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10.5 Categorisation of Complaints

An insurer must categorize reportable complaints in accordance with the following minimum categories: Complaints relating to the design of a policy or related service, including the premiums or other fees or charges related to that policy or service. Complaints relating to information provided to policyholders. Complaints relating to advice. Complaints relating to policy performance. Complaints […]

10.4 Allocation of Responsibilities

The board of directors of an insurer is responsible for effective complaints management and must approve and oversee the effectiveness of the implementation of the insurer’s complaints management framework. Any person that is responsible for making decisions or recommendations in respect of complaints generally or a specific complaint must – Be adequately trained. Have an […]

10.3 Requirements for Complaints Management Framework

The complaints management framework must at least, provide for – Relevant objectives, key principles and the proper allocation of responsibilities for dealing with complaints across the business of the insurer. Appropriate performance standards and remuneration and reward strategies (internally and where any functions are outsourced) for complaints management to ensure objectivity and impartiality. Documented procedures […]

10.2 Establishment of Complaints Management Framework

An insurer must establish, maintain and operate an adequate and effective complaints management framework to ensure the fair treatment of complainants that – Is proportionate to the nature, scale and complexity of the insurer’s business and risks. Is appropriate for the business model, policies, services, policyholders, and beneficiaries of the insurer. Enables complaints to be […]

10.1 Introduction

Complainant means a person who submits a complaint and includes a – Policyholder or the policyholder’s successor in title. Beneficiary or the beneficiary’s successor in title. Person whose life is insured under a policy. Member  Person that pays a premium in respect of a policy. Potential policyholder or potential member whose dissatisfaction relates to the […]

9.10 Prohibited Claims Practices

An insurer may not – Dissuade a claimant from obtaining the services of an attorney or adjustor. Deny a claim without performing a reasonable investigation. Deny a claim based solely on the outcome of a polygraph, lie detector, truth verification or similar test or procedure.

9.9 Reporting of Claims Information

An insurer must have appropriate processes in place to ensure compliance with any prescribed requirements for reporting claims information to any relevant designated authority or to the public as may be required by the Authority.

9.8 Communications with Claimants

An insurer must ensure that its claims processes and procedures are transparent, visible and accessible through channels that are appropriate to the insurer’s policyholders and claimants. All communications with a claimant must be in plain language. An insurer must disclose to the claimant – The type of information required from the claimant. Where, how and […]

9.7 Record Keeping, Monitoring and Analysis

An insurer must ensure accurate, efficient and secure recording of all claims received, irrespective of whether the claims are valid or not. The following must be recorded in respect of each claim received – All relevant details of the claimant and the subject matter of the claim. Copies of all relevant evidence, correspondence and decisions.  […]