annual report 2019 - osti.co.za · osti annual report 2019 5 contents 06 report by the chairman 08...

annual report 2019

FORMAL COMPLAINTS

RECEIVED

10 367

FORMAL COMPLAINTS CLOSED

9 167

COMPLAINTS CAPTURED

13 787

DAYS AVERAGE TURNAROUNDTIME

117

AMOUNT RECOVERED

R94,934,891

CALLS RECEIVED BY CALL CENTRE

85 483

$

key figures as at 31 December 2019

about usWe resolve disputes between consumers and short-term insurers:

• inacooperative,efficientandfairmanner;• withminimumformalityandtechnicality;• astransparentlyaspossible,takingintoaccountourobligationsforconfidentialityandprivacy.

Thisinvolvesunderstandingallaspectsofadisputewithouttakingsides,andmakingdecisionsbasedonthespecificfactsandcircumstancesofeachdispute.

mission

To resolve short-term insurance complaints fairly,efficientlyand

impartially.

4 OSTI ANNUAL REPORT 2019

OSTI ANNUAL REPORT 2019 5

contents06 ReportbytheChairman

08 ReportbytheOmbudsman

10 MessagefromtheCEO

14 Finance Matters

16 OfficeStatistics

18 AStatisticalAnalysisofMattersClosedby

OSTI in 2019

22 ExplanatoryNotesandInsurerStatistics

26 The Uninsured and the “Not-So-Insured”

28 MisrepresentationAftertheInceptionofthe

Policy

31 Same-same,butDifferent….(inthecontext

ofcellphoneclaims)

32 TheFastTrackProcess

33 OSTI’sInternsonOSTI’sRoleinResolving

Disputes

34 BoardofDirectors

35 StaffoftheOmbudsman

36 TermsofReference

42 MembersoftheOmbudsmanScheme

43 UsefulInformationaboutOtherOffices


Thisismythirdreport–andwhowouldhaveimagined

it being written, on my balcony, in the midst of a

pandemicthatisahumantragedy.COVID-19isindeed

ahumantragedyofenormousdepthandproportions.

OSTI remains an independent organisation. It

continues to deliver fair and just outcomes. The

organisation remains strong in all its areas, and this

is a tribute to the administrative and professional

skills, thecontinuedteamwork,and theenergyofall

involved.Theorganisationhasnotlostitsfocus,and

isingoodshape.

The“soft”amalgamationhasgoneoffseamlessly.The

singleInsuranceOmbudsmanisnowverymuchapart

ofus. JudgeRonMcLarenisresponsible,ethicaland

professional. He is liked and respected by theOSTI

team. Hehas forgedstrongrelationships, inashort

time,withpeopleintheOSTIfamily.

Edite continues to demonstrate real and true

leadership (more about her leadership during the

COVID-19pandemiclater).ShehasensuredthatOSTI’s

roleremainstoresolvecomplaintsinthequickesttime

period.Justiceandfairnessremainsparamount,even

if the resolutiondoesnotalwaysseem fair from the

outside.

The office remains stable in the midst of all the

changesaroundtheamalgamationandincreaseinthe

numberofcomplaintslodgedduringtheyear,andinto

2020.Variousinitiativesintroducedovertheyears,like

goingpaperless,haveandcontinuetobearfruit.The

paperlessworldhasparticularlyservedOSTIwellunder

thelockdowncausedbytheCOVID-19pandemic.

I thank my board for all their contributions made

during this period. The success of OSTI is also very

muchdueto theopendebatepolicyadoptedduring

boardmeetings.Theboardwillremainunaffecteduntil

the “soft” amalgamation is settled through required

legislativeenactments.

I cannot end without referencing the COVID-19

pandemicanditsimpactonOSTI.Management,ledby

EditeandMiriam,wasaheadofthecurve.Icommend

them for thinkingahead– it ensured that staffwere

enabledtoworkfromhome.Theboardestablishedan

OSTI COVID-19 Crisis Committee (OCCC), chaired by

meandconsistingofEdite,Miriam,GailWalters,Collin

Haroon Y LaherChairman of the Board

report by the chairman

MolepeandGerhardGenis.TheOCCCfocusedonthe

well-beingandhealthoftheOSTI,andcommunicated

with themregularly tocheckon theirwell-beingand

health. Staff settled into their new reality and are

workingwell together to achieveOSTI’s goals. They

areincontactwithcolleagues.Aspartofitsmandated

terms of reference, the OCCC also looked at the

financial and operational impact of COVID-19. OSTI

remainsfinanciallysound,andtherewasnomaterial

impactinApril2020onthetargetsforthemonth.The

situationwillbemonitoredcloselybytheOCC.Ithank

themembersof theOCCC for their contributionson

the issues that impact on OSTI in a post-COVID-19

world. Together, we have lived the words of our

President,CyrilRamaphosa:“The action we take now

must … be measured and incremental … We cannot

take action today that we will deeply regret tomorrow.”

Iwishyouhealthandsafety.

Haroon Y LaherChairperson

REPORTBYTHECHAIRPERSON 7


During 2019 OSTI handled a record number of

disputes.Despitethemajorchallengeofthisincrease

in dispute numbers, from 9779 received in 2018

to 10 367 in 2019, we managed to maintain our

timeframeswithoutcompromising thequalityofour

recommendations.Thisdespitetheintroductionofa

newcomplaintshandlingprocess.Wealsocontinued

developingabetterunderstandingofourrelationship

withourcustomers–bothinsurersandcomplainants

–tomakeourservicemoreopenandaccessible.

OneofthekeytenetsofOSTI’srole istoensurethat

thecomplaintsitreceivesareresolvedasexpeditiously

as possible. However, as is so often the case with

efficiencyenhancements,rapidresolutioncancomeat

thecostofqualitydecision-making.Overthepastfew

yearsOSTIhasfocusedonimprovingthequalityofits

decision-making processes. Regrettably, but perhaps

inevitably,thishasmeantthatitsrateofresolutionhas

decreased.

During2019OSTIgaveconsiderablefocustostreamlining

its operational processes, re-examininghow it uses its

contractorsandreviewingmanyofitssuppliers.

Withthechangestotheresolutionprocessnowfirmly

embeddedwithintheorganization’sinfrastructure,itis

myfirmbeliefthatOSTIwill,intheensuingyears,find

theappropriatebalancebetweenefficiencyandquality.

AsOSTIworkstoimproveitsownservice,itwillcontinue

toengagewithstakeholdersandcomplainantsthrough

mediation and conciliation to help them resolve issues

themselves without resorting to decision-based

disputeresolution.

Single entry portalIn addition to the significant operational changes

thatOSTIembarkedon in2019,OSTIspentmuchof

2019 engaged in discussions with the Ombudsman

forLong-TermInsuranceinthehopethatitwouldbe

abletoregisterin2019asingleinsuranceombudsman

scheme for the resolution of all insurance related

complaints.Theaspiration tocreateasinglescheme

arose in response to National Treasury’s call to all

financial ombudsman schemes to self-determine

a rationalisation process. Due to delays in the

commencementofchapter14oftheFinancialServices

RegulationAct,theregistrationofasingleschemewas

not possible. Instead the two schemes resolved to

enter into a shared services agreement and appoint

oneOmbudsman for theadjudicationofboth short-

termandlong-terminsurancecomplaints.

ThisdecisionmeansthatmytimeasOSTI’sOmbudsman

cametoanendwitheffect from31December2019.

Retired JudgeMcLaren, the currentOmbudsman for

Long-term Insurance, in addition to his current role,

tookovertheadjudicativeroleofOSTI’sombudsman

Deanne WoodOmbudsman

report by the ombudsman


functionswitheffectfrom1January2020.Iwishhim

everysuccessinhisnewrole.Iamconfidentthatthe

insurance industrywill benefit enormously from the

cohesiveness and consistency that his appointment

willbring to insurancecomplaints lodgedwitheither

ofthetwoschemes.

Asasecondlegtotheplantocreateasinglescheme,

the operational elements of my role as the Chief

ExecutiveOfficerofOSTIweretakenoverbymyable

deputy,EditeTeixeira-Mckinon,from1October2019.

InthefewmonthsofmyremainingtermIwasableto

observehersettle intohernewrolewithconfidence

andease.IhavenodoubtthatOSTIwillflourishunder

hermeasuredandthoughtfulleadership.

A note of thanks Iwould like to thanktheOSTIBoard,under itsChair

Haroon Laher, for giving me the opportunities to

implementradicalchangestoOSTIandforitssupport

fortheimprovementsthatIbelievewehavemadeto

ourserviceoffering.Ithasbeenbothaprivilegeand

responsibilitytobethecustodianofsuchanimportant

organisation. I amproudofall thatOSTI’s staffhave

achieved over the past three and a half years and

amparticularlyproudof theway inwhich theyhave

overcome the significant challenges that accompany

anymajoroverhaul.Iwouldliketothankmyexecutive

andmanagement team for their persistent support,

wisecouncilandinvaluableinput.Ithankeveryoneat

OSTIfortheircommitmentandwillingnesstoembrace

new challenges, and for working together to deliver

a fair andefficientdispute resolution service for the

benefitoftheSouthAfricaninsurancecommunity.

Deanne WoodOmbudsman for Short Term Insurance

March 2020

REPORTBYTHEOMBUDSMAN 9


Istartedwritingmyreportforthe2019AnnualReportwhilststillworkingattheoffice.ItscontentshavesincethenchangedmanytimesasIwasstrugglingtorelatetoa timepre-COVID-19.Mymindcouldnotrelate toa lifebefore theWorldHealthOrganisationdeclaredthecoronavirusapandemicandbeforeourPresidentproclaimed COVID-19 a national disaster on 15 March 2020andimplementedatotallockdownon27March2020.

Whatanincrediblyturbulenttimeithasbeenandwhata“baptismoffire”formehavingonlybeeninofficeforafewmonths.

It is amazing howwe have been able to implementmajor changes at the speed of lightning. Literallyovernight, working from home was no longer aprivilegeforafewstaffmembersbutwasthewayallofusweregoingtowork.Usuallysuchchangeswouldhave taken time tobe implementeddue toplanningsessions,debates,revisionofpoliciesandsoon.

AtitsfirstmeetinginMarchthisyear,whichwasshortlyafterthepandemicwasdeclaredanationaldisasterinSouthAfrica,ourBoardofDirectorsestablishedasub-committee, named the COVID-19 Crisis Committee.This committee was mandated to prioritise and regularlymonitorthehealthandwell-beingofOSTI’sstaff;thefinancialandliquiditypositionsofOSTIandtheimpactofthelockdownonOSTI’soperationsandtoidentifylocalandglobaltrendsaffectingOSTIpostCOVID-19.

Inthiscrisis,thehealthandsafetyofourstaffwasandcontinuestobeatoppriority.Afterall,staffcannotbeexpectedtofocusontheirworkresponsibilitieswhen

theirownwell-beingand thatof their familiesare inperil. Our leadership team immediately focused ondoing whatever was necessary to ensure the healthandsafetyofstaffandgettingeverystaffmembersetuptoworkremotely.Allstaffwhowerealreadyableto,wereaskedtostayathomeandworkfromhome.Therestwerethenconfiguredtoworkremotely.

Becauseworkingfromhomewasformostofourstaffanewwayofworking, leadershipneededtoprovidethemwithsupportandguidance.Aprotocolandtipsonworkingfromhomeweresenttoeveryonebeforethelockdownbecameeffective.

With the rapid move to working from home, camea greater need for trust. The leadership team wasrequired to trust the staff, every staff member totrusteveryotherstaffmemberandthestafftotrustleadership. Trust is even more important duringexceptional times like these. Leadership took theapproachthat,ifyougivestaffyourtrust,theywill,inreturn,betrustworthy.

Within a few days of being in lockdown, leadershipcommunicated to the staff the two essentialconceptsthatencapsulatetrust,namelyfreedomandresponsibility. We explained that freedom, which isalsoreferredtoasempowerment, istheopportunityto exercise personal choice and to have ownership oftheworkthatonedoesandthedecisionsthatonemakes.Responsibilityisensuringthatpersonalchoiceisexercisedwithcareandconcernforotherpeopleandthe requirements of OSTI. Together, these conceptsareordinarilyfundamentaltodrivingfulfilmentinanyorganisationandevenmoresoduringacrisis.

COVID-19 and OSTI’s responseEdite Teixeira-McKinonChief Executive Officer


Effectivecommunicationduringanycrisisiscrucialtomaintainingtrustwithallstakeholders,ourstaffbeingoneofthem,andtorestoringmoraleandconfidence.We adopted a robust communication approach, especially as this crisis, like any other crisis, addedanother layer of complexity to communication withthe circulationof false/fakenews.Ourapproachhasbeen toover-communicate;educatingand informingourstaff.

Evenifwe,astheleadershipteam,donothavealltheanswerstothechallengeswearefacing,ifstaffknowwhatwearethinkingandhowwearethinkingaboutthesituation,ithelpsthemfeelasenseofcontrol.

We immediately, on hearing the lockdownannouncement, setupWhatsAppgroups forquickercommunication between teams and between memberswithinateam.Thiswasinvaluable,especiallyintheinitialstageswhensettingupstaffathomeandwhensomestaffexperiencedconnectivityissues.Thisphase requiredpatienceandsupport fromeveryonewhilst we, together with our IT consultants, workedthrough the challenges of transitioning everyone toworkremotely.

Oncewehadbeen in lockdownfora fewweeksandthenovelty started towear off, our responsibility asleadership expanded to taking whatever steps wecould to safeguard the psychological and emotionalwell-beingofourstaff.Thiswasparticularlynecessarywhen the lockdownwas further extended.Wewereverymindfulofthevulnerabilityofthosestafflivingontheirownandwefirstreachedouttoandconnectedwiththem,beforedoingthesamewitheachandeveryotherstaffmember.

We sent regular communications on taking careof one’s mental health and later we arranged forcounsellingsessionsfortheentirestaffcomplement.

Our second priority was and still is to ensure thecontinued delivery of our services as an alternativedispute resolution forum and serving our membersandtheirconsumers,whoalsobecomeourcustomers.Indoingthis,wearealsoworkingtowardssecuringourrelevance,postCOVID-19.

Having over a year ago moved our IT and casemanagementsystemsintothecloud,wewereequippedtocontinueregisteringandresolvingcomplaintsfromhome. Our telephone system is also securely savedin the cloud and our call centre functionality is fullyoperationalwiththeabilitytoreceiveandroutecalls.Themajorityof complaints are lodgedviaemail andonourwebsite.Complaintsareprimarilyresolvedviacorrespondenceandallourstaffhaveremoteaccessto our case management system, which is totallypaperless.

We have been on all social media platforms for afew years and we quickly developed a social mediacampaigninresponsetoCOVID-19andthelockdown,highlighting our services and providing consumerswithtips.

Thetotal lockdown,whichforcedallourstafftoworkfromhome,resultedinheavierthannormaltrafficontheremoteconnectivitynetworkscausingcapacityandaccessconstraintsbuttheresourcefulnessofourstaffhasmeantthat,untilthetimethatIwascompletingmyreport,productivityhadnotbeenimpacted.Ithasbeen,untilnow,“businessasusual”innotsousualtimes.

MESSAGEFROMTHECEO 11


We have provided virtual group coaching andcounselling sessions to all our staff to ensure theirongoing development and to support them in theseanxietyprovokingtimes.

A new normal and the theme of our annual report

Whenwecomeoutontheothersideofthepandemicand the lockdown there is no doubt that there willbenogoingback to thenormsof thepast - insteadanewnormalwillemerge.Morethanever,wewillberequired to be less wasteful, cut costs and operatemorecosteffectively.

A new norm is already emerging with meetingsbecoming quick, often impromptu and flexible. Wehavenoticedthat,withoutasking,staffhavetendedtoputmorehours intoworksimplybecause theyhavemorehoursavailableasaresultof, for instance,nothavingtospendtime,hoursinsomecases,travellingtoandfromwork.

Teamworkhas improved; there isagreaterspiritofco-operationandhelpfulness.Thestaffhaveadoptedamantleofmaturity and responsibility in respectoftheirwork.

There is already a heightened awareness of theenvironment and its protection, and how fragile life

is.Thereisanincreasedappreciationofwhatwehaveandagratefulnessforfreedom.

Althoughwe cannot yet fully see thenewnormandalthoughweare all going through incredible changeboughtonby the impact of the coronavirus,we stilloperate in patterns of daily habits, behaviours andconsistentactionsthatdefinehowpeople,placesandthingsinteract.

Patternsenableustomakesenseofourworld,whichbrings me to the theme of the images used in ourannual report; human beings and nature comingtogether to create beautiful patterns, geometry andshapes.Apatternisdefinedas“anoticeableregularityinthenaturalandman-madeworldthatrepeatsitselfinapredictablemanner”.1

Despiteallthechangeandchaosthathastakenplacethroughout the world over the last few months anddespite the fact thatweneedchangeandsometimeschaostoevolve,westilllookforpatternsinoureverydaylives.Changeandroutine,inwhateverform,cananddoco-existandbothareneededforprogresstotakeplace.Awarenessofthebasicpatternsthatexistinourworldwillhelpusseewhatishappeningaroundus.

Wehavehadtocreateanewroutine/patterntocopewithournewrealityandamoreisolatedexistence.

Togetherwith theCOVID-19CrisisCommittee,wewill


1 UsingPatternstoMakeSenseofYourWorld–ScottJancy

continue to monitor developments both locally andinternationallyinrespectoftheresponsestoCOVID-19.We will develop OSTI’s response and implement scenarioplanning.Wewillcontinuetoadviseourstaffandotherstakeholdersastothestepsthatwearetakingto address the position as it develops so as to provide foraresponsethatismeasuredandappropriate.

Being a leader during COVID-19

Itisduringtimeslikethesethatwe,asleaders,needtodemonstrateconcernfortherealfearsandanxietiesthatstaffareexperiencing,notonlyprofessionallyandeconomically,butsociallyandpersonally.Eventhoughwe do not have all the answers to their questions, we should listen to and empathise with their fears andnothesitatetoshareourownconcernswiththem.Asaleaderoneneedstobeevenmoreunguardedthanusualincircumstanceslikethese.

Simultaneously, leadership needs to take a rationalline and vigilantly focus on protecting the financialperformance from the “softness” that accompaniessuchadisruptivecrisis.Thissometimesrequirestakingdecisiveactiononincompleteinformation.

As Bob Chapman, the CEO of Barry-Wehmiller, said“youcancreateeconomicvalueandhumanvalue inharmony”.2

Ultimately, a leader during these times needs to betransparent about the harsh realities and must inspire otherstopersevere.

A word of thanks

IandtheleadershipteamatOSTIaregratefultoallourcustomers, the insurer members and insureds, and all ourotherstakeholdersfortheiron-goingsupport.

We are especially grateful to our staff who havedemonstratedincredibleresilienceandadaptabilityintryinganduncertaintimes.

Our sincere appreciation goes to our board forestablishing the COVID-19 Crisis Committee. Thiscommittee is headed by our Chair of the Board,MrHaroonLaher,andthreeothermembersofourboard.Theyhaveselflesslygivenoftheirtime,freelysharedtheirexpertise,andhavebeeninstrumentalinguidingandsupportingmeandmyleadershipteam.

Thank you all for your dedication and passion inensuringthatOSTIcontinuestoprotectitsstaff,serveitsstakeholdersandoperateeffectively.

Edite Teixeira-MckinonChief Executive Officer

April 2020


2 TrulyHumanLeadershipinUncertainTimes–BobChapman–CEO,Barry-Wehmiller


Miriam MatabaneGeneral Manager

finance matters

2019 Annual Financial Statements

PricewaterhouseCoopers Inc. audited the annual

financialstatementsfortheyearended31December

2019. The financial statements were prepared in

accordancewiththeInternationalFinancialReporting

StandardsandtherequirementsoftheCompaniesAct

ofSouthAfrica.

With effect from 01 January 2019, and for the 2019

financialyear,OSTIadoptedIFRS16-Leases.IFRS16

replaces IAS 17 - Leases and sets out the principles,

measurement anddisclosureof leases. IFRS 16has

introduced the amended requirements with respect to

leaseaccounting. The right-of-useofassetsand the

leaseliabilityarepresentedasseparateitemsonthe

Statement of Financial Position. Interest charges on

the lease liabilityare reflectedaspartof thefinance

costs,whilsttheright-of-useoftheassetisdepreciated

overthetermoftheleaseandthisdepreciationcharge

is presented in the Statement of Comprehensive

Income.

OSTIrecordedRevenueofR45.2millionfortheyear,an

increaseof19%comparedto2018(R38.1million).The

varianceismainlyduetotheannualfeepercomplaint

increasefrom2018ofR4000percomplainttoR4300

percomplaintin2019.

OSTI recorded operating costs of R42.8 million for

theyear,anincreaseof8%comparedto2018(R39.7

million).Thefavourablevarianceisasaresultofcost

containmentmeasuresimplementedbymanagement.

TheBoardofDirectorsisoftheopinion,basedonthe

information and explanations given bymanagement

andtheexternalauditors,thatthesystemofinternal

FINANCE MATTERS 15

control provides reasonable assurance that the

financialrecordsandcontrolsmaybereliedonforthe

preparationoftheFinancialStatements.

The approved and audited Financial Statements are

available on our website: www.osti.co.za

Acopyofour2019AnnualFinancialStatementswillbe

emailedtoallourmembers.

Financial PositionOSTI remains financially sound with all member

insurershavingsettledtheiroutstandingdebtsinfull

forthefinancialyearended31December2019.

The OSTI recorded a total of 10 367 registered

complaints for 2019, representingan increaseof 6%

compared to 2018 (9 779). This increase is primary

attributable to the launch of the new complaints

handling process in January 2019 with one of its

objectivesbeingthe improvementofefficienciesand

thestrengtheningofinternalcontrols.

OSTIcontinuestocloselymanageitscashbalancesto

ensureavailabilityofsufficientcashtomeetfinancial

obligationswhentheyfalldue.

We would like to extend our gratitude to all our

membersfortheirsupportandcontributions.

Board, Audit and Risk CommitteeThe Board and Audit and Risk Committees approve

thefinancialreportsandreviewstrategic,operational

and compliance risks quarterly. The focus of risk

management at OSTI is on identifying, assessing,

managing and monitoring risks to ensure that

mitigating measures are effectively implemented.

OSTI endeavours to minimise operating risks by

ensuring that an appropriate infrastructure, controls

andICTsystemsareinplace,andaremanagedwithin

predetermined procedures and constraints. OSTI’s

finance department thanks the members of the

committeesfortheirinvaluablesupportandguidance.

New MembershipYardriskInsuranceLimited’sapplicationformembership

wasapprovedduring2019andMutualandFederalRisk

Financing’sapplicationwasapprovedinMarch2020.

Thelistofmembercompaniesisenclosedinthisreport.

Miriam MatabaneGeneral Manager


office statistics

Formal rulings against insurers - 2019

Finalisation per period

Finalised within 4 months

Finalised between 4 and 6 months

Finalised in over 6 months

56%20%

24%

Total cases closed: 100%

Claim types resolved ratio - 2019

MiscellaneousTotal Closed: 1 558Settled: 534Ratio: 34,27%

Home Owners Total Closed: 1 843Settled: 268Ratio: 14,54%

MotorTotal Closed: 4 492Settled: 859Ratio: 19,12%

Household ContentsTotal Closed: 551Settled: 99Ratio: 17,97%

Commercial Total Closed: 723Settled: 133Ratio: 18,40%

Formal complaints closed

2015 2016 2017 2018 2019

9 944 9 9628 631 9 474 9 167

CP TimberTransport/ New National Assurance Company Limited (C456/18)


Types of complaints by cases (on matters received for 2019)

Total Complaints Closed

Total Complaints Received and Total Complaints Closed

Total Complaints Received

2017

9 09

79

962

7,9%

49,0%

17,0%

20,1%

6,0%

HouseholdContents 551

Commercial 723

Other and non-claim related 1 558

HomeOwners 1 843

Motor 4 492

Total 9167

Rand value of complaints resolved in favour of insured - Claim type

60 000 000

56 000 000

52 000 000

48 000 000

44 000 000

40 000 000

36 000 000

32 000 000

28 000 000

24 000 000

20 000 000

16 000 000

12 000 000

8 000 000

4 000 000

0

Commercial Home Owner Household Motor Other Non-Claim Related

R3 8

28 3

15

R136

319

2018R87 250 982

R13

987

137

R12

369

548

R3 2

88 6

05

R53

641

058

R5 3

15 6

95

2017R87 101 353

R19

982

717

R11

829

111

R4 2

80 9

12

R45

692

919

R7 3

39 0

30

2016R99 139 593

R16

029

454

R10

159

765

R59

238

533

R6 3

72 8

11

2015R100 712 182

R18

513

071

R15

498

565

R7 3

39 7

24

R52

897

530

R6 4

63 2

92

2015

9 94

49

784

2016

8 63

110

175

2018

9 47

49

779

2019R94 934 891

R10

386

013

R980

524R1

8 25

5 29

9

R14

653

628

R2 9

58 0

40

R47

701

386

20199

167

10 3

67


Ayanda MazwiSenior Assistant Ombudsman

a statistical analysis of matters closed by OSTI in 2019

During2019,OSTIfinalizedatotalof

9 167 formal complaints.

Themajoritywere in respect ofmotor vehicle claims

at 49% followed by homeowners/building claims at

20%, commercial claims at 8% and household content

claims at 6%,withthebalanceof17%ofcomplaintsbeing

non-claim relatedorrelatedtoothertypesofcover.

The majority were in respect of :

“So what concerning these categories did people complain about the most? ”Motor vehicle claims The majority of these complaints, at 73%, were

for accidental damage. Warranty and mechanical

breakdown claims comprised 8%. Theft and hijack

claims also comprised 8%. This trend remains

consistentwithpreviousyears.

OSTI considered 4492 motor vehicle claim disputes

in 2019. The primary cause for complaints related

to claims settlement calculations. The type ofdisputes falling under this category vary. Our office

wishes however to highlight that the predominance

of these disputes related to vehicle credit short-fall

anduninsuredaccessories. Standard comprehensive

motorvehicleinsurancewillnotnecessarilycoverthe

totalamountowedtothebankinrespectofafinanced

vehicle.Vehiclecreditshortfallisthegapbetweenthe

vehicle’sinsuredvalue(coveredundercomprehensive

motorvehicleinsurance)andtheamountowingtothe

financehouse. Shouldavehiclebestolenorwritten

offinanaccident,thevehicle’screditshortfallcanbe

crippling as the consumer is left owingmoney on a

motorvehicle thathe/sheno longerhas.Consumers

must,therefore,ensurethattheirpoliciesincludecover

for thecredit short-fallandanyfinancedaccessories

whichhavebeenaddedtotheinsuredmotorvehicle.

Motor vehicle claims at 49%.

Followedby homeowners/building claims at 20%.

Commercial claims at 8%.

Household content claims at 6%.

With the balance at 17% ofcomplaintsbeingnon-claimrelated or related to other typesofcover.


These coveroptionsare inmost casesofferedat an

additional premium and administered under their own

terms,conditionsandexclusions.

The secondary cause for complaints was rejections

based on the insured’s alleged non-disclosure or misrepresentation of underwriting details at the sales stage. In 2018, OSTI saw a 22% decrease in

the number of these complaintswhen compared to

the previous year. In 2019, therewas a further20% decrease.OSTIalwayshighlights in itsengagements

withconsumersandthepublicatlarge,theimportance

ofprovidingtruthfulandaccurate informationtothe

insurerduringtheunderwritingofthepolicy,aswellas

theinsurer’sobligationtoconductthesalesprocessby

agreedindustrycodesofpracticeandthePolicyholder

ProtectionRules.

238 complaints relating to rejections on the ground

that the insured was driving under the influence of alcohol(DUI)wereconsideredbyOSTIin2019.In2018,we recorded a 15% decrease when compared to the

previousyear.Thestatisticsin2019indicateafurther

13% decrease. This is encouraging as it displays animprovement in consumer responsible conduct, such

asusinge-hailingservices,andthepositive influence

ofmeasures taken by insurers in this area, such as

providing their customerswith chauffeured services.

OSTI has always cautioned consumers that a DUI

rejectionmaybe justifiedoncircumstantialevidence

alone, despite the driver not having been tested for

alcohol by way of a breathalyzer or blood test, or

havingbeenconvictedofacriminaloffenseconcerning

the incident. In previous years, some insurers relied

on insufficient circumstantial evidence to justify

these rejections, in which case OSTI would overturn

the insurers’ decisions. Perhaps these statistics also

indicate that insurers are validating DUI claims in a

fairermanner.

In 2019, 19% of motor vehicle claim disputes were

resolvedinfavoroftheinsured’sclaim,andOSTIput

R47 701 385,68backintothepocketsoftheinsured.

Homeowners insurance claims54% of complaints considered by OSTI under

homeowner’sinsurancerelatedtoclaimsfordamage

causedbyacts of nature, largelystorm-related.This

figuredroppedfrom58% recorded in 2018.

OSTI considered 1843 homeowners’ insurance claim

disputes. The primary cause for complaints, at30%, wastherejectionofclaimsonwear and tear, gradual deterioration and lack of building maintenance

beingtheproximatecauseofthedamage.Whilethis

causeforcomplaintdeclinedby18% when compared

to 2018,thisrejectionreasoncontinuestobethemain

basis for consumer dissatisfaction in homeowner’s

insurancecoverage.Ifthedamageclaimedisattributed

tothepoorconditionoftheproperty,thepolicymay

not respond - even if an insured event did occur. In

general,OSTI bases its assessment of thesematters

on the information contained in expert reports and

photographssubmittedbytheparties.Theevidentiary

burdenof proof lieswith the insurer if it rejects the

claim on an exclusion and the insurer must establish

a causal connection between the condition of the

propertyandthedamage.



The secondary cause for complaints related to

rejections based on no insured event having operated. Theinsurerisonlyliableiftheclaimmade

fallswithinthescopeofcoverprovided,inotherwords,

ifan insuredeventasstated in thepolicy termsand

conditionsisprovenbytheinsuredasbeingthecause

of the damage. Here, the burden of proof is on the

insured, who must provide evidence and demonstrate

thattheeffectivecauseofthelossisaninsuredevent.

15% ofhomeowner’sinsurancedisputeswereresolved

infavoroftheinsureds’complaint,witharecovery of R14 653 628,32.

Household content insurance claimsTheft and burglary claims comprised 67% of

complaintsconsideredbyOSTIunderthiscategory,a

4%declinecomparedtolastyear’sfigure.

Claims settlement calculations remain the primary cause for complaints, as in the previous year. The

disputesmainly related to issuesof underinsurance,

replacementvaluesandproofofownershipinrespect

oftheclaimeditems.

The secondary cause for complaints was rejections

where the insurer’s underwriting criteria for the insured event were not met. Examples

include minimum security requirements, such as a

burglar alarm with armed response, burglar bars,

and burglar gates not being complied with by the

insured.Consumersareadvisedtoreviewtheirpolicy

documents and ensure compliance with their insurers’

conditionsofcover.

Complaints relating to damage caused by power surge increased from 3% in 2018 to 6% in 2019.

Thismay be attributed to load-shedding and power

failures experienced in the year. Damage caused by

powersurge isexcluded in somehouseholdcontent

insurance policies. Consumers must read through

their policy terms and conditions and consult with

theirinsurersorbrokerstoensurethatthereiscover

in place to repair or replace their valuables in this

event.

18% of household content insurance disputes were

resolved in favor of the insureds’ complaint, with a

recovery of R2 958 039.99.

Commercial insurance claimsThe majorityofcommercialcomplaintsconsideredby

OSTI related to motor vehicle (32%) and building (23%) claims.OSTIconsidered723 commercial complaints in

2019.Overall, theprimary cause for thecomplaints

wasrejectionsbasedongradual deterioration, wear, and tear and lack of maintenance. The secondary



cause for complaints was the claims settlement calculations followed by rejections on the groundthat the insurer’s specificconditions of cover were not met,suchasavalidprofessionaldriver’slicense,avehicle’sroadworthiness,alarmwarrantiesandfire

safetymeasures.

18%ofcommercialinsurancedisputeswereresolved

infavoroftheinsureds’complaint,andOSTIrecovered R18 255 299.01.

‘Other’ & non-claim related policy complaints Theremainingcomplaintsrelatetovariousinsurance

products - including personal accident, water loss,

travel insurance, all risks, mobile device cover, legal

expenses, hospital, and medical gap cover. General

policy-related disputes include policy amendments/

endorsements, policy cancellations/lapses, premium

increases/rebates,andservice-relatedcomplaints.We

oftenfindthattheprimary causeforcomplaintsunder

thiscategory isthe quality of the communications

that takeplacebetween the insurerand the insured

during underwriting and over the operation of the

policy.

This category, overall, comprised 17% of the formal

complaintsconsideredbyOSTIin2019.34%ofthese

disputes were resolved in favour of the insureds’

complaint.Overall,OSTIrecoveredR11 366 537.68forinsuredsinthiscategoryofcomplaints.

OSTI’s Customer ExperienceIn2018,OSTIreportedthat60%ofcomplainantswho

completedourcustomerexperiencesurveysindicated

that they were satisfied with our service, processes,

andcommunications.

In January 2019, OSTI adopted, as part of its

commitmenttodevelopingabetterunderstandingof

itsrelationshipwithcustomers,astrongercustomer-

centric approach. We introduced insurer surveys in

theevaluationofOSTI’soveralldeliveryofserviceand

qualityoutcomes.

In relation to the number of complaints finalized

in 2019, 22% of complainants and 25% of insurers

completedsurveys.Outofthese,75% were satisfied with our service, processes, and communications.

Customerexperience,inthecontentofOSTI,entails,at

itscore,deliveringhighqualityandefficientcomplaint

resolutions and customer experience therefore

remainsanintegralpartofourbusinessstrategy.

Ayanda MazwiSenior Assistant Ombudsman



Explanatory notes1. Thedatamustbeunderstoodinthecorrectcontext

anditisthereforenecessarytorecordsomewords

ofexplanationinrelationtothesestatistics.

2. TheofficeoftheOmbudsmanhaslimitedjurisdiction

over commercial lines policies and, in any event,

has jurisdiction for personal lines business only

up to R3.5 million, save for home owner claims

where the jurisdictional limit is R6.5 million. The

statistics therefore focus only on personal lines

claims (statistics provided by the Financial Sector

Conduct Authority (“FSCA”)) and personal lines

complaintsreceivedbythisoffice.Commerciallines

complaints,whicharenotreflectedinthestatistics,

representabout8.0%ofthetotalcomplaintstothe

officeoftheOmbudsman.

3. Alsoexcludedfromtheinsurerstatisticsarethose

complaints resolved “on transfer”. In terms of

the complaints handling process that came into

effect on 1 January 2019, an insurer is given an

opportunitytoresolveacomplaintdirectlywiththe

insuredwheretheinsuredlodgedacomplaintwith

OSTI before first approaching his/her insurer to

resolvethecomplaint.Thisprocessisreferredtoas

the“ontransfer”process.Iftheinsurerresolvesthe

complaint to the satisfaction of the insured, then

the decision of the insurer is not recorded as an

overturnagainst the insurer in thesestatisticsbut

is included in the overall office statistics. Further

commentsontheoverturnrateappearbelow.

4. Noadverseconclusionsshouldbedrawnagainstany

insurerbasedpurelyonthenumberofcomplaints

against them received by this office. Larger

insurersissueproportionatelymorepolicieswhich

cannotformthebasisofacomplainttothisoffice

due toour jurisdictional limits.Thus, forexample,

when considering the percentage of complaints

receivedby this office against a large insurer, the

largeinsurer,uponasuperficialanalysis,therefore

appears to attract a relatively low number of

complaints.Whatisthemoreimportantstatisticis

theproportionofpersonallinescomplaintsrelative

to an insurer’s share of the total personal lines

claimsreportedtotheFSCA.Theclearestindicator

ofthisiscolumn5,beingthenumberofcomplaints

to this office per thousand claims received by an

insurer.Wherean insurer receivesahighnumber

explanatory notes and insurer statistics

EXPLANATORY NOTES AND INSURER STATISTICS 23

of complaints to this office per thousand claims,

this may be an indicator that claims are dealt

withunfairlybythe insurer.However,thisstatistic

shouldbeconsideredinconjunctionwithcolumns8

and9,beingtheshareofmattersresolvedthrough

conciliation by the parties/enforcement by OSTI.

Theoverturnrateisanindicatorthatthedecisionof

theinsurerwithrespecttoacomplaintwaschanged

insomerespectbythisofficewithsomeadditional

benefit to the insured. Further comments on the

overturnrateappearbelow.

5. Please note that a claim can be received by an

insurer in year one and a complaint in respect of

thatclaimmaybereceivedbyOSTIonlyinyeartwo

– hence the number in column 1may be greater

thanthenumberincolumn3.Thestatisticsrecord

the numbers received by insurers and the OSTI

respectivelyduring2019.

6. Alsonotethatundercolumn1,certaininsurersmay

beshownbytheFSCAstatisticsashavingreceived

noclaimsduring2019.Thismaybeexplainedonthe

basisofeitherthecompanyissuingonlycommercial

linespoliciesor that thecompany isdormant.We

repeatthatonlypersonallinesstatisticsareincluded

inthetableasthisiswhathasbeenreceivedfrom

theFSCA.(columns1and2)

7. The overturn rate per insurer as shown in the

table is forpersonal linesclaimsonly. Itexcludes

commercial lines claims and complaints resolved

ontransfer(seepoint3above).Ifahighoverturn

rate is registered, this may, but not necessarily,

indicatethattheinsurerisnottreatingitscustomers

as fairly as it should.However, theoverturn rate

should be treated with considerable caution as

a high overturn rate can also be indicative of a

high degree of co-operation being received by

theOmbudsman’sofficefromaparticularinsurer

inresolvingacomplaint to thesatisfactionof the

customer.TheOmbudsmantakesintoaccountthe

following two circumstances in determining the

Overturn Rate:

a) Thedecisionoftheinsurerisoverturnedbythe

Ombudsmanbywayofarecommendationwhich

isacceptedorbywayofaFinalRuling.

b)A resolution of the dispute has beenmediated

by the Ombudsman with the insured receiving

abenefitwhichhe/shewouldnothavereceived

withouttheinvolvementoftheOmbudsman.

8. Anymediaqueriesinrelationtotheinsurerstatistics

shouldbedirectedtotheparticularinsurer.


1 2 3 4 5 6 7 8 9

Name of Insurer*

Claimsreceived

by

Insurers(FSC

Astatistics)

Shareofclaim

sreceived

byth

epa

rticularinsurer

(FSC

Astatistics)

Com

plai

nts

rece

ived

byOSTI

Shareofth

etotal

numbe

rofcom

plaints

received

byOSTI

Num

berofCom

plaints

received

byOSTIp

er

thou

sand

Cla

ims

received

byInsurer

Complaintsfin

alised

byOSTI

Complaintsfin

alised

with

som

ebe

nefitto

th

e in

sure

d

Shareofm

atters

resolved

throug

hconciliationbypartie

s

Shareofm

atters

resolved

throug

hen

forcem

entb

yOSTI

Abacus 4972 0,13% 10 0,11% 2,011/1000 8 5 50,00% 12,50%

Absa 133805 3,55% 604 6,46% 4,514/1000 609 112 16,91% 1,48%

AIG Insurance 9805 0,26% 32 0,34% 3,264/1000 28 8 25,00% 3,57%

Alexander Forbes 55790 1,48% 166 1,78% 2,975/1000 158 23 13,92% 0,63%

Allianz 857 0,02% 4 0,04% 0/1000 3 0 0,00% 0,00%

Auto & General 240254 6,38% 400 4,28% 1,665/1000 319 42 11,29% 1,88%

Bidvest 24410 0,65% 80 0,86% 3,277/1000 68 8 8,82% 2,94%

Bryte 153 062 4,07% 163 1,74% 1,065/1000 134 48 33,58% 2,24%

Budget 78687 2,09% 374 4,00% 4,753/1000 330 35 9,09% 1,52%

Centriq 37567 1,00% 147 1,57% 3,913/1000 148 53 31,76% 4,05%

Chubb 1432 0,04% 5 0,05% 3,492/1000 4 0 0,00% 0,00%

Compass 10 501 0,28% 57 0,61% 5,428/1000 128 6 4,69% 0,00%

Constantia 55441 1,47% 271 2,90% 4,888/1000 203 59 27,09% 1,97%

Dial Direct 34277 0,91% 192 2,05% 5,601/1000 142 18 10,56% 2,11%

Discovery 198979 5,29% 312 3,34% 1,568/1000 297 48 14,48% 1,68%

FirstforWomen 45405 1,21% 174 1,86% 3,832/1000 142 13 7,04% 2,11%

FirstRand Short-term 14437 0,38% 2 0,02% 0,139/1000 1 1 0,00% 100,00%

Genric 53 526 1,42% 45 0,48% 0,841/1000 59 11 15,25% 3,39%

Guardrisk 270230 7,18% 544 5,82% 2,013/1000 509 128 22,59% 2,55%

Hollard 313 522 8,33% 497 5,32% 1,585/1000 534 125 22,10% 1,31%

HollardSpecialistInsurance Limited

32859 0,87% 76 0,81% 2,313/1000 86 26 29,07% 1,16%

Indequity 2 619 0,07% 4 0,04% 1,527/1000 6 2 16,67% 16,67%

Infiniti 30 216 0,80% 57 0,61% 1,886/1000 53 4 7,55% 0,00%

KingPrice 112182 2,98% 501 5,36% 4,466/1000 405 48 10,12% 1,73%

LegalExpenses 24443 0,65% 109 1,17% 4,459/1000 70 12 17,14% 0,00%

LionofAfrica$ 898 0,02% 90 0,96% 0/1000 138 54 38,41% 0,72%

Lloyd's 199 0,01% 2 0,02% 0/1000 6 1 16,67% 0,00%

Lombard 17855 0,47% 69 0,74% 3,864/1000 59 11 16,95% 1,69%

MiWay 118948 3,16% 432 4,62% 3,632/1000 437 32 5,72% 1,60%

insurer statistics

1 2 3 4 5 6 7 8 9

Name of Insurer*

Claimsreceived

by

Insurers(FSC

Astatistics)

Shareofclaim

sreceived

byth

epa

rticularinsurer

(FSC

Astatistics)

Com

plai

nts

rece

ived

byOSTI

Shareofth

etotal

numbe

rofcom

plaints

received

byOSTI

Num

berofCom

plaints

received

byOSTIp

er

thou

sand

Cla

ims

received

byInsurer

Complaintsfin

alised

byOSTI

Complaintsfin

alised

with

som

ebe

nefitto

th

e in

sure

d

Shareofm

atters

resolved

throug

hconciliationbypartie

s

Shareofm

atters

resolved

throug

hen

forcem

entb

yOSTI

Momentum ST 43549 1,16% 94 1,01% 2,158/1000 81 7 8,64% 0,00%

Monarch 17438 0,46% 8 0,09% 0,459/1000 5 3 60,00% 0,00%

Nedgroup 70666 1,88% 312 3,34% 4,415/1000 265 61 21,13% 1,89%

New National 17595 0,47% 181 1,94% 10,287/1000 191 43 20,42% 2,09%

NMS 111668 2,97% 2 0,02% 0,018/1000 3 3 100,00% 0,00%

Oakhurst 64898 1,72% 332 3,55% 5,116/1000 324 54 14,51% 2,16%

Old Mutual 244370 6,49% 792 8,47% 3,241/1000 724 129 16,71% 1,10%

OUTsurance 291 901 7,75% 298 3,19% 1,021/1000 275 22 8,00% 0,00%

PPS 6184 0,16% 12 0,13% 1,940/1000 3 2 66,67% 0,00%

Renasa 92397 2,45% 182 1,95% 1,970/1000 155 43 27,74% 0,00%

SAFIRE 7163 0,19% 6 0,06% 0,838/1000 7 0 0,00% 0,00%

SAHL 24344 0,65% 86 0,92% 3,533/1000 74 6 5,41% 2,70%

Santam Ltd 383938 10,20% 557 5,96% 1,451/1000 473 73 14,16% 1,27%

Santam Structured 33982 0,90% 210 2,25% 6,180/1000 183 22 12,02% 0,00%

SASRIA 1142 0,03% 2 0,02% 1,751/1000 3 3 100,00% 0,00%

Shoprite 17915 0,48% 3 0,03% 0,167/1000 5 3 60,00% 0,00%

Standard 128935 3,42% 637 6,81% 4,940/1000 544 76 12,13% 1,84%

Unitrans 4677 0,12% 5 0,05% 1,069/1000 6 3 50,00% 0,00%

Vodacom 107177 2,85% 150 1,60% 1,400/1000 110 67 57,27% 3,64%

Western National 17646 0,47% 38 0,41% 2,153/1000 41 12 24,39% 4,88%

Workerslife 15 0,00% 23 0,25% 0/1000 22 8 31,82% 4,55%

YardriskInsurance Limited@

0 0,00% 0 0,00% 0/1000 0 0 0,00% 0,00%

TOTAL 3 764 778 100,00% 9349 100% 2,48/1000 8 578 1573 16,72% 1,62%

Please Note:TheStatisticsforABSAInsuranceCoLtdincludestatisticsforABSAIdirectandABSAInsuranceRiskManagementServicesLimited.TheStatisticsforOldMutualInsureincludestatisticsforIwyzeandMutual&FederalRiskFinancing.

EXPLANATORY NOTES AND INSURER STATISTICS 25

FSCA Legend @ New license$Run-offofbusiness


Thegenerallyacceptedstatisticisthatonly30to35%

ofmotorvehiclesonSouthAfricanroadsareinsured.

This statistic is simplybasedon recordeddata. It is

my contention, however, that in reality a greater

proportion of vehicles considered insured may

not in factbe insured.My submission is admittedly

based onwhat somemay call “anecdotal evidence”

from complaints received by our office. The ratio

of complaints received by OSTI to the total claims

submitted to insurers is only 0.24% for 2019, so

perhapsitisindeedonlyanecdotal.

Partofthereasonforthisviewisthatsomeconsumers

of insuranceproductsdonot complywith the terms

andconditionsoftheirpolicies.Thismaybeeitherasa

resultofthemnotbeingawareoftheirresponsibilities,

or,alternatively,simplyignoringsuchresponsibilities.

Weoftenfindthatinsuredsareofthemistakenbelief

that, by simply paying premiums, they are entitled

to have all their claims settled by their insurers. On

thecontrary, theombudsman‘sfinding in thematter

discussed below demonstrates how important it is

thatinsuredshonourtheirownobligations.

Mostmotorpoliciesimposethefollowingresponsibilities

whicharesometimesignoredornotmet:

1. Thedutytomakeaccuratedisclosuresatalltimes;

2. Thedutytoallowonlylicenseddriverstodrivethe

insuredvehicle;

3. Thedutynottodrivetheinsuredvehiclewhilstthe

driverisundertheinfluenceofalcohol;

4. Thedutynottodrivetheinsuredvehiclerecklessly;

5. Thedutynottouseanun-roadworthyvehicleon

publicroads;and

6. Thedutytomaintaintheinsuredvehicleandkeep

itinagoodstateofrepair;

Theeffectofignoringornotmeetinganyoftheabove

responsibilities is that, when an insured claims, the

insurermaybeentitledtodeclineliability.

Inotherwords,whilethevehiclewouldatfacevalue

be insured, in reality, and as a result of the insured

notcomplyingwiththeobligationssetoutinthepolicy

termsandconditions,thevehicleisnotcovered.The

insuredwouldbeoperatingon thepremise that the

vehicle is insured while his/her own conduct would

leadhim/hertobeingexposedto,atleast,someofthe

risksthatmaymaterialise.

InoneofthecasesOSTIrecentlydealtwith,thepolicy

required that the insured keephis vehicle in a good

state of repair. However, for whatever reason, the

insureddidnotdothis.

On a particular day, while the insured was driving

his vehicle, he noticed that the vehicle was on fire.

He, togetherwithmembersof thecommunity in the

area, tried to douse the fire. There appeared to the

insuredtobenospecificreasonwhythefireignited.

Theinsuredsubsequentlyregisteredaclaimwiththe

insurer.

Peter NkhunaSenior Assistant Ombudsman

the uninsured and the “not-so-insured”


Duringtheassessmentoftheclaim,theinsurerfound

thatthevehiclehadbeenpoorlymaintained.Itfurther

found that the fire incident was as a result of the

vehiclenothavingbeingproperlymaintained.

The assessor appointedby the insurer to determine

thecauseofthefiremadethefollowingfindings:

i. Therewerenosignsoffiredamagetothevehicle

exceptforfiredamageintheenginecompartment;

ii. Thefiredamageappearedtoemanatefrominside

theengine;

iii. Therewasevidencethattheenginehadoverheated

asaresultofacrackedandbrokenplasticbreather

pipeofthepositivecrankcaseventilationsystem;

iv. There was also evidence of one of the coolant

hoseshavingbeenfittedby tying itwith apiece

of wire instead of a circlip/clamp normally used

forsuchfitments,andthesealontheendofthe

rubberpipewasdamaged;

v. Inaddition,therewasfurtherevidenceofadvanced

wear and tear, including oil leaking through the

turbocharger’soilseals;and

vi. Itwastheassessor’sviewthatthefirewasthedirect

resultofthepoorconditionofthevehicleandthat,

if the vehiclehadbeenproperlymaintained, the

firewouldnothaveoccurred.

On the basis of the assessor’s findings, the insurer

declinedliabilityfortheclaimandreliedonthepolicy

wordingwhichstatedthattheinsurerwasnotliablefor

“failure,breakageorrust,wearandtear,depreciation,

perishing,fading,mechanicalorelectricalbreakdown”.

Being unhappy with the outcome of the claim, the

insuredlodgedacomplaintwithouroffice.

It was the ombudsman’s finding that the insurer’s

stanceontheclaimcouldnotbefaulted.

It is clear from the above example that, while this

vehicle and the insured would have formed part of

the statistics of the insured population, based on

the condition of the vehicle, it was not, in fact, as

comprehensivelyinsured.Intermsofthepolicy,there

wasnocoverforanylossesrelatingtoaccidents,fire

ortheotherrelatedperilswheretheconditionofthe

vehiclewasmaterialtotheloss.

Inthecasediscussedabovetheinsuredhadfailedto

keephisendofthebargain,whilst,atthesametime,

expectinghisinsurertohonourtheclaim.Inthiscase,

had the insured maintained his vehicle, as required in

termsofthepolicy,therewouldhavebeennolossor

damageandthereforenoclaim.

It is conceivable that the insured’s conduct could

resultinallofthebenefitsunderaninsurancepolicy

becomingnullified,andnotonlysomeofthem.

Insurance consumers are therefore encouraged to

familiarise themselves with their policy terms and

conditions and to conduct themselves accordingly,

otherwise,theymayfindthemselvesunabletoenjoy

thebenefitsoftheirpolicies.

Peter NkhunaSenior Assistant Ombudsman



Mr. V lodged a claim with his insurer for damage

to his motor vehicle arising out of a motor vehicle

accident.Thevehiclewasbeingdrivenbytheinsured’s

daughter-in-law, Mrs. M. The insurer rejected the

claimon thegroundsofmaterialmisrepresentation/

non-disclosure, on the basis that there was a material

changeinrisk,ofwhichithadnotbeeninformed.

The insurer advised that the regular driver of the

vehicleonthepolicywastheinsured’sson,Mr.M.Inthe

insurer’srejectionlettertheinsurerstatedthat,when

thecoverfortheinsuredvehiclewasaccepted,itwas

accepted based on the information and disclosures

providedbyMr.V’sbrokerwhenaddingthevehicleto

thealreadyexistingpolicy.Mr.Vsignedaformwhich

noted all the relevant and necessary details. The

insureradvisedthatMr.Vwasaskedforthedetailsof

theregulardriverofthevehicleandtheriskaddress

as this had a direct impact on the insurer’s decision to

accepttherisk.Theinsurerreferredtothedocument

whereMr.V statedand signed thatMr.Mwouldbe

theregulardriverofthevehicle.Thevehiclehadbeen

boughtforMr.M.

During the investigation of the claim, the insurer

foundthatMr.andMrs.Mwereseparatedfromtheir

marriageforapproximatelysixtoeightmonthsprior

totheaccidentandtheywerenotlivingtogether.Mrs.

M was living at a different address to the address

notedonthepolicy.Whentheyseparated,Mr.Mtold

Mrs.Mthatshecouldmakeusethevehicleforherself

andtheirchildren.Mrs.Mhadbeenusingthevehicle

eversince.

The insureradvised thatbothMr.MandMr.Vwere

awarethatMrs.Mdidnothaveadriver’slicenseand

onlyhadalearner’slicenseandtheywereawarethat

Mrs.Mwouldbeusingthevehicleastheregulardriver.

Theinsureradvisedthatitwasnotinformedthatthe

regular driver and risk address had changed. The

insurersubmitted that the failurebybothMr.Vand

Mr. M to disclose the changes in the risk resulted

in a non- disclosure of material facts. The insurer

submittedthat,ifithadbeenmadeawarethatMrs.M

wouldbetheregulardriverofthevehicle,itwouldnot

haveacceptedtheriskastheregulardriver,interms

ofthepolicy,isrequiredtohaveavaliddriver’slicense.

Theinsurerreferredtothefollowingpolicywording:

“information that affects and changes the risk:

there is an obligation on you to advise us immediately

on the happening of any event that may affect our

decision to accept the risk or the terms on which we

accept the risk or our continued acceptance of the

risk. Should you not adhere to these obligations, we

may void the whole or any part of this policy and the

section as from inception or date of change” and for

this general condition, the term “you” includes any

person acting on your behalf. “

AccordingtoMr.V,hediddeclarethatMr.Mwouldbe

theregulardriver,thatMrs.Mwoulddrivethevehicle

andthatshedidnothaveavaliddriver’slicense.

Mr.VsubmittedthatheinformedhisbrokerthatMrs.

Mhadalearner’slicense.Headvisedthatherepeatedly

Thasnim DawoodSenior Assistant Ombudsman

misrepresentation after the inception of the policy


askedhisbrokertoconfirmthatMrs.Mwascovered

by the policy even though she only had a learner’s

license.AccordingtoMr.V,thebrokerconfirmedthat

Mrs. Mwas covered. The insuredargued thatMrs.

Mcompliedwiththelegalrequirementsofaholderof

a learner’s license, especiallywith the condition that

such person may drive a vehicle if another person,

who has a valid driver’s license, accompanies him or

her.Mr.Vsubmitted that thepolicycontractdidnot

defineordescribetheterm“driver’slicense”andthat

itdidnotmakeanymentionofalearner’slicense.He

arguedthat,asaresult,whilethepolicydoesnotmake

referencetoalearner’slicense,thereisnorestriction

ontheterm“driver’s license”. AccordingtoMr.V,he

informedhisbrokerthatMrs.Monlyhada learner’s

license and his broker assured him that she was

coveredunderthepolicy.

Mr.V thenreferredtothepolicywordingandstated

thatitdidnotdefinea“regulardriver”.Mr.Vsaidthat

his broker’s explanation was that “as long his son

was declared the regular driver, then his wife was

automaticallyincludedandcoveredbytheinsurer.”

Mr.Vsubmittedfurtherthatthechangeinriskaddress

was only material to the risk of theft and hijacking

and that it was notmaterial to the risk of accident.

He argued that he had disclosed all the necessary

informationtohisbroker.

The insurer submitted that “license” means a valid

driver’s license and that the reference to a learner

driveristheretoensurethatthereisnoconfusionthat

a learnerdriverneeds to complywith the legislation

concerninglearnerdrivers.Theinsurersubmittedthat

theissuewasnotwhetherMrs.Mcouldlawfullydrivea

vehicleinthecircumstancespermittedbytherelevant

legislation.TheissuewasthatMrs.Mhadbecomethe

regulardriverofthevehiclewhichwasariskthatthe

insurerwouldnothaveaccepted.


The insurer advised that the risk it underwrote

changed fundamentally and that the insurer did not

cover regular drivers who held only learner drivers’

licenses.TheinsurersubmittedthatMr.Vdidnotmeet

hisdisclosureobligationsintermsofthepolicyinthat

theinsurerwasnotmadeaware,atanytimepriorto

theaccident,thattheregulardriverofthevehicleand

theriskaddresshadchanged.

TheinsurerdidnotviewMr.ManMrs.Masbeing“one

astheother”.Theinsurersubmittedthatfactorssuch

asage,drivingexperienceandthenumberofyearsof

holdingavaliddriver’slicense,haveadirectimpacton

theacceptanceofariskand,iftheriskisaccepted,the

conditionsandratesthatareappliedtothepremium.

Theinsurerreferredtotheregulardriverclauseinthe

policywhichreadsasfollows:

“2 REGULAR DRIVER CLAUSE

We use pertinent information about the stated

regular driver to determine the premium we charge

to insure each vehicle. This information includes

the person’s age, driving history, driving ability and

financial status. You have to advise Us immediately

of a change in the following:

2.1 The regular driver of a vehicle;

2.2 The occupation of the regular driver;

2.3 Change of use of the vehicle;

2.4 The financial status of the regular driver

(including information relating to any

judgments, convictions or if the regular driver

has been declared insolvent or placed under

administration);

2.5 Change of address where vehicle is kept overnight.

We may decline to indemnify or compensate You

for Your loss, damage or any liability under this

section if the risk is materially changed without

Our written consent.”

The insurer stated that, when considering a change

intheriskaddress,theinsurerassessesnotonlythe

newaddressbutalsothesecurityofthepremisesand

wherethevehicleisparkedatnight.

The insurer advised that in this matter it had not been

givenanopportunitytoassessthechangesintherisk.

The insurer submitted thatMr.V’s failure to disclose

thechangeintheregulardriverresultedinamaterial

non-disclosurewhichentitledittovoidthepolicy.

The issues that OSTI had to decide were whether there

wasamaterialchangeinriskandwhethertheinsurer

wasentitledtorejecttheclaimbasedonmaterialnon-

disclosure.

When the policy was underwritten, the insurer was

advised that the regular driver of the vehicle would

be Mr. M and he was noted as such. It is common

causethatMr.Mwasinpossessionofavaliddrivers

license.ItisalsocommoncausethatMrs.Monlyhad

alearner’slicense.InorderforMrs.Mtohavedriven

theinsuredvehicle,shewouldhaveneededtocomply

with the requirements of the relevant legislature, in

particular, todrive thevehiclewhileaccompaniedby

apersonwhohadavaliddriver’slicense.Atthetime

oftheaccident,Mrs.Mhadbecometheregulardriver

of the vehicle. Thismeant that therewas amaterial

changeintheriskandthefactthatMrs.Monlyhada

learner’slicensewasclearlymaterialtotherisk,ifnot

totheloss.Theinsurerwouldnothaveacceptedthe

risk had it know thatMrs.Mwas the regular driver.

The insurer did not accept regular drivers who only

hadlearner’slicenses.

Underthecircumstances,ourofficefoundthatthere

hadbeenamaterial change in the risk in respectof

the regular driver and that the insurer was entitled

torejecttheclaimonthisbasis.Mr.Vdidnotinform

the insurerof thischangeand,hadthe insurerbeen

informed, itwouldnothave continued toaccept the

risk.

As a result the insurer’s rejection of the claim was

upheldandMr.V’scomplaintwasdismissed.

Thasnim DawoodSenior Assistant Ombudsman


Darpana HarkisonSenior Assistant Ombudsman

same-same, but different …(in the context of cell phone claims)

Theinsuredsubmittedaclaimforthetheftofhiscellphone,

aSamsungS7Edge,whichtookplaceduringaburglary

at his risk address on 20 October 2018. The insured

referredthemattertotheOmbudsman’sofficeduetohis

dissatisfactionwiththeinsurer’sofferofsettlement.

On5 January2018, the insuredcontacted the insurer

toamendthepolicyasheandhiswifehadseparated.

Whentheinsuredaskedtheinsurer’ssalesconsultant

whathewouldbepaidbytheinsurershouldanything

happen to his cellphone, the insured was advised that

hewouldbepaidtheinsuredamount,beingR15000.00,

minushisexcessofR500-00.

At the time that the insured submitted the claim, the

SamsungS7Edgecouldnotbereplacedandtheinsurer

offered to settle the insured’s claim by replacing the

SamsungS7EdgewithaSamsungGalaxyS8.However,

basedonhisconversationwiththeinsureron05January

2018,theinsuredwasadamantthattheclaimmustbe

settledonacash-in-lieubasisinthesumofR14500.00.

The issue to be determined by OSTI was whether

the insurer’s offer of settlement amounted to

indemnificationonthepartoftheinsurer.

Short-term insurance contracts are contracts of

indemnity whichmeans that the insurer’s obligation

is to place the insured back in the same financial

positionthathewas in immediatelyprior to the loss

or damage. Indemnity also means that the insured

shouldnotprofitfromtheinsurer’ssettlementofthe

claim.Therefore,iftheinsurerweretosettletheclaim

onacash-in-lieubasis inthesumofR14500.00,this

wouldhaveamountedtotheinsuredmakingaprofit

fromthe lossand theofferwould falloutsideof the

scopeofashort-terminsurancecontract.

The policy wording which the insurer relied on to

substantiateitsofferofsettlementprovidedthat:

“Need to claimWe have the choice to settle your claim in any of the

following ways:

• Paying out cash to you.

• Repairing the damage at a repairer of our choice.

• Replacing the item at a supplier of our choice.

• Any combination of the above.

What’s it worth The insured value that’s noted on your policy schedule is

the maximum amount that we’ll pay for any claim, less

the excess amounts payable by you, and less any dual

insurance and under-insurance.”

Itwaspointedout to the insured that,whendealing

with contents items, which depreciate in value due

to use and rapidly changing technology, it becomes

difficultforaninsurertoplacetheinsuredbackinthe

samefinancialposition.Consequently,anextensionof

the indemnityprinciple is thatwhere therisk item is

insuredfor itsreplacementvalue,the insurer isthen

permitted to replace the lost used item with a new

itemwhichissimilartotheitemwhichwasoncover.

It was not in dispute that the replacement phone, which

the insurer sought to provide to the insured, was a

newer and more modern phone than the one that was

oncover.Therefore,theinsuredwasadvisedthatthe

insurer’soffertoreplacetheSamsungS7Edgewitha

SamsungS8Galaxydidamounttoindemnificationon

thepartoftheinsurer.

Theinsurerthenofferedtosettletheclaimonacash-

in-lieu basis in accordance with the policy wording,

which granted the insurer the right to decide the

mannerinwhichtheinsuredwastobeindemnifiedin

theeventofaloss.

Inconclusion,OSTIheldthattheinsurerhadsuccessfully

proven that,onabalanceofprobabilities, itsofferof

settlementwasfairandreasonableandinaccordance

withitsobligationstoindemnifytheinsuredassetoutin

thepolicywording.Arecommendationwasaccordingly

madetotheinsuredtoaccepttheinsurer’soffer.

Darpana HarkisonSenior Assistant Ombudsman


InOctober2018,OSTIembarkedonanewproject in

the office’s case resolution department. This project

came about aftermuch internal deliberation aswell

as research of international ombud schemes that

workonasimilarmodeltotheoffice’smodel.Having

analysed all the pros and cons, it became clear that

there was a need to try this new way of resolving

complaints,especiallysinceboththeinsurermembers

andcomplainantswouldbenefitfromit.

The Fast Track Department, colloquially and within

the office called “the Trackies”, was established

and the fast track process was implemented. The

department, consistingofassistantombudsmenand

case administrators, is tasked with effectively and

efficiently profiling every personal lines complaint

thatisregisteredbytheoffice.Acomplaintisprofiled

to determine whether or not it is capable of being

resolvedearlyinthedisputeresolutionprocess.

Oncea complaint is identifiedaseasily resolvable, a

decision ismade and the complaint is resolved. The

party against whom the decision has beenmade is,

however, given an opportunity to disagree with the

decision and to provide additional information in

substantiationof itsdisagreement. If thearguments

raisedbythispartyrequirefurtherinvestigation,then

the case is transferred to the Standard Complaints

HandlingDepartment.

An important and essential element that is required,

toenabletheTrackiestoprofileacomplaintaseasily

resolvable,isthequalityoftheinsurers’firstresponses

tothecomplaints.Thequalityandcomprehensiveness

of an insurer’sfirst answer is crucial to thisprocess.

Without quality and comprehensive responses,

togetherwithalltheevidencereliedonbytheinsurers,

complaints cannot be resolved early in the dispute

resolutionprocess.

Due to the volume of new complaints and the strict

timeframessetfortheTrackiesteam,thereisnotime

to request further information fromthe insurer, if it is

not included in the first response. The result of the

insurernotprovidingalltheinformationupfrontisthata

complaint,whichcouldhavebeenresolvedatthisstage,

cannotberesolvedandmustbereferredtotheStandard

ComplaintsHandlingDepartmentforresolution.

The statistics show that the decision to implement

a fast track process was justified. The fast track

departmentcontributedtoresolving36%ofthetotal

complaintsresolvedbyOSTIin2019.Theaveragetime

takentoresolvethesedisputeswas50calendardays.

Earlierthisyear,allofthesenioradjudicatorsacquired

accreditationasmediators.Mediationisanalternative

wayofresolvingdisputesand,goingforward,thefast

trackteamwillfocusmoreonimplementingamediation

processthatissuitabletoOSTI’senvironment.

Mediationearlyinthedisputeresolutionprocesstends

tobemoreeffectivethanlaterintheprocess,whenthe

parties’ stances have become more entrenched and

thepartiesbecomelesslikelytoagreetoanegotiated

outcome.

The Fast Track Department is also well-positioned

through its profiling capabilities to identify those

matterssuitedtoresolutionbymediation.

Hannes Bester Assistant Ombudsman and Team Leader of the Fast Track Department

Hannes Bester Assistant Ombudsman and Team Leader of the Fast Track Department

the fast track process

OSTI is an independent and impartial, non-profitindustryombud-scheme.Theofficedoesnotrepresenteither party in a complaint. Instead, the office actsindependentlyandimpartially.OSTIcannotinvestigateor gatherevidenceonbehalfof complainants. Itwilltherefore not contact service providers or obtainexpertreports.

Thegeneralexpectationofalmosteverycomplainantin our office is that, because they are paying theirpremiums, their claims, which are true and honest, shouldbehonouredbytheinsurers.

Asastartingpoint, inorderforan insuredtohaveavalid complaint against the insurer, the insured isrequiredtodemonstratethatshe/hehasavalidclaimin terms of the insurance policy. This means thatthe insured carries the primary burden of provingthat the loss or damage claimed for falls within thescopeofcoverprovidedbythepolicy.Inotherwords,the insured isrequirednotonly toallegebutalso toprove the claim which involves the presentation ofsubstantiveevidence.

The onus is on complainants to provide OSTI with the evidenceonwhichtheyrelytosupporttheirmatters.

Theoutcomeofacomplaintisdeterminedbyweighingtheversionofeventsonabalancingscaleoffairnessandreasonablenesstoestablishwhatismorelikelyorprobable.Thisexercise iscalleddecidingacaseona“balance of probabilities” and refers to the standardtestusedwhendecidingcivildisputes.

Asanombudschemeouraimistoprovideaninformaland easily approachable forum for the resolution ofdisputes whilst using alternative dispute resolutionmethods. This encompasses the use of a range ofdifferentandflexibletechniquesthatpromoteaccessto free, effective and efficient dispute resolutionmechanisms.Theideaofalternativedisputeresolution,or“ADR”,istoprovideabridgebetweennoredressatall,andcostlyandcomplicatedcourtprocedures.

OSTI’s approach is to apply flexible standards andprinciplessuchasequity,fairnessandreasonablenessto the particular circumstances of every individualcomplaint. This enables us to consider each matteron its ownmerits rather than by simply and strictly

OSTI’s interns on OSTI’s role in resolving disputes

applying the law. OSTI is mandated in its terms ofreference to resolve complaints using the criteria oflaw,andwhereappropriate,equityandfairness.

Ourofficecannotgivelegaladvicetothepartiesabouta specific complaint as this would compromise itsability to act independently in resolving the dispute.OSTI is not a court of law and therefore does notconductformalhearingsinthesamewayacourtdoes.

Complainantsarenotboundbyourdecisionsandourdecisions are only binding on the insurers. If eitherthecomplainantorinsurerisunhappywithadecisionby OSTI, the complainant or insurer has the optionof escalating the matter in terms of our escalationprocess,whichcanbefoundonourwebsiteundertheheading“ComplaintsHandlingProcess”.

As OSTI is an alternative to the court system, it iseasilyapproachable,hasamoreflexibleprocessandisinexpensiveforcomplainants.Moreoftenthannotweare able to resolvematters to the satisfactionofbothparties.Theforumgivesbothpartiesachancetopresenttheircaseandtelltheirstorywhichmitigatesagainsttheescalationoftheconflict.

When policyholders submit claims to insurers theyexpect insurers to finalise their claims as soon aspossible.Complainantshavethesameexpectationofourofficewhentheylodgetheircomplaints.

Whilst OSTI has an effective complaints handlingprocess, this can be impacted by the quality of andspeed at which information and documentation isprovided by a complainant. Complainants thereforehave a significant role to play in the processing andfinalisationoftheircomplaints.

The cooperation of the insurer also has a bearingon the time it takes to resolve a complaint againstit. Insurers, like complaints, are required to provideevidence to support their stances and defences oneachmatter.

In circumstances where the insurer avoids liabilitybecause of an exclusion or exception in the policy,thedutytoprovetheexclusionorexceptionlieswiththe insurer. All three parties to a complaint, namelyOSTI, the insuredandthe insurer,playarole inhowefficientlycomplaintsareresolved.



Haroon Laher

Richard Steyn

Viviene Pearson

Makgompi Raphasha

Collin Molepe

Gail Walters

board of directors

Gerhard Genis

Magauta Mphahlele

Paul Crankshaw

Leigh Bennie

Thuli Zungu


staff of the ombudsman

Ombudsman Retired Judge Ron McLaren

Chief Executive OfficerEdite Teixeira-Mckinon

General ManagerMiriam Matabane

Senior Assistant OmbudsmanAyanda MazwiDarpana HarkisonPeter NkhunaThasnim Dawood

Office ManagerAzeht Du Plessis

Assistant OmbudsmanAbri VenterHannes BesterJohan Janse van RensburgJohn TheunissenKgomotso MolepoNadia GamieldienRegina ChindomuSangeetha SewpersadValerie MngadiZuleckha Cara

Junior Assistant OmbudsmanLatoya Masango

Assistant to the Ombudsman and Chief Executive OfficerJanine Jacobs

Project CoordinatorMarilize Blignaut

Complaints Registration ManagerKarinien Kok

Complaints Registration AdministratorsGadija FisherMaureen NelRefilwe Mokoena

Complaints Transfer ManagerJo-Anne Goqo

Complaints Transfer AdministratorMary TshabalalaMelissa van Zyl

Case AdministratorsAadielah SolimanClaudia KampmannJoanne SergelLouisa GodspowerSelinah ZwaneVantera Freemantle

ReceptionistLebohang Morokolo

ClericalMavis Mabaso

Clerical Assistant/CleanerMariam Khampepe


terms of reference

1. Preamble1.1 TheOmbudsmanisappointedtoservetheinterest

of the insuringpublic andall short-term Insurersregistered under the Short-term Insurance Actand including Lloyds. The Ombudsman provides,freeofcharge,anaccessible,informalandspeedydispute resolutionprocess to PolicyHolderswhohave disputes with their Insurers where those disputesfallwithintheOmbudsman’sjurisdiction.

1.2 The Ombudsman acts independently andobjectively in resolvingdisputesand isnotunderinstructions fromanybodywhenexercisinghisorherauthority.TheOmbudsmanresolvesdisputesusingthecriteriaoflaw,equityandfairness.TheseTermsofReferencedefinethepowersanddutiesoftheOmbudsman.

1.3 The services rendered by the Ombudsman arenotthesameasthoserenderedbyaprofessionallegaladvisorandareconfinedpurelytoresolutionin terms of clause 3.1 below or mediation orconciliationinanattempttosettlecomplaints.

2. DefinitionsIn these termsof reference the followingexpressionshavethefollowingmeanings:2.1 “the Board”means the Board of Directors of the

OmbudsmanforShort-termInsuranceNPC;2.2 “CommercialLinesPolicy”meansapolicy(a)issued

toapersonwho isnotanaturalperson,or (b) ifissuedtoanaturalpersonisintendedtoindemnifysuchanaturalperson inrespectofacommercialenterpriseconductedbythenaturalpersonforhisorherownbenefit.

2.3 “the Complainant” means any Policy Holder whomakesacomplainttotheOmbudsmaninrespectofanyinsuranceservicesprovidedbytheirInsurer;

2.4 “Ruling” means, with respect to a complaint, awrittendirectiveissuedbytheOmbudsmanwhichisbindingontheInsurerandwhichisbasedeitherinlaworequity;

2.5 “the Ombudsman” means the Ombudsman forShort-termInsuranceappointedfromtimetotimeby the Board of the Ombudsman for Short-termInsuranceNPC;

2.6 “Ombudsman’s office” means the office of theOmbudsmanestablishedtoperformthefunctionssetoutinthesetermsofreference;

2.7 “Policy”meansashortterminsurancePolicyissuedbyanInsurertoaPolicyHolder;

2.8 “Policy Holder” means the person entitled to beprovidedwiththePolicybenefitsunderaPolicy;

2.9 “Insurer”meansashort-terminsurerregisteredassuch in termsof the Short-term InsuranceAct of1998;

3. The Ombudsman’s Powers and Duties3.1 TheOmbudsmanshall:

3.1.1 actwithinthesetermsofreference;3.1.2 receive complaints relating to the provision

within the Republic of South Africa ofinsurance services by an Insurer to a PolicyHolder;

3.1.3 resolve such complaints, relating to theprovisionofinsuranceservices,byagreementorbythemakingofarulingorbysuchothermeans as may seem expedient, subject tothesetermsofreference.

3.2 The Ombudsman should advise the public onthe procedure for making a complaint to theOmbudsman’s office and should take such stepsasarereasonablypossibleconducivetoclientandindustryeducationandtraining.TheOmbudsmanshallinhisannualreportreferredtoinclause3.9belowprovidedetailsofstepstakeninthisregard.

3.3 Onreceiptofacomplaintintheprescribedformat,the Ombudsman will notify the Insurer of thecomplaintbyprovidingthedetailsofthecomplainttotheInsurer,andtheInsurershallthenbeobligedto give all relevant information and assistancerequired (including documentation requested bythe Ombudsman) to enable the Ombudsman toassessfullythemeritsofthecomplaint.

3.4 During any period in which the Ombudsman isunable to exercise his duties owing to absence,incapacityordeathorinasituationwhereaconflictof interest may arise, the Board may appoint adeputyoractingOmbudsmantoactinplaceoftheOmbudsman.

3.5 The Ombudsman shall have the overallresponsibility for the conduct of the day to dayadministrationandbusinessoftheOmbudsman’soffice. The Ombudsman may appoint anAdministratortoberesponsibletohimfordaytodaymattersofadministrationoftheOmbudsman’soffice.

3.6 TheOmbudsmanshallhave thepoweronbehalfoftheOmbudsman’sofficetoappointanddismissemployees,consultants,legalexperts,independentcontractors and agents and to determine theirsalaries,fees,termsofemploymentorengagement.

3.7 The Ombudsman shall have the power to incurexpenditureonbehalfoftheOmbudsman’sofficein accordance with the current financial budgetapprovedbytheBoard.

3.8 The Ombudsman shall give the Board anyinformation and assistance which it reasonablyrequires,includingthemakingofrecommendationstotheBoardonanyissueswhichtheOmbudsmanbelievesrequirestheBoard’sattention.


3.9 TheOmbudsmanshallpublishanannualreportontheactivitiesoftheoffice,whichshallbepublishedby30Mayofeachyear.Suchreportwillbeavailabletothepublic.

4. The Jurisdiction of the Ombudsman4.1 TheOmbudsman shall only consider a complaint

madetohimifheissatisfiedthat:4.1.1 the complaint is not the subject of existing

litigation;4.1.2 the complaint is not the subject of an

instructiontoanattorneyincontemplationoflitigation against the relevant Insurer exceptwhere the attorney has simply assisted thePolicyHolderinbringingtheapplicationtotheOmbudsman;

4.1.3 the complaint does not involve amonetaryclaim in excess of the amount determinedby the Board from time to time and that inrespect of Commercial Lines Policies theannualturnoveroftheComplainantdoesnotexceedtheamountdeterminedbytheBoardfromtimetotime.*

*The limits are currently as follows namely, (a) R4 million for house owner’s claims; (b) R2 million for all other claims provided that (c) in respect of Commercial lines policies, the turnover of the insured entity must not exceed R25 million per annum

4.1.4 the complaint ismadebyaPolicyHolderoradulyauthorisedrepresentativeofthePolicyHolder towhomor forwhom the insuranceservicesinquestionwereprovided;

4.1.5 the complaint relates to any dispute inregard to a Policy and/or any Claim orClaims thereunder or any dispute in regardto insurance premiums, or any dispute onthe legal construction of the Policy wordingrelating to a particular complaint complyingwiththerequirementsofthisclause4.1;

4.1.6 the complaint is being pursued reasonablyby the Complainant and not in a frivolous,vexatious, offensive, threatening or abusivemanner, as the Ombudsmanmay decide inhisorhersolediscretion;

4.1.7 the complaint has not become prescribedintermsofthePrescriptionAct,1969oranyenforceable time bar provisions containedinthePolicy,providedthatinrelationtoanyenforceabletime-barprovisionsinthepolicy4.1.7.1 theOmbudsmanshallhavethepower

to condone non-compliance therewith upongoodcauseshown,and

4.1.7.2 the provisions of any enactmentwhich provides for the extension ofanyperiodcontainedinsuchtime-barprovisionshallbegiveneffectto.

4.2 ShouldacomplaintbelodgedwiththeOmbudsman’sofficeandthereaftertheComplainantreferssuchdispute toanattorney for the further conductofthedisputeand/ordirectcorrespondencewiththeInsurer,orforlitigation,thentheOmbudsmanwillimmediatelywithdrawfromthematter.

4.3 With thewrittenconsentofan Insurerandathisdiscretion the Ombudsman may investigate acomplaintwhichexceedshisjurisdictionandmakearecommendationoraRulinginrelationthereto.

4.4 A Complainant may at any time terminate theOmbudsman’s adjudication of the complaint andresorttolitigation.

5. Limits on the Jurisdiction of the Ombudsman Subject to thesetermsofreference, theOmbudsman

shall have the power to consider a complaint made to himandmakearecommendationorRuling inregardthereto except:5.1 WheretheOmbudsmandeterminesthatitismore

appropriatethatthecomplaintbedealtwithbyacourtoflaworthroughanyotherdisputeresolutionprocess;

5.2 Wherethematterisalreadyundertheconsiderationbythepersonappointedtoadjudicatedisputesinterms of the Financial Advisory and IntermediaryServicesAct.

6. Time Barring Provisions6.1 Any enforceable time bar clauses in terms of a

PolicyshallnotrunagainstaComplainantandshallbeinterruptedduringtheperiodthatthecomplaintisunderconsiderationbeforetheOmbudsman.Inparticular, the Insurer waives and abandons all or any rights to rely in subsequent litigation on anytime barring provisions in the Policy applying tothecommencementof litigationafter rejectionofaclaim,orafterthehappeningformingthesubjectoftheclaimorafternotificationoftheclaim.IntheeventofthecomplaintbeingfinalisedintheofficeoftheOmbudsmantheComplainantshallhave30(thirty) days or the remaining period of the timebar provision of the relevant policy, whichever isthe longer, within which to institute proceedingsagainst the relevant Insurer, provided however,thattheClaimhadnotalreadybecometimebarredin terms of the Policy when the complaint wasreceivedbytheOmbudsmanandtheOmbudsmanhasnotcondonedthelatereceiptofthecomplaintasisenvisagedinclause4.1.7

6.2 For the purposes of clause 6.1, the time duringwhich a matter is before the Ombudsman shall(provided that the complaint is accepted foradjudication)commenceonthedaythatitislodgedwiththeOmbudsman’sofficetothetimethattheOmbudsmandismissesthecomplaintormakesaRuling.

6.3 SaveasmaybeotherwiseprovidedintheFinancialServices Ombud Schemes Act 37 of 2004 asamendedor inanyotherlegislationrelatingtoorgoverning the Ombudsman, the lodging of anycomplaint with the Ombudsman shall in no wayaffect the runningofprescription in termsof thePrescriptionAct,1969inrespectofsuchcomplaint.

7. Rulings7.1 When all the material facts are agreed or the

factshavebeenestablishedto theOmbudsman’ssatisfaction on a balance of probabilities, theOmbudsmanmaymakeaRuling.


7.2 Rulingsshallbebasedonthelawandequity.7.3 Where a material fact cannot be established

or cannot be resolved on a clear balance ofprobabilities the Ombudsman may not make aRuling.InsuchcasestheOmbudsmanshalladvisethe Complainant that the complaint is not one on which he or she can assist and that alternative recoursemaybesoughtthroughthecourts.

7.4 Any Ruling made by the Ombudsman shall bebinding on the Insurer concerned savewhere anappealagainstsuchRulingisnotedasisprovidedinClause8below.

8. Right of Appeal against Rulings or Findings of the Ombudsman8.1 Anypartyaffectedbyanyformalrulingorfinding

on the part of the Ombudsman may appealagainst the ruling or finding of theOmbudsman,eitherinpartorinwhole.Inthiscontexta“Ruling”shall mean, in relation to a complaint received, “a writtendirectiveissuedbytheOmbudsmanwhichisbindingontheinsurerandwhichisbasedeitherin laworequityand fairnessoracombinationoflawandequity”.“Finding”shallmean,withrespectto a complaint, “awritten directive issued by theOmbudsman in relation to the complaint received intermsofwhichtheOmbudsmanhasdismissedthe complaint or declined to intervene in a dispute betweenthecomplainantandinsurer”.

8.2 No appeal against the ruling or finding of theOmbudsman shall be considered by any AppealTribunal, unless the Ombudsman shall have grantedtheapplicantleavetoappealagainstsuchrulingorfinding.

8.3 TheOmbudsmanshallonlygrant leavetoappealtoanyappellantwhereheisoftheopinionthat:8.3.1Thereisareasonableprospectthattheappeal,

either inwholeor inpart, ifprosecuted,willsucceed;and

8.3.2 Thematter isoneofcomplexityordifficulty;or

8.3.3 Therulingorfindinginquestioninvolvesissuesor considerations which are of substantialpublic or industry interest or importance orIt is in the interestof justiceorpublicpolicythattherulingordecisionbeconsideredbyanAppealTribunal;or

8.3.4 The ruling or decision involves principles oflawwhere the lawmaybe considered tobeuncertainorunsettled;or

8.3.5 ThematterindisputeinvolvesthejurisdictionoftheOmbudsmantoentertainthedispute;or

8.3.6 The issues are of such a nature that thejudgment or order sought by the appellantwillnotbeofacademicrelevanceonlyandwillhaveapracticaleffectorresult.

8.4 Thepowertograntleavetoappealascontemplatedinthissectionshallnotbelimitedbyreasononlyofthevalueofthematterindispute,ortheamountclaimed or awarded by the Ombudsman, or byreasononlyofthefactthatthematterindisputeisincapableofbeingvaluedinmoney.

8.5 NoticeofanyintentiontoappealagainstanyrulingorfindingoftheOmbudsmanshallbefiledwiththeOmbudsmanwithinaperiodof30 calendardaysof thehandingdownofanyrulingorfindingandshall statewhether theappellant appealsagainstthe whole or part of the ruling or finding of theOmbudsman,thefindingsof factand/orrulingoflawappealedagainstandthegroundsuponwhichtheappeal is founded. Thenoticeof intentiontoappealshallbeaccompaniedbyanapplicationforleavetoappeal.

8.6 ANoticeofCross-Appealshallbedeliveredwithin15 calendar days after delivery of the Notice ofAppeal, or within such other period of time asmay, upon good cause shown, be permitted bythe Ombudsman. The provisions of these ruleswithregardtoappealsshallequallyapplytocross-appeals.A“cross-appeal”shallmeanaprocessbywhich therespondent inanyappealproceedings,having been advised by the Ombudsman ofreceiptofanoticeofintentiontoappeal,wishesinturn to appeal against the terms of the ruling orfindingmadebytheOmbudsmaninrelationtothecomplaintsubmittedtotheOmbudsman.

8.7 Whereanappealhasbeennoted,oranapplicationforleavetoappealhasbeenmade,theoperationand execution of the ruling or finding of theOmbudsman shall be suspended, pending thedecision of the Appeal Tribunal on the matter,unless the Ombudsman, on the application of apartyandongoodcauseshown,otherwisedirects.

8.8 UponreceiptofaNoticeofAppealtheOmbudsmanshallwithinaperiodof5businessdaysthereafternotifyeveryotherpartytothedisputethataNoticeofAppealhasbeenreceived.

8.9 All documentation in connectionwith any appealproceedings including the notice of intention toappeal and the application for leave to appeal,shallbeservedupontheofficeoftheOmbudsmanbyhandoralternativelybywayofregisteredpostor by e-mail save where the Ombudsman shallhave expressly consented to any other methodof service. Documentation served upon theOmbudsman shall be in A4 format and shall beclearly legible and capableof beingphotocopied.Wherever possible, original documents shouldform the subject of any appeal proceedings butcopiesofdocumentsshallbeacceptablesubjecttotheprovisionsofthesetermsofreference.

Applications for Leave to Appeal8.10Any party who desires to appeal against any

rulingorfindingoftheOmbudsmanshall,within30 calendar days of the handing down by theOmbudsmanof anyfinal rulingor finding, serveupon the Ombudsman as provided for herein,a Notice of intention to Appeal, together withan Application for Leave to Appeal which shallset out the basis for the proposed appeal ascontemplated inClause8.5above, togetherwithreasonswhyLeavetoAppealagainstsuchrulingorfindingshouldbegrantedbytheOmbudsman.The granting of leave to appeal shall be a pre-requisitefortheprosecutionofanyappeal.

8.11Failing receiptby theOmbudsmanofanyNotice


of Appeal within the time period referred to inparagraph8above, thefinal rulingorfindingbytheOmbudsman shall becomefinal andbindingupon theparties and shall be carried into effectwithoutfurtherdelay.

8.12Any late filing of a Notice of Appeal or anApplication forLeavetoAppealshallbenullandvoid savewhere accompanied by an applicationfor condonation for the late filing of the appeal.Any application for condonation must set outin full the reasons why condonation should begranted,thereasonsforanynon-complianceandthatthematterisoneworthyofconsideration.

8.13The Ombudsman, after considering anyapplicationforcondonation,maygrantorrefusesuchapplicationinhisdiscretion.

8.14WhereleavetoappealagainstanyrulingorfindingoftheOmbudsmanisrefusedbytheOmbudsman,the unsuccessful party may, within 15 businessdays of notification of such refusal, petition theChairman of the Appeal Tribunal, to review thedecisionoftheOmbudsmannottograntleaveforappeal. The same provision shall apply mutatIsmutandis to any application for condonation forthelatefilingofanappeal.

8.15Any such request shall be addressed to theChairman of the Appeal Tribunal via theOmbudsmanwhoshallconveysuchrequesttotheChairman of the Appeal Tribunal. The Chairmanof the Appeal Tribunal shallwithin a reasonableperiod of time but in any event not later thana period of 15 calendar days of the receipt ofany such petition, either confirm or amend thedecision of the Ombudsman not to grant leaveto appeal or refusal to condone any applicationfor the latefilingofanappeal.TheOmbudsmanshallthereafterwithinaperiodof5businessdays,informthepartiesaccordingly.

Appeals8.16An appeal against the ruling or finding of the

OmbudsmanshallbeheardbyanAppealTribunalwho shall consider the matter as if it were theOmbudsman and shall include the consideration of procedural as well as substantive matterspertainingtotheobjectionraisedbysuchpartytothedecisionoftheOmbudsman.

8.17The Appeal Tribunal may, where it considers itnecessary or in the interests of justice, permitthe leadingof evidenceor newevidenceon anymatter, even if theOmbudsmanhimself did notholdahearing,orreceiveevidenceonanymatterpriortomakingafindingonanycomplaintreferredtohim.

8.18Where theAppealTribunaldecides topermit,orcalls for the leading of evidence, or evidence isledonmaterialthatwasneverconsideredbytheOmbudsman,thetribunalmaydecide, in itssolediscretion to invite the Ombudsman to consider the matter in the light of such evidence and tocanvass the views of the Ombudsman on thematter. The Ombudsman should be invited tocomment on the new material in the manner and onsuchtermsasitmayregardtobefairtobothparties.

8.19Savewhere the Appeal Tribunal permits or callsfor the leadingofevidence,noevidenceshallbeledandthemattershallbedecidedbytheAppealTribunal on the basis of the record of appealfurnishedtoitbytheOmbudsman,includingthedocumentationfiledbytheparties inconnectionwiththeappeal.

8.20Therecordofappealshall,savewhereintheopinionof theOmbudsman additional documentation isrequired,consistofthefollowing:-8.20.1Thecomplainant’sApplicationforAssistance

formandsupportingdocumentation;8.20.2 Theinsurer’sresponsetothecomplaint;8.20.3 The complainant’s reply to the insurer’s

responsetothecomplaint;8.20.4 TheOmbudsman’sfindinginrelationtothe

complaint and any reasons furnished bytheOmbudsmanforanyrulingorfinding;and

8.20.5 Thesubmissionsorrepresentationsmadeby the parties to the Appeal Tribunal inconnectionwiththeappeal.

8.21The Ombudsman may, in his discretion, whensubmitting the documentation to the AppealTribunal in connection with any appeal, makerepresentations to the Appeal Tribunal by wayof explanation or elaboration of his earlierdetermination and shall be entitled in such representations to deal with such matters as policy, industry practices and the approachfollowed by him in regard to equity. In additiontheOmbudsmanmayfurnishtheAppealTribunalwith suchother informationashemay considerto be of assistance or guidance to the AppealTribunal, save that the parties shallbeaffordedanopportunitytorespondtoanysuchadditionalmaterialthusplacedbeforetheAppealTribunal.

8.22Save as aforesaid, the Ombudsman shall notparticipate in the appeal process save where he shouldbeaskedtodosobytheAppealTribunalitselfonsuchtermsandinsuchmannerasmaybedeterminedbytheTribunal.

Composition of the Appeal Tribunal8.23TheChairmanof theBoard, in consultationwith

theVice-Chairman,mustappointthemembersoftheAppealTribunalfromthepersonsnominatedbytheOmbudsman.

8.24TheAppealTribunalmustconsistofaChairpersonand at least two members appointed for aminimumperiodoftwoyears.

8.25The Chairman of the Board must appoint theChairperson of the Appeal Tribunal and suchChairpersonmust either be a retired Judge or apracticingAttorneyorAdvocate,orapersonwhoformallypracticedasanAttorneyorAdvocate,withatleasttenyears’experienceandwithappropriateexperienceinInsuranceLaw.

8.26The Chairperson of the Appeal Tribunal isresponsibleforassigningmattersforadjudication,takingintoconsiderationthenatureandcomplexityof the dispute or any special circumstance, to apanel of two or more members of the Appeal


Tribunalwhoaresuitablyqualifiedtodecideonaparticularmatter.

8.27TheChairmanofthepanelmustbetheChairpersonoftheAppealTribunal.

8.28Theperson’snominatedbytheOmbudsmanmustbe:8.28.1 Practicing Attorneys or Advocates or

persons who formerly practiced as anAttorney or Advocate, with at least tenyears’ experience and with appropriateexperience in Insurance Law, and mayincluderetiredJudges;or

8.28.2 Persons with extensive experience inrelation to the insurance industry andwhobyvirtueoftheirknowledge,trainingand experience are able to perform thefunctions of a member of the AppealTribunal;or

8.28.3 Academics with the particular knowledgeof specific areasof the laworpersonsofspecificknowledge,skillortrainingwhoseexpertise as an expert in any particularfieldmaybeappropriate.

8.29The Chairman of the Appeal Tribunal may, inconsultationwiththeChairmanoftheBoardandthe Ombudsman, appoint a person who is not a member of the Appeal Tribunal to serve on thepanel if in theopinionof theChairpersonof theAppeal Tribunal such appointment is merited or deemeddesirable.

The Hearing of Appeals8.30TheOmbudsmanshallbeinchargeofallpractical

oradministrativemattersprecedingandrelatingtothehearingofanappealandshallberesponsiblefor the preparation of the record, the giving ofnoticesand themakingof arrangements for thehearing of an appeal, the recording of evidence,ifany,andallsuchothermattersincidentaltothehearingordisposaloftheappeal.

8.31The Appeal Tribunal shall determine its ownprocedurebothpriortoandduringthecourseofthehearing,includingthehearingoforalevidence.

8.32Appeals shall be heard at such place and timeand in such manner as the Appeal Tribunal shall determinefromtimetotime.

8.33Notlaterthan10businessdaysbeforethehearingof an appeal, the appellant shall deliver to theOmbudsman a concise and succinct statement ofthemainpointswhichhe intendstoargueonappeal, as well as the list of legal authorities (ifany)tobetenderedinsupportofeachpointtoberaised.Notlaterthan5businessdaysbeforethehearingofanappeal,therespondentshalldeliverasimilarstatement.

8.34The Chairman of the Appeal Tribunalmay, afterconsultation with the Ombudsman, direct that a contemplatedappeal bedealtwith as anurgent

matter and that the appeal be prosecuted at such timeandinsuchmannerastheChairmanoftheAppealTribunaldeemsappropriate.

8.35TheAppealTribunalshouldapproachthematteronappealputforwardasifitweretheOmbudsmandetermining the complaint. The Appeal Tribunalshalltakeintoaccountthebalanceofprobabilitiesanditsfindingshallbebasedonthecriteriaoflaw,equityandfairness.

8.36TheAppealTribunalshalldeliveritsjudgmentonthematter in writing to theOmbudsmanwithinone calendar month of the conclusion of thehearing. TheOmbudsman shall in turn deliver acopy thereof to thepartieswithinaperiodof10businessdays.

Representation8.37Anypartytoanyappealshallhavetherighttobe

representedatthehearingbut,whereverpossible,the parties should confine their submissions inregard tomatters before the Appeal Tribunal towritten submissions contained in a statement of case including, where appropriate, heads ofargument.

8.38Any party who employs a representative torepresenttheirinterestbeforetheAppealTribunalshall be personally responsible for any fees andexpensesassociatedwithsuchrepresentation.

The Effect of the Decision and Order of the Appeal Tribunal8.39Where a complainant appeals against the ruling

orfindingof theOmbudsman,suchpersonshallabidebythedecisionoftheAppealTribunalandtheorderoftheAppealTribunalshallbefinalandbindinginrelationtotheproceedingsbeforetheofficeoftheOmbudsman.Thecomplainantshallhowever be entitled, if so desired, to thereafterpursuethematterfurtherinanycourtoflaw.

8.40An unsuccessful appellant insurer shall have nofurther right of recourse or action and shall bebound by the terms of the order of the AppealTribunalsavethatnothingcontainedhereinshallinanywayaffecttherightofaninsurertoreviewanyrulingmadebytheOmbudsmanortheAppealTribunalinacourtoflaw.

Precedent8.41In recognition of the requirement that rulings

made by the Ombudsman shall not establishany precedent in the Ombudsman’s office, thedecisions of the Appeal Tribunal shall not beaccordedanyformalstatusorregardedascreatingbindingprecedents, butmay serve as guidelinesfor future cases. Such findings or orders mayhowever, serve as strong persuasive value fortheOmbudsman and any other Appeal TribunalinwhichthesamedisputemayberaisedsoastoensureconsistencyinthedecisionsoftheofficeoftheOmbudsman.


Cost to the Parties to Appeals8.42Where an insurer notes an appeal against any

finalrulingoftheOmbudsmanandisnot, intheopinionof theChairmanof theAppeal Tribunal,successful with such appeal, it shall defray thecostofsuchappealincurredbytheOmbudsmaninconnectionwiththeappealproceedings.

8.43Where the insurer is the appellant in anyproceedings, save where the Chairman of theAppealTribunalmaydirectotherwise,thecosttobe paid by the insurer in relation to any appealproceedingsmaybedeterminedbytheBoardoftheOmbudsman for Short-term Insurance, fromtimetotime.

8.44Where the complainant is the appellant in anyappealproceedings theOmbudsmanmay, inhisdiscretionand taking intoaccount, interalia, theamountoftheclaim,thecomplexityoftheissuesand the complainant’s personal circumstances, calluponsuchpartytopayadepositinanamountdeterminedbytheOmbudsmanwhichdepositshallberefundedtotheappellantshouldtheappellantbesuccessfulintheappeal.Intheeventthattheappeal fails, thedeposit shallbe forfeited to theofficeoftheOmbudsmanandshallconstitutetheonlyliabilityonthepartofthecomplainantforthecostsof theappealproceedings. If theappeal is,intheviewoftheAppealTribunal,successful,theamountpaidbytheappellantshallberefundedtotheappellant.

8.45Innocaseshall theAppealTribunalawardcostsinfavourofasuccessfulpartyandinnocaseshalla losing party to an appeal be ordered by theAppeal Tribunal to pay costs to the other party,savewheretheChairmanof theAppealTribunalconsiders that, having regard to thepresenceofexceptional circumstances, a punitive order as to costsagainstanypartyismerited.

9. Policyholder/Complainant’s RightsThe Policy Holder/Complainant’s rights to instituteproceedings in any competent court of law against theInsurer shall not be affected by any of the provisionsof these terms of reference provided that, if the PolicyHolder/Complainant institutes proceedings while thecomplaintisunderinvestigationbytheOmbudsman,theprovisionsofclause4.2shallapply.

10. PrecedentsRulings shall not establish any precedent in theOmbudsman’soffice.

11. Confidentiality(AsapprovedattheAnnualGeneralMeetingheldon28thJune2011)11.1TheOmbudsmanshallafaraspossible,maintain

confidentiality unless the parties concernedexpresslyexempthimorher fromthatdutyand

thedutyshallcontinueaftertheterminationofhisor her services. The duty of confidentiality shallhowever,notpreventtheOmbudsmanfrom:

11.1.1 Publishingdetailsofrulingsmadebyhimorher.

11.1.2 Reportingondetailsofrulingsorfurnishingstatisticalinformationinconnectionwiththeworkings of theoffice to the SouthAfricanInsurance Association (SAIA), the FinancialServicesBoard (FSB), theNationalTreasuryoranyotherbodyororganisationwhichmaybeentitledtoreceivesuchinformationfromtheOmbudsmaninconnectionwithhis/heractivitiesand/orwhichmayhavealegitimateinterest in such information, having regardtoitsstatutorymandate,roleasanindustryassociationorotherwise.

11.1.3 Publishingstatisticsandrelatedinformationin the Annual Report of the Associationconcerning complaints received by theOmbudsman against members of theAssociationasapprovedbytheBoardoftheOmbudsmanforShort-termInsurancefromtimetotime.

11.1.4 Filing, either onbehalf of theCompany, oranycomplainantfromwhomacomplaintisreceived, a complaint with SAIA in connection with any Code of Conduct applicable to oradopted by that organisation and whichmay be applicable to any member of theCompany.

11.2The Insurer and the Complainant shall not beentitled to make use of any information whichcomes to their knowledge as a result of theinterventionoftheOmbudsmanduringthecourseofanyinvestigationbyhimorher.

11.3A complaint will be regarded as confidential asbetween the Policy Holder, the Insurer and theOmbudsman and it is for the Ombudsman todecide what should be disclosed to the Insurer and/orthePolicyHolder.

11.4Documentsbrought intobeingasaresultofanyapproach to the Ombudsman shall not be liable to disclosureorbe thesubjectofadiscoveryorderorsubpoenaintheeventofanylegalproceedingsbetweentheComplainantandtheInsurer.

11.5TheOmbudsmanoranymemberofhisstaffwillnotbeliabletobesubpoenaedtogiveevidenceonthesubjectofacomplaintinanyproceedings.

12. Complaints not settled in defined periodThe Ombudsman shall report to the Board all complaints, which have not been completed in one or wayoranotherwithinatime,laiddownbytheBoard.This timeperiodshall initiallybesetat6 (six)monthscalculated from thedate that a complaintbecameanacceptedcomplaint.


members of the ombudsman scheme

Abacus Insurance Limited

Absa Insurance Company Limited

AIG Insurance Company

Alexander Forbes Insurance Company

Allianz Global Corporate

Auto & General Insurance Company

Bidvest Insurance Limited

Bryte Insurance Company Limited

Budget Insurance Company Limited

Centriq Insurance

Chubb Insurance South Africa Limited

Compass Insurance Company Limited

Constantia Insurance Company Limited

Dial Direct Insurance Limited

Discovery Insure

First for Women Insurance Company Limited

FirstRand Short-term

GENRIC Insurance Company Limited

Guardrisk Insurance Company Limited

Hollard Insurance Company

Hollard Specialist Insurance Limited

Indequity Specialised Insurance Limited

Infiniti Insurance Limited

King Price Insurance Company Limited

Legal Expenses Southern Africa Limited

Lion of Africa Insurance Company Limited

Lloyd’s South Africa (Pty) Limited

Lombard Insurance Limited

MiWay Insurance Limited

Momentum ST Insurance Company Limited

Monarch Insurance Company Limited

Mutual and Federal Risk Financing

Nedgroup Insurance Company Limited

New National Assurance Company Limited

NMS Insurance Services (SA) Limited

Oakhurst Insurance Company Limited

Old Mutual Insure Limited

OUTsurance Insurance Company Limited

Professional Provident Society Short-term Insurance Company Limited

Renasa Insurance Company Limited

SAFIRE Insurance Company Limited

SAHL Insurance Company Limited

Santam Limited

Santam Structured Insurance Limited

SASRIA SOC LIMITED

Shoprite Insurance Company Limited

Standard Insurance Limited

Sunderland Marine (Africa) Limited

Unitrans Insurance Limited

Vodacom Insurance Company Limited

Western National Insurance Limited

Workerslife Insurance Limited

Yarkrisk Insurance Limited


useful information about other offices

1. Ombudsman for Long-TermInsurancePrivateBagX45,Claremont7735Telephone:0216575000Sharecall:0860103236Fax:0216740951E-mail:[email protected]:www.ombud.co.za

2. Financial Advisory and Intermediary Services Ombud546JochemusStreet,ErasmusKloof,KasteelPark2ndFloorSharecall:0860324766Telephone:012470908/0127625000Fax:0123483447E-mail:[email protected]:www.faisombud.co.za

3. The Ombudsman for BankingServices34-36FrickerRoad,GroundFloor,Illovo,JohannesburgSharecall:0860800900Telephone:0117121800Fax:0114833212E-mail:[email protected]:www.obssa.co.za

4. Credit OmbudPOBox805,Pinegowrie,2123CallCentre:0861662837Tel:0117816431Fax:0866747414E-mail:[email protected]:www.creditombud.org.za

5. Motor Industry Ombudsman of South AfricaSuite156,PrivateBagX025,LynnwoodRidge,0040Telephone:0105908378CallCentre:0861164672Fax:0866306141E-mail:[email protected]:www.miosa.co.za

6. Consumer Goods and Services Ombud292SurreyAvenueFerndaleRandburg,2194Telephone:0117812607CallCentre:0860000272Fax:0862061999E-mail:[email protected]:www.cgso.org.za

7. Ombudsman Central HelplineSharecall:0860OMBUDS/0860662837

8. Pension Funds AdjudicatorPOBox580,Menlyn,0063Telephone:0123461738/0127484000Fax:0866937472E-mail:[email protected]:www.pfa.org.za

9. National Credit Regulator127,15thRoad,Randjespark,MidrandCallCentre:0860627627E-mail:[email protected]:0115542600/0115542700Fax:0872347822Website:www.ncr.org.za

10. Public ProtectorPrivateBagX677,Pretoria,0001Telephone:0123667000/0123367112Fax:0123623473Tollfreenumber:0800112040E-mail:[email protected]:www.publicprotect.org

11. Financial Sector Conduct Authority POBox35655,MenloPark,0102Toll-free:0800203772Telephone:0124288000Fax:0123466941E-mail:[email protected]:www.fsca.co.za

12. National ConsumerCommissionPrivateBagX84,Pretoria,0001Tel:0124287000Fax:0867584990E-mail:[email protected]:www.nccsa.org.za

13. City of Johannesburg Ombudsman48AmeshhoffStreet,BraamfonteinSappiBuildingCallCentre:0102882800Website:[email protected]

14. National Consumer TribunalTelephone:0126838140/0127429900Fax: 012 663 5693E-mail:[email protected]:PrivateBagX110,Centurion,0046

15. Office of the Tax OmbudMenlynCorner,2nd Floor,87FrikkieDeBeerStreet,Menlyn,Pretoria,0181Telephone:0124319105CallCentre:0800662837Fax:0124525013E-mail:[email protected]

16. S.A. Military Ombudsman PrivateBagX163,Pretoria0046Telephone:0126763800Tollfree:0807266283Fax : 012 661 2091E-mail:[email protected]

PostalAddress:POBox32334,Braamfontein,2017Tel:+27117268900| Fax:+27117265501| Sharecall:0860726890

Website:www.osti.co.za| E-mail:[email protected]:www.insuranceombudsmanportal.co.za

One Sturdee-1SturdeeAvenue,FirstFloor,BlockA,Rosebank,Johannesburg,2196