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. […]
9.6: Decisions Relating to Claims and Time Limitation Provisions for the Institution of Legal Action
An insurer must accept, repudiate or dispute a claim or the quantum of a claim for a benefit under a policy within a reasonable period after receipt of a claim. An insurer must within 10 days of taking any decision, notify the claimant in writing of its decision. If the insurer repudiates or disputes a […]
9.5: Claim Escalation and Review Process
An insurer must establish and maintain an appropriate internal process in terms of which claims decisions can be escalated and/or reviewed and claims related disputes can be resolved. Procedures within the claims escalation or review process should not be overly complicated or impose unduly burdensome paperwork or other administrative requirements on claimants. The escalation or […]
9.4: Allocation of Responsibilities:
The board of directors of an insurer is responsible for effective claims management and must approve and oversee the effectiveness of the implementation of the insurer’s claims management framework. Any person that is responsible for making decisions or recommendations in respect of claims generally or a specific claim must – Be adequately trained. Be experienced […]
9.3: Requirements for Claims Management Framework
The claims management framework must, at least, provide for – Relevant objectives, key principles and the proper allocation of responsibilities for dealing with claims across the business of the insurer. Appropriate performance standards and remuneration and reward strategies (internally and where any functions are outsourced) for claims management in general and specifically for claims assessment […]
9.2: Establishment of Claims Management Framework
An insurer must establish, maintain and operate an adequate and effective claims management framework to ensure the fair treatment of policyholders and claimants that – Is proportionate to the nature, scale and complexity of the insurer’s business and risks. Is appropriate for the business model, policies, services, and policyholders and beneficiaries of the insurer. Enables […]
9.1 Introduction
For purposes of this rule, reference to a policyholder includes a member of a group scheme.
8.4: Signing of Blank or Uncompleted Forms
No insurer or intermediary may in connection with any transaction relating to a policy require, permit or allow a policyholder, potential policyholder, member of a group scheme or potential member of a group scheme or claimant or potential claimant to sign any blank or partially completed form necessary for the purpose of the transaction, where […]
8.3: Waiver of Rights
No insurer or intermediary may request or induce in any manner a policyholder, potential policyholder, member of a group scheme or potential member of a group scheme or claimant or potential claimant to waive any right or benefit conferred on that person by or in terms of a provision of these rules, or recognize, accept […]