final-determination17

2017

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Final Determination 2016

2016

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  • pdf Case25 - Late Submission - Equity Jurisdiction
    Late submission of a disability claim. A group policy provided for submission of a claim within three months of the date of disability; the claim was submitted late due to the complex nature of the insured's medical condition; exercise of equity jurisdiction.
  • pdf Case 24 - Credit life claim; submission of documents to assess claim
    Credit life claim; claim declined as documents and information outstanding; insurer alleged it could not assess if there had been non-disclosure; found that complainant submitted adequate information for disability claim to be assessed
fd-15

2015

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  • pdf Case 23 - Disability Claim
    Group life policy – insurer terminated disability benefits on grounds complainant can perform an alternate occupation; what constitutes an alternate occupation?
  • pdf Case 22 - Payment of Interest
    Late payment of claim due to suspicion of suicide – Date from which interest is payable
  • pdf Case 21 - Compensation Award
    Old funeral policy - £50 sum insured in the policy - Insurer offered R104 on death of life assured
  • pdf Case 20 - Compensation Award
    Life Policy – Policy cancelled by insurer in accordance with master policy. No cancellation clause in summary provided to members
  • pdf Case 19 - Pre-Existing Conditions Exclusion Clause
    Pre-existing conditions exclusion clause – claim declined on the grounds that the life assured’s condition falls within the pre-existing conditions exclusion clause.
fd-14

2014

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fd-13

2013

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  • pdf Case 15 – Payment of PHI benefit
    Payment of PHI claim after cessation of membership – fairness of insurer’s decision – insurer had incorrectly terminated PHI benefit
  • pdf Case 14 – Ceded policies surrendered
    Policies ceded on divorce to minor children – cedent subsequently surrendered policies – children (now majors) contesting surrender
  • pdf Case 13 - Late Submission of Group Scheme Funeral Benefit Claim
    Policy providing submission by nominee of claim within six months from date of death; late submission due to personal circumstances and policy unknown to nominee; insurer unable to show specific prejudice if claim admitted; exercise of equity jurisdiction
  • pdf Case 12 - Final Determination
    Policy providing that claims must be submitted within a stipulated time; complainant given 4 months sick leave to receive treatment; thereafter her condition deteriorated; finally, some nine months after the stipulated time had expired, doctors declared her permanently disabled; Ombudsman’s equity jurisdiction applied.
fd-12

2012

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  • pdf Case 11- Funeral Policy
    Funeral Policy – policy term providing for payment to relative if no spouse and no beneficiary – on death of the life insured the insurer paid the ex-spouse – as this was not in accordance with the policy provisions, insurer ordered to pay his mother
fd-11

2011

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  • pdf Case 10 - Interpretation of income protection policy
    Interpretation of income protection policy - whether the wording can be interpreted, as contended by complainant, to include automatic benefit increases when complainant in claim - determination by the office in favour of the complainant. (In an appeal by the insurer the Appeal Tribunal upheld the office's determination) (Case 10/2011 - Final Determination)
  • pdf Case 9 - Pre-existing exclusion claus
    Pre-existing exclusion clause - did clause cover condition for which insured was hospitalised (Case 9/2011 - Final Determination)
fd-10

2010

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  • pdf Case 8 - Late submission of disability claim
    Late submission of disability claim; complainant dismissed while still able to work and reinstated after he became disabled; application of equity jurisdiction (Case 8/2010 - Final Determination)
  • pdf Case 7 - Non-disclosure
    Claim repudiated on grounds of alleged non-disclosure (Case 7/2010 - Final Determination)
  • pdf Case 6 - Funeral Policy
    Funeral Policy – interpretation of conditions regarding reinstatement after lapsing (Case 6/2010 - Final Determination)
  • pdf Case 5 - Funeral benefit claim
    Funeral benefit claim – repudiation of claim on grounds of late notification. Is this the appropriate case for the Ombudsman to exercise his equity jurisdiction? (Case 5/2010 - Final Determination)
  • pdf Case 4 - Failure to furnish copy of policy to policyholder & respond to Ombudsman
    Failure to furnish policyholder with copy of the policy for more than a year after inception of the policy. Failure to provide responses to Ombudsman – is an award of compensation appropriate, and if so, what is the appropriate amount? (Case 4/2010 - Final Determination)
fd-09

2009

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  • pdf Case 3 - Permanent Incapacity Benefit
    Permanent Incapacity Benefit - does the complainant qualify for a higher percentage? (Case 3/2009 - Final Determination)
  • pdf Case 2 - Non disclosure
    Non disclosure – could it reasonably have been expected from the applicant to have mentioned her condition at proposal stage? (Case 2/2009 - Final Determination)
  • pdf Case 1 - Income Disability Claim
    Income Disability claim – impact of termination of scheme membership (Case 1/2009 - Final Determination)

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