be honest and transparent in your dealings with your insurer, and are required to ensure that you understand the terms and conditions of your contract. To make sure your claims process proceeds smoothly, you’d be well advised to adhere to the following standard obligations governing most insurance contracts:
The information you provide to your insurer should be complete and detailed, both in terms of the items you’re looking to insure as well as your personal needs so as to ensure your cover is tailored to you.
- Ask questions
As a policyholder you must ensure you understand your policy. So if you don’t understand any of the terms or exceptions included in the policy document, make sure to ask as many questions as you need to clarify your understanding.
- Update your insurer
Should any of your personal details change – from your address to your occupation to the use of an insured property or vehicle – you should notify your insurer immediately. Any significant changes to your situation will impact your risk profile for better or for worse, and by keeping your insurer updated, you’ll avoid having to file a claim based on outdated data. Equally, should you be unable to pay your monthly payments, it’s best to advise your insurer as soon as possible, as failure to pay your premium within grace period may negatively impact your claim.
- Report incidents
In the event of an incident that might lead to a claim against your policy, notify your insurer as soon as reasonably possible and as indicated on your policy wording.
Be co-operative in assisting your insurer as they assess damage and determine the cost of repairs or replacements; this will help speed up the process.
- Know and exercise your rights
Know your rights as a consumer and a policyholder and use all valid platforms to voice any concerns you may have.
Remember that any contract is an agreement between two parties, both of whom are tasked with meeting certain requirements. Should you believe that your insurer has not fulfilled the requisites outlined in your insurance contract, you are fully entitled to have your complaint heard.
MiWay is a licensed non-life insurer and Financial Services Provider (FSP 33970).