CR128 Bad service – compensation
Bad service – compensation
The complainant added her sister to an existing funeral policy on 7 August 2001. When her sister died on 12 October 2002 she submitted a claim on 16 October 2002 to which, she said, the insurer did not respond. She enquired but all she got was “promises, promises every time which are never fulfilled.”
She eventually lodged a complaint at our office and it was referred to the insurer on 3 June 2004. After several reminders the only response received from the insurer was that the deceased had died within the six-month waiting period (the date of death was wrongly indicated by it as 31 December 2001).
Upon further enquiries the insurer then raised a new defense, namely that the claim was declined because the deceased was not covered on the policy and no premiums were received for the deceased. The complainant then provided proof that the deceased was indeed covered and on 18 February 2005 we informed the insurer accordingly. After several further reminders, the insurer informed us on 6 April 2005 that the claim would be paid. On 30 July 2005, after a further three reminders, the insurer advised that they could only process the claim upon receipt of the death claim papers.
The complainant provided us with the claim documentation on 19 September 2005 and we sent the documentation to the insurer on 21 September 2005. On 9 November 2005 the insurer raised a fresh defense and informed us that they would not be paying the claim as the claim was not lodged in time. They stated the following: “As per the rules…. no claim will be paid if a claim is received by the call center 90 days after the date of death, or if all documentation as requested by the call centre are not received with in the 90 day period, the claim will be treated as null and void.” Once again, the defense had no merits as the complainant could show that she did lodge the claim in good time.
After discussing this case at an adjudicators’ meeting, we informed the insurer that since they had admitted liability on 6 April 2005 it was our opinion that they should pay the claim with interest, together with compensation in the amount of R1 500. The insurer thereupon responded by saying that due to personnel changes, they had only then began to investigate the claim properly and that it should never have been admitted in the first place as it was not lodged in time.
At a further adjudicators’ meeting the provisional ruling was made final and the case was marked as ‘incompetent’.