Ombudsman

Can your car insurance claim be rejected because you are a bad driver?

Can-your-car-insurance-claim-be-rejected-because-you-are-a-bad-driverHow does the quality of your driving affect your car insurance claim? On the roads it often becomes apparent that we are not equal – perhaps so when reflecting on Human Rights – but not so when it comes to driving ability!!

Fortunately for many vehicle owners the car insurers do not drive with them before issuing a car insurance policy. All that the car insurers have available to them is information as to driving experience, previous accident record and insight with regards to traffic violations. Much of these have to be disclosed by the vehicle owner and there is no measure of “Are you a good driver?”

We would like to reflect on the above question by referring to a decision from the Ombudsman. The question presented to the Ombudsman was whether the lack of due care – i.e. the failure to prevent the vehicle accident claim on account of poor driving – would justify the decision to reject the car insurance claim….

Onus on insurer to prove lack of due care

The Insured obtained her Driver’s Licence on 22nd July 2004 and eleven months later, i.e. on 17th June 2005 and at 08h00, she was on her way to work. Her inexperience in driving was manifested in that she drove too closely behind a truck, which in her words, “stopped abruptly” and to avoid a collision with the back of the truck, she decided to enter the intersection and collided with a vehicle travelling in the opposite direction which was turning right.

When the Insured entered the intersection, the traffic light had already turned red against her. The Insurer rejected the claim on the ground that the Insured failed to exercise due care and the action taken was in their view grossly negligent.

Ombudsman’s reponse

The Ombudsman referred the Insurer to the well-known case of Santam Limited versus CC Designing CC 1994 SA 199, and in the unreported judgement of Stax Masango and Lloyd’s of London, where it is stated that the onus is on the Insurer to prove that the Insured’s “conduct was such that the one would conclude that he recognised the dangers to which he was exposed and deliberately courted them by taking measures, which he himself knew were inadequate to avert them or about the adequacy of which he simply did not care, in the knowledge that he was insured”.

Under threat of a ruling the claim was settled.

[Source: Ombudsman's Briefcase Issue No. 02/2006]

Your car insurance claim would as a result not be fairly rejected simply because you are a bad driver. This will however have a significant effect on your car insurance premium if you are involved in several vehicle accidents. Not only will your premium increase sharply – but the car insurer could decide not to provide a specific high risk driver with car insurance cover!!

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Does your car warranty provide the required protection?

The Car Insurance Blog has warned vehicle owners against many of the dangers lurking in car insurance products – and the false promises from unscrupulous operators. We have also warned policyholders to be cautious of the fine printDoes your car warranty provide the required protection? in car insurance policies!

It is however not only car insurance companies that we need to approach with caution – there are other hazards to approach with caution as well. Too many fraudsters are trying to exploit the car insurance industry with the purpose of making a quick buck!!

Car Insurance warranties and a warning from the Ombud!

The process of gaining mobility and protection requires more than the mere purchase of a vehicle and a car insurance policy. There are also other links in this chain – and one of these includes the car warranty.
It is these warranties that have attracted the attention of the Ombudsman for Short Term Insurance. Concern has been raised by the Ombudsman about the increasing number of false vehicle warranty contracts concluded between dealers and car buyers.

In a statement released on Wednesday, ombudman Brian Martin said it frequently transpires that vehicle warranty products sold to the consumer are not underwritten by a registered insurer and are nothing more than a contractual arrangement between the car owner and the dealership.

This contractual arrangement does provide sufficient protection to the unsuspecting new vehicle owner. In the event of a dispute, the Ombudsman does not have the jurisdiction to intervene and assist the vehicle owner – and the vehicle owner has to take the long and expensive road to of a legal process that will most likely end up in court!!

Licensed Insurers, the Ombudsman and Protection

We would like to urge all vehicle owners to gain an understanding of insurance and what is needed to protect themselves from the wrong operators.

Many warranties are marketed as insurance policies administered by “insurance administrators” and have all the hallmarks of an insurance policy. Later, when a “claim” is rejected by the so-called insurance administrator, consumers may be advised to turn to the ombudsman if they are unhappy with the administrator’s decision.

If the indicated dealer is however not a registered insurer, the issue falls outside the ombudsman’s jurisdiction. When these complaints are referred to the Motor Industry Ombudsman, this ombudsman also declines to intervene as he deals with matters relating to motor vehicles, and not financial services products.

The Ombudsman for Short-Term Insurance has recognized that the uninformed vehicle owner is placed in a nasty predicament and has referred this matter to the Financial Services Board. It is the duty of the FSB to clamp down on those providing financial advice and products which are not licensed by the FSB.

Advice to Vehicle Owners when Purchasing Car Warranties

• A car warranty is a financial product and should be sold by a licensed financial services provider.
• If this product is offered as an underwritten insurance policy, the vehicle owner will be protected under the financial legislation.
• A financial services provider will only be licensed if such provider has a sound financial status and the necessary professional liability insurance.
• The vehicle owner would be able to seek redress from the FSB and the Office of the Ombudsman.
• Ask questions regarding the product – and in particular whether it is underwritten by a registered insurer.
• Ask for the FSP number of the insurer and check whether this insurer is licensed with the FSB
• Always remember – if something appears to be too good to be true – it most often is!!

The Car Insurance Blog at carinsurance.arrivealive.co.za would like to urge vehicle owners to take their time and do their homework when purchasing a vehicle warranty or car insurance product. You will most likely take the time to ask around and do research about the vehicle you wish to purchase – do the same for your warranty and car insurance product!!

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What can I do if unsatisfied with the repairs done to my vehicle?

Not all cars are written off in an accident – Many of these can be repaired by professional vehicle mechanics and repair shops! This often presents a dilemma to the vehicle owner. What can he do if these repairs were not performed to his satisfaction and the vehicle is simply not in the shape it is used to?

What can I do if unsatisfied with the repairs done to my vehicle

Nature of the repair complaint

The complaint usually is either that the repair work done is inefficient or defective or that the vehicle has not been restored to its pre-accident condition, or a combination of both.

This necessitates a closer focus on the relationship between the insured vehicle owner, his car insurance company and the vehicle repairer. The best advice is always to return to the terms and conditions of the car insurance policy!

What does the car insurance policy stipulate?

To ascertain whether you have a valid complaint against the Insurer under the policy, you must first appreciate its rights in regard to repairs. In nearly all comprehensive policies the Insurer has a choice – it can either pay your loss or damage, i.e. the reasonable costs of repair, or at its expense reinstate the vehicle to its pre-accident condition.

If your insurer decides to pay your loss, then usually the legal position is that you may appoint the repairer and that you are responsible to pay the repair costs. You also have legal rights against the repairer if he does not do the job properly. Your Insurer has no part in the dispute, and its obligation is simply to pay you what it costs to repair the car. In practice it sometimes pays the repairer, but it has no right (unless the policy says otherwise) to do this without your permission.

If the insurer decides to it decides to reinstate the vehicle to its pre-accident condition, the legal position is different. The Insurer may and usually does nominate the repairer, and consequently the Insurer, and not you, must pay the bill and approve the work.

If you are not satisfied that the vehicle has been properly “reinstated” then your remedy is against the Insurer, and if the Insurer will not get it done properly, the Insured may get it done himself and claim the cost from the Insurer.

Car Insurance Policy should provide the answer

It might however not be as simple as one of two options! Some policies contain provisions that seem to “mix up” the two choices, for example, that the Insurer may nominate a repairer even where it does not choose to reinstate, or that the Insured is always primarily liable for repairers’ costs. It needs a careful look at the policy and the facts, therefore, to determine which of the two routes the Insurer has adopted.

Who decides that the repair is defective?

You will need independent and expert opinion to show that the repairs are defective, or that there has not been proper reinstatement. A competent check and report by an organisation like the AA could be useful, or a qualified opinion by your usual servicing garage that the condition is not what it used to be or ought to be.

Do you sign release documentation?

On the Car Insurance Blog [carinsurance.arrivealive.co.za] we have urged policyholders to be cautious of the fine print in policies!

Beware of the signature of the “discharge” form which might be placed under your nose when you call for the vehicle. There is no legal obligation on you to sign a form which discharges the Insurer or the repairer from all liability before you have been given any real opportunity to check the quality of the repairs. If they won’t hand the car over without it, put a big “UNDER PROTEST” next to your signature, which will support an argument later that you only signed because they refused to return your property unless you did.

Although it is often practically speaking a sensible thing to do, there is no legal obligation on you to pay your “excess” to the repairer. If the Insured is reinstating, then your obligation is to pay your Insurer the excess when it has complied with its obligation to reinstate, and if it is paying out your loss, then it is entitled to deduct the excess from that payment. Either way, legally speaking, the repairer has nothing to do with your excess. Only pay the excess to the repairer if you are satisfied that the Insurer has appointed the repairer as its agent to receive the payment on its behalf.

Summary and Advice:

1. Find out if your Insurer is paying you your loss or reinstating the vehicle.

2. If it is paying your loss (less excesses) you deal with the repairs and the repairer. Your loss is usually the fair and reasonable cost of repair.

3. If it is reinstating, the repairers are Insurers agents and should look to Insurers for payment; you are entitled to the repaired vehicle in as good a state as it was prior to the accident, and you are obliged to pay any excess to the Insurer.

4. Read your policy conditions to check whether there is anything which affects the basic positions set out above.

5. If you are satisfied that you can prove that what the Insured is offering you in money does not represent your proper loss less excess, or that the vehicle has not been properly restored, then object, and if you cannot achieve satisfaction, approach the Ombudsman if you want mediation, or your Attorney for advice as to whether you should assert your rights in a Court of Law.

[Information from the Office of the Ombudsman]

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Your car insurance company needs to know who is driving your car!

Written on March 3rd, 2010 by admin
Categories: Car Insurance Advice, Ombudsman

car-insurance-regular-driverIt is important to be aware of the terms and conditions of your car insurance policy. It is also important to remember that your car is not insured without full disclosure of who the regular drivers of that car might be. The vehicle owner can also nominate specific drivers of that vehicle.

The Ombudsman for Short-Term Insurance has warned consumers to ensure that they fully understand and appreciate the basis upon which motor vehicle insurance is taken out and the category of persons who are insured whilst driving a motor vehicle belonging to an insured.

Why is “regular driver” and “nominated driver” important for car insurance?

“Motor vehicle policies are commonly underwritten on the basis of a “regular driver” or a “nominated driver”, however in insurance, a regular driver is not the same as a nominated driver”, says Ombudsman for Short-Term Insurance, Brian Martin. These concepts are used in order to assess the risk associated with the insurance of a particular motor vehicle and the premium to be charged. The identity and profile of the driver of a motor vehicle is obviously an important factor in risk, which the insurer is being asked to assume as well as the premium to be charged.

Certain policies of insurance define a “regular driver” as “the person who uses the motor vehicle the most frequently and more than any other”, but this definition is not without its difficulties. The concept is not always capable of precise definition. Where a policy is underwritten on a “regular driver basis”, other persons may drive the motor vehicle in addition to the regular driver, provided that they are in possession of a valid driver’s license and that they are only the secondary driver. It is vitally important that consumers correctly identify the regular driver in instances where more than one person will drive a motor vehicle, to be insured on a regular driver basis and that they provide this information to their insurance company or broker.

A “nominated driver” policy, on the other hand, only gives cover to persons who are actually nominated and recorded as a nominated driver on the policy of insurance. Any person who is not nominated and recorded, as a nominated driver on the policy schedule will not be covered.

What will happen if the vehicle is incorrectly insured and incorrect information disclosed?

The Ombudsman says that consumers should take heed of the fact that if a vehicle is incorrectly insured or incorrect information is furnished to an insurer concerning either a regular driver or a nominated driver, this can result in a policy being declared void from inception, or the insurer having no liability to compensate for any loss or damage. “Utmost care must be exercised in ensuring that the correct information is given to an insurer and that any change in one’s circumstances or day-today living is immediately communicated to one’s insurer or broker so that the necessary endorsements or changes to the policy can be made. Changes could include any change of address or change in the use of a motor vehicle”, says Brian Martin.

If consumers are in any doubt as to whether their motor vehicle is correctly insured or not, they should seek professional advice from a licensed broker, insurance advisor or attorney prior to taking out the policy. This will avoid many problems that could arise at a later stage.

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Car insurance claims may find smooth tyres slippery!

Written on October 12th, 2009 by admin
Categories: Car Insurance Advice, Car Insurance Claims, Ombudsman, Safe Driving Tips, road safety

Run FlatThe past weekend I have spent quite a bit of time researching run flat tyre technology and the impact that this might have on the safety of road users. Tyre manufacturers are spending much time and funding on efforts to develop tyres that are safer and that provides “run flat capabilities”.

All these efforts are however in vain if the driver does not monitor the condition of his tyres. We can have the best tyres from the most reputable tyre manufacturers, but if those tyres have travelled too far and are worn out, they simply would not be able to provide the necessary grip on the roads!

In the event of a car insurance claim, the insurer may reject the claim if the accident was the result of operating a non-roadworthy vehicle. We have previously written about this in a blog titled “Car insurance claim can be rejected if vehicle tyres are not roadworthy!”. It is however important to recognize that such dismissal/ rejection of a car insurance claim would not be accepted merely by having a look at the appearance of the tyres –but by asking whether there is a causal connection between the smoothness of the tyres and the accident.

We would like to refer to an actual example/ decision by the Ombudsman for Short Term Insurance.

Facts:

The Insured entered a traffic light controlled four-way intersection at a speed of 50 to 60 Km/h. The green light was in his favour and just before he entered the intersection, an Isuzu white Bakkie entering the intersection from the opposite direction executed a turn to the lsuzu’s right, i.e. across the direction of travel of the Insured. The Insured applied brakes slightly and noticed that the light was still green for him. To his surprise a Mazda 323 followed the manoeuvre of the Isuzu Bakkie and a collision occurred. The Insured’s Toyota collided with the Mazda’s left rear door. The Insurer rejected liability on the ground that the two front tyres were smooth and that liability is excluded as a result of “damage to the vehicle caused by or attributable to an unroadworthy condition of the vehicle”.

Ombudsman’s response

The Ombudsman pointed out that having regard to the circumstances of the collision, the smooth tyres had no causal connection to the collision and the subsequent damage to the complainant’s vehicle. The Insurer was persuaded to meet the claim.

From the above we can see that the mere presence of smooth tyres will not repudiate the accident claim – it must be one of the factors that caused the accident. The condition and smoothness of your tyres are important for car insurance – but even more so for your safety on road!

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Can polygraph testing stop car insurance fraud?

Written on October 7th, 2009 by admin
Categories: Car Insurance Advice, Car Insurance Claims, Insurance Fraud, Ombudsman

polygraph for insurance fraudInsurance fraud is one of the reasons why we complain about expensive car insurance premiums. Too many claims include some element of fraud, varying from exaggeration of the amount claimable to outright falsity of the alleged facts relied on.

When submitting an insurance claim the insured client makes specific statements and disclosures – and the onus rests on the insurer to investigate whether this claim does have merits and to consider whether payment should be made.

If it is found that the insured client has engaged in fraudulent conduct or used fraudulent means or devices to obtain any benefit not due to him, not only would the claim be rejected but the policy is likely to be cancelled and the client might struggle to obtain insurance cover in the future.

Unfortunately the fraudulent claims cause the innocent to suffer with the guilty. Claims are ever more minutely scrutinised, ever more closely examined, ever more treated with suspicion, and the genuine claimant is experiencing this negativity!

But can we not use the lie-detector or polygraph test to establish whether the claimant is submitting a fraudulent and untruthful claim?

Recently, one of the ways in which some Insurers are trying to solve the problem is by making use of the polygraph or “lie detector” and asking or compelling the Insured to submit to such a test. The Policy Protection Rules provide that no Insurer can compel an Insured to undergo a Polygraph or Lie Detector test.

But what if I am so convinced that I do have a claim and my version is the truth – and I want the insurer to know this and favourably consider my claim? The Insured client may decide to willingly undergo a Polygraph/ Lie Detector test. If he does agree to undergo the test then he/she has the right to have a legal representative or any other person present. The Insured is also entitled to a recording of the questions put and the answers given.

If you voluntarily undergo the Polygraph or Lie Detector test and fail it, the Insurer is still not entitled to repudiate the Policy based on such failure.

The Short Term Insurance Ombudsman has provided a few suggestions to the insured client who considers undergoing a polygraph test:

(a) Take legal advice before making a decision, especially if the claim is substantial and you have reason to believe that the Insurers suspect misrepresentation or fraud.

(b) Do not go to the test alone. Obtain a recording as suggested.

(c) If, after you have undergone the test, Insurers repudiate the claim, you are entitled to consult a lawyer, or make a formal application to the Ombudsman to investigate the matter if you maintain that the repudiation was not justified.

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Will car insurance cover texting and distracted driving?

Written on October 6th, 2009 by admin
Categories: Car Insurance Advice, Car Insurance Claims, Ombudsman

texting-and-distracted-drivingAt present we do not have reported decisions by the Ombudsman on this topic. There is however enough information to warn that a car insurance claim resulting from an accident caused by texting and driving could be rejected!

We would like to place ourselves in the position of the Ombudsman and consider how such a scenario would be judged. The best starting point would be to ask what the law says about cellular phones and driving…
We would like to refer to the Road Traffic Act and the “Prohibition on use of communication devices while driving”

1) No person shall drive a vehicle on a public road -

(a) while holding a cellular or mobile telephone or any other communication device in one or both hands or with any other part of the body;

(b) while using or operating a cellular or mobile telephone or other communication device unless such a cellular or mobile telephone or other communication device is affixed to the vehicle or is part of the fixture in the vehicle and remains so affixed while being used or operated, or is specially adapted or designed to be affixed to the person of the driver as headgear, and is so used, to enable such driver to use or operate such telephone or communication device without holding it in the manner contemplated in paragraph (a), and remains so affixed while being used or operated.

It is important to keep in mind that “using or operating” is not restricted to speaking on the cellular phone but could include reading or typing a text message, reading e-mail, surfing the Web, looking at video on your smart phone, looking up a number. Anything you do that requires manipulating a keyboard can cause a distraction and could be interpreted as such under this prohibition!

We should also consider reported decisions in other matters. The Ombudsman has agreed with insurers in the past and rejected claims for accident damage caused by drunk driving and the driving of non-roadworthy vehicles. It is only reasonable that the vehicle owner should only be covered when operating his vehicle within the Rules of the Road.

How big is the threat of texting as a driver distraction? I would like to quote just a few points made on the Arrive Alive website:

  • According to the National Roads and Motorists Association, text messaging drivers spent up to 400 percent more time with their eyes on the phone instead of on the road.
  • Texting reduces reaction times of drivers.
  • The reaction times of texting driver deteriorated by 35 per cent, much worse than those who drank alcohol at the legal limit, who were 12 per cent slower, or those who had taken cannabis, who were 21 per cent slower.
  • When texting, you tend to wander across the lane.
  • Research found that drivers who sent or read text messages were more prone to drift out of their lane, with steering control by texting drivers 91 per cent poorer than that of drivers devoting their full concentration to the road.
  • The Transport Research Laboratory concluded that text messages took on average 63 seconds to compose while the phone owner is driving- compared with 22 seconds when sent from a desk.

Research has found that driving while texting is a bigger danger than impaired driving! We can expect that more insurers will refer in policy documentation the exclusion of damage caused by texting and driving!

If there is evidence that the driver caused the accident while texting behind the wheel, we believe that any car insurance claim emanating from such accidents would be justifiably rejected!

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Be alert to the fine print in car insurance policies

Written on October 1st, 2009 by admin
Categories: Car Insurance Advice, Ombudsman

Read the fine printInformation provided by the Ombudsman for short term insurance reveals that car insurance policies are frequently disputed by vehicle owners. About 67 percent of complaints registered with the ombudsman in 2007 relate to motor vehicle claims, 12 percent to homeowners insurance and 11 percent to miscellaneous cover issues.

But why do we find so many disputes? Industry experts believe these disputes are mainly attributable to the insured not fully understanding what his or her policy actually covers. Insured car owners often claim that they have not noticed the “fine print” in their contracts or have been misled into signing the policy document. In this Blog post we will investigate the nature of the fine print and offer advice to our policy holders.

What is fine print in a contract?

Fine print is seen as controversial because of its deceptive nature. Even though the exact terms of the agreement is “technically” available to the consumer, it often designed to be overlooked. Consumers are baffled by the technical and insurance jargon typically used in insurance policy handbooks and contracts, and have difficulty to understand these terms in plain English. When some of the content appears to be “hidden” inside the contract, this poses a risk to the consumer.

The unsuspecting customer, who can instantly see the basic aspects of the agreement, will, due to natural impulsive behavior, time constraints, and/or personal need, generally not bother to learn the caveats, instead focusing on the positives of the agreement.

It is important to note that “fine print” in a car insurance policy should not be seen as necessarily being in a smaller “font” or letter type, but it rather refers to a term or fact to be found elsewhere in the contract in an annexure or from a link to another page or sub-clause!

Can we blame the fine print or are policy holders at fault as well?

Policy holders are quick to blame the insurer or broker – but need to accept blame as well! We often neglect to take the time to familiarise ourselves with the content of the contract. Special attention should be given to the following aspects:

  • Exclusions — certain insurance companies exclude hail damage to motor vehicles.
  • Policy conditions — familiarise yourself with the insured amount on your policy (how much will the insurer pay out in the event of a claim, how many claims will be paid, etc.)
  • Definitions — familiarise yourself with these (power outages, for instance, do not form part of the insured peril definition).
  • Restrictions of use — in the case of motor vehicle insurance, for example, one must stipulate whether your vehicle is being used for private or business purposes.
  • Security/maintenance — understand exactly what security or maintenance measures need to be in place in terms of your home and motor vehicle (failure to do so may result in a claim being repudiated).
  • Liability — what protection does your insurance policy offer in terms of, for instance, passengers in your vehicle or people on your property?
  • Excesses (First Amount Payable) — determine whether any deductibles, such as excess payments, are applicable as the sum you are insured for may not necessarily be the sum that is paid out.
  • Car hire — find out whether this is standard on your policy as it may only be applicable in the event of theft or write-off.

How can we protect the consumer from “fine print”?

With proper education, consumers can be warned to read the fine print and to see the red flags on an offer that is too good to be true. We would like to provide the following advice to our car insurance clients:

  • Never jump into signing the pre-printed agreement – the excuse of ignorance and “but I did not know what I was signing” might not be accepted.
  • Find out what the insurance terms in your contract mean before you choose an insurance provider.
  • Know exactly what you are getting into and what you can expect to get out before you sign the contract.
  • Read all terms and exclusions thoroughly before signing.
  • Ask questions to your insurer – and request the reply or confirmation in writing.
  • Ask about possible scenarios – What if this happens..? What if that happens?
  • Remember that you have 30 days to cancel the policy if you are not satisfied with its terms and conditions, including any exclusions you might not have been told about.
  • It is NEVER too late to gain clarity – the contract can at any time be clarified and amended, and if you are not happy with the new terms, you can always opt for another insurer willing to provide this!

We will in a next Blog discuss the protection provided to the policy holder by legislation.

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Car insurer must know the risk area where you are driving.

Written on September 30th, 2009 by admin
Categories: Car Insurance Advice, Car Insurance Claims, Ombudsman
Risky driving!

Risky driving!

A car insurer has to take several factors into account when calculating the car insurance premium payable. These factors include driver factors, vehicle factors as well as the area where the owner intends to drive such vehicle most of the time. The car insurer will seek to determine how these factors will influence the risk to vehicle loss or vehicle damage.

Why do we say that the area is important? Insurers can use accident data and crime statistics to determine what the risks are to the specific vehicle to be insured. In the same way that property prices differ from area to area, the risks to vehicle damage or loss may differ. Accident data will reveal that many more accidents occur in the heavily vehicle populated cities than in towns and rural areas. Crime statistics will also confirm that the risks of hijacking, vehicle theft and smash-and –gab are much greater in our cities than in smaller towns! It is only reasonable to expect that the greater the risk of vehicle damage/ loss, the higher the insurance premium payable.

But why is this important for the insured client? Apart from determining the premium payable, the client will have to ensure that he abides by the stipulation in his policy contract to disclose any changes in the risk status. This means that in the event of a change in regular driver of the vehicle or risk area, the insurer has to be informed and a new premium calculated. Failure to do so will constitute a serious breach of contract and the insurer could reject his claim!

I would like to provide an example from a decision by the Ombudsman:

Facts:

The Insured owned five vehicles, all of which were insured and it was noted on the information given that the risk area was Durban, where the Insured resided. A Toyota Conquest was regularly used by the Insured’s daughter, and in April 2005 was taken with her when she moved to Johannesburg to attend university. The Insured did not advise the Insurer of the change in risk profile, and when a claim was lodged five months later, it was rejected. The Insured was adamant that there was no obligation on him to have advised the change in risk area as this requirement was never brought to his attention at any stage.

Ombudsman’s Response

The Ombudsman (subject to critical comment from the Insured), advised the Insured that the Insurer’s decision was correct and gave the relevant explanation in support of the rejection of the claim.

[Source: Ombudsman's Briefcase Issue No. 02/2006]

This Decision should raise alarm bells with many insured vehicle owners. This is a scenario that often plays out with our young drivers. Parents buy a vehicle for a child on the platteland or small town, insures the vehicle correctly in the name of the young driver and then allows the child to take the vehicle to the city where the child studies or works for 3 years or more.

Failure to disclose to and notify the insurer of such a change in the risk area is a breach of contract and will entitle the insurer to reject a claim by the insured client. We are not referring to short term changes such as business trips, vacation etc, but rather a prolonged change in risk area where the vehicle is to be driven.

We need to emphasize the importance of communication between the client and his insurer. Car insurance should not be seen as a once-off event – but rather as a continuous relationship between parties which needs adjustment and fine-tuning as circumstances change!!

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Insurers MUST provide policy documentation!!

Written on September 18th, 2009 by admin
Categories: Car Insurance Claims, Ombudsman

Insurers-MUST-provide-policy-documentationWe have previously commented on the Car Insurance Blog on the need for keep records of all the insurance correspondence. This was addressed in a Blog Post titled “Do you keep your car insurance policy documentation in a safe place?” This however also implies that the client does in fact receive the policy documentation from the insurer…

What if the client asks for the documentation and the insurer neglects to provide this?

This scenario was analyzed in detail in a Ruling by the Ombudsman for Short Term Insurance.

Facts:
On 2nd May 2003, the Insured purchased a Toyota Corolla and Comprehensive Insurance was arranged by the sales person employed by Imperial Motors. In confirmation of the cover, a schedule titled “Toyota Comprehensive Insurance Schedule” which was underwritten by a registered Insurer in terms of the Insurance Act of 1998 was handed to the Insured. Almost a year later, a claim was submitted for damages sustained in a collision. The claim was admitted by the Insurer, which advised that an Excess of R7 250.00 was applicable as set out in the Policy wording.

The Insured did not receive a Policy wording despite repeated requests. The Insurer was unable to show from its records that a Policy wording had in fact been sent out, which would have alerted the Insured to the Excesses payable in the event of a claim. The Insurer was also not able to demonstrate that the Excesses were drawn to the Insured’s attention and merely relied on the fact that the Policy clearly showed the applicable Excesses.

Ruling by the Ombudsman:

The ruling was made taking account of the following facts:

  • Despite repeated requests, the Insured was not placed in possession of a fully claused Policy wording showing the applicable Excesses.
  • The Insured was not given the opportunity of either accepting or rejecting the terms of the Policy, as these were not explained at the time of the taking out of the Policy.
  • It is probable that a lower Excess would have been applicable had the Insured been given the opportunity of sourcing a Policy with some other Insurer on better terms.

The Insurer did not concede and stated that the full Excess as per its Policy be paid. The Ombudsman exercised his rights in accordance with the principle of equity and ruled that the Excess be reduced to 5% of the claim, resulting in a decrease of the Excess by R5 200.

Commentary on the Ruling:

The ruling was made based on the facts presented to the Ombudsman. The excess amounts were found to be excessive (ie an exorbitant amount) and unusual (as compared to excesses normally applied in the insurance industry) as the amount was based on a percentage of the Sum Insured rather than as a percentage of the amount claimed or a fixed excess amount. The Insurer couldn’t prove to the Ombudsman that the Insured was informed of the excess amount applicable and therefore a ruling was made.

This Ruling confirms the need for effective administration by the Insurer. Insurers have an obligation to disclose all the wording, terms and conditions of policies to their insured clients. Failure to do so may prove to be costly!!

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