Long term life insurance ombudsman lucknow,in life insurance when must insurable interest exist 0),whole life insurance also known as 527s - Tips For You

Long-term insurance products, which include life assurance, disability assurance and funeral cover, can be complicated.
If you have a dispute with a life assurance company, resorting to the courts to protect your rights can be expensive and time consuming. The Office of the Ombudsman for Long-Term Insurance was established to provide policyholders with a means of resolving disputes without having to turn to the courts.
Although the specific complaint resolution processes adopted by each of the six schemes differs, all of them aim to make rulings that are fair and equitable. Both parties to a dispute are given an opportunity to respond to the factual and legal submissions of the other party.
Galgut says if his office feels a settlement is possible, it will invite the assurer to make an offer, at the same time suggesting the terms that his office considers suitable. If there are no new facts or submissions, the provisional ruling is accepted as the final ruling. Galgut says it is important to remember that although the final ruling by the ombudsman is binding and legally enforceable on the assurer, it is not binding on the consumer.
If you are unhappy with a ruling and you don’t want to go to court, the ombudsman’s office has an appeal process in terms of which it appoints a retired judge to re-hear your case. However, the retired judge charges a fee, which could be up to R20 000 for a case that takes the judge two months to review. However, you will only pay a maximum of R10 000, regardless of what the judge’s costs amount to. Most of the complaints received by Galgut’s office last year related to claims that were declined because policyholders had either failed to meet their policy conditions or did not understand those conditions correctly. Galgut says the definition of disabilities and the exclusions related to disabilities are a common cause for complaint. Brian Galgut cited the following case, which is currently being investigated by his office, as an example of the type of complaint on which he has to rule.
Senior Connections, The Capital Area Agency on Aging's Long Term Care Ombudsman Program provides advocacy and assistance to residents of the City of Richmond and the Counties of Charles City, Chesterfield, Goochland, Hanover, Henrico, New Kent and Powhatan. Trident Area Agency on Aging is a not for profit organization that provides Assistance, Advocacy, and Answers on Aging.
Barcelona, Mobile World Congress, 26 February 2013 – TomTom and Telmap today announce an agreement for TomTom to supply maps and road data to location-based services provider Telmap.
In addition to highly-accurate maps, Telmap users can now access other TomTom content, including Points of Interest, Junction Views, 3D City Maps and Voice Maps. Displays additional information in urban areas, including building footprints and land use details such as ponds, park areas and golf courses. Adds significant structures and monuments to maps to aid navigation and improve the display. Founded in 1991, TomTom (AEX:TOM2) is the world’s leading supplier of in-car  location and navigation products and services focused on providing all drivers with the world’s best navigation experience.
Our products include portable navigation devices, in-dash infotainment systems, fleet management solutions, maps and real-time services, including the award winning TomTom HD Traffic. Telmap, which is an Intel company since 2011, is a world leader in mobile location-based services. Telmap is the #1 provider of choice for mobile location-based services and its technology has been selected by leading industry players such as Orange France, Vodafone, Vodacom, Cell C, SFR, O2, Telefonica, SingTel, OPTUS, Cellcom, Pelephone, Partner and more. Several other online mediums have been included in the drive to create a better understanding of the need for safety. When disputes arise between assurers and consumers, it is almost always when policyholders want to claim their benefits.
You could wait for two or more years after a summons has been served before your case is heard, Brian Galgut, the ombudsman for long-term insurance, says. The Long-Term Insurance Ombudsman’s office is one of six ombuds offices in the financial services sector [in 2008], of which four are voluntary and two are statutory. The office of the long-term insurance ombudsman does not require you to fill in a form when you complain, but your complaint must be in writing – an email, fax or letter. So, once you submit a complaint to the ombudsman, it is forwarded to the assurer concerned. During the course of the exchanges, either you or the assurer may be called on to produce relevant documents or statements from witnesses.
In a provisional ruling, the ombudsman provides comprehensive reasons for his determination but gives the consumer and the assurer a final opportunity to furnish new facts or submissions that might throw a different light on the matter. If, based on the written material before the ombudsman, a vital dispute of fact arises that cannot be resolved, he may (where possible) hold a hearing so that the relevant witnesses can “testify” and be questioned by him.
Even once a final ruling has been made against you, you retain the right to sue the assurer in court. An appeal against a determination is not an appeal in court, so there are no legal fees because parties usually represent themselves. The judge can call for new evidence, conduct a full hearing or correspond with those involved. But because of the protracted court case, the claim was only lodged two years after the man’s death.
With this partnership, Telmap, an Intel company, will utilise TomTom content to enhance its products and services, including mobile navigation apps distributed via application stores and mobile operators worldwide.
This enables Telmap to add new functionality to its products and services, which means users of Telmap’s apps will benefit from better routing and improved visuals. You are invited to come and visit us to get a first impression of Telmap app working with TomTom data in one of the Intel booths. Telmap customers in Europe and South Africa can benefit from TomTom data now, with North American launch to follow soon. It displays the location and key attributes of restaurants, petrol stations, hotels, retailers and more. Headquartered in Amsterdam, TomTom has over 3,500 employees and sells its products in over 40 countries. Telmap provides mobile operators with cloud-based, managed location-based services that are fully designed to open new business opportunities and generate new revenue streams. Second, the Telmap offering includes a robust location platform with a set of APIs that are designed to support Telmap customers and third party developers in delivering a strong LBS strategy and are available through the Intel Developer Program. The past 7 years of commitment to create road safety awareness has also contributed to a greater understanding of not only the tragedy and despair of road accident victims - but has also the dire financial consequences for victims and those left behind. A voluntary scheme is one that is established by the relevant industry and to which virtually all industry players belong, although they are not obliged to do so. If your appeal is unsuccessful, you can still take the assurer to court if you wish to do so.

Her husband had group life cover and his death benefit was valid if he was in the company’s employment when he died. Telmap is also providing the same service with its own branded mobile application called M8, your local mate.
And third, a full set of professional services such as porting, billing and local content integrations, channel marketing, business intelligence and more.
It finalised 3 822 complaints against long-term insurers and recovered more than R147m for consumers, while awarding more than R450 000 in compensation for poor service.
The complainant, a member of a group disability insurance scheme arranged by his employer, had been dismissed from his job. The company has established a solid reputation for providing its customers with innovative, value added end-to-end mobile location based services that enrich on-the-go experiences through integration of local content, community interactions, and relevant retail offers. He referred a dispute to the CCMA, but while the CCMA process was ongoing he became disabled (from heart disease). Rather than face a disciplinary hearing, the man offered to resign, which the company accepted. It has to hear both sides of the case and ensure that facts relevant to each case are disclosed to both parties. The CCMA did not rule on the dispute because the parties concluded a settlement agreement in terms of which he was reinstated retrospectively.
It is a credit to the body that in the 26 years it has made decisions it has only been taken on review on the basis of procedural unfairness once. A disability claim was later lodged, but the insurer said it was received outside the time limit for lodging claims.For some time there was confusion surrounding whether and when the insurance cover had in fact been reinstated along with the reinstatement of employment. While there is no specific date for the implementation of TCF regulations, the Financial Services Board (FSB) has stated that it expects regulated entities to already be applying fair treatment principles in their overall business processes. There was also confusion after the complainant was reinstated about when the waiting period began (the waiting period was 6 months of absence from work due to illness before a claim could be lodged). His body was only discovered the next morning and the date of death was recorded as October 1.
After two versions of a story are considered the evidence is weighed and the Ombudsman will decide which version of events is more probable. He was dismissed on grounds of alleged misconduct on 5 May 2008, and the employer removed him from the group policy.
After a lengthy court process, they obtained a High Court ruling stating that it was likely that he had died on September 30. Principles of equity and fairness still form the foundation of the complaints resolution process in both the short and long-term insurance industries.
In terms of the agreement he was reinstated retrospectively in his employment from 5 May 2008, and the employer was to reinstate him on the policy with payment of premiums from May 2008 to the date of his reinstatement, so that he could apply for disability benefits. The disability claim forms were signed on 30 June 2009 and reached Old Mutual on 23 July 2009.3. A recent development allows for the Ombudsman to ‘name and shame’ the insurer in the event a determined complaint resolution is required.
McLaren said this was to encourage insurers to benchmark their standards of complaints handling against other insurers and to learn from insurers which appear to be better at complaints handling. The relevant clauses in the policy regarding the time for submitting claims read as follows:“The claim must be submitted to Old Mutual no later than 4 weeks after the expiry of the waiting period or 13 weeks after the date on which the loss of limbs occurred, as the case may be. There have been eight or nine such determinations published, and although many insurers were concerned over the possible fallout from this newfound transparency, there hasn’t been major public outcry or any negative effect as a result.Ombudsman Statistics to Q3 2011There were 7161 complaints submitted to the Ombudsman in the year to 30 September 2011. Not all of these complaints became full blow cases as many were outside the office’s jurisdiction. Such period will be calculated from the first day that the Insured Person is absent from work”.4. The office has finalised 3147 cases and a total exceeding R78 million has been recovered for respondents so far this year. On 4 November 2009 Old Mutual declined the claim on the grounds that he had not been actively at work since 6 May 2008, and that the claim was submitted late.The arguments5. A measure of the efficacy of the long-term insurance industry’s claims resolution process is that 42% of claims were resolved wholly or partially in favour of the complainants.
The parties’ arguments have been made in correspondence which ensued after the complaint was lodged with our office on 15 March 2010. The current percentage is viewed favourably but any slippage towards the 50% level would leave a black mark against the industry. An impartial observer would justifiably ask: “Why are these cases not resolved by the insurer before they come before the Ombudsman?”The Ombudsman deals with cases in a number of ways.
The complainant argued (12 March 2010) that his understanding was that the waiting period would have commenced from 3 February 2009 when he was reinstated and should have been re-introduced onto the policy.
The Old Mutual Internal Arbitrator noted (22 April 2010) that the “actively at work” requirement only applied to death claims, but took the view that the claim had been properly declined on the ground of late submission. He stated that it would not be equitable to decline the claim on the ground that it was submitted more than 4 weeks after the expiry of the waiting period, but it would be equitable to decline it on the ground that it was submitted more than 4 weeks after the date on which the complainant’s membership of the scheme was re-instated, ie 3 February 2009. This shift is ascribed to an increased case load due to a change to the Policyholder Protection Rules, effective 1 January 2011, requiring insurers to provide policyholders with the Ombudsman’s details when declining claims.
Another is the surge in complaints dealing with funeral cases (up from 15% in 2003 to 37% today), possibly due to greater financial awareness among lower LSMs and publicity around scams in this segment of the market.Preiss observes that the mix of complaints received by the office have changed significantly too.
Nowadays there are hardly any miss-selling complaints (these typically fall under the ambit of the FAIS Ombudsman in the advice space). The Internal Arbitrator argued further on 13 May 2010 that it was not necessary to consider whether Mr B had been confused as to the time period for submission, as he had received further information from the employer convincing him that the reinstatement amounted to anti-selection. Credit life complaints, which account for 11% of cases, have also reduced as less credit is extended and credit life insurers up their respective games. He quoted from an email dated 12 May 2010 received from the employer: “B was not expected to work again. He had to be employed in order to apply for disability”, and argued that the real reason for Mr B’s reinstatement was to enable him to apply for disability benefits. However after receiving further information from Mr B’s attorney, about the substantive and procedural fairness of the dismissal, the Internal Arbitrator stated (27 July 2010) that he was no longer concerned that there was any anti-selection.10.
In recent years these cases have become more complex and often stem from questionable or strange underwriting decisions. Nevertheless, he remained of the opinion that Old Mutual was justified in rejecting the claim on grounds of late submission, for the reasons set out in his letter of 22 April 2010, and he referred to Old Mutual’s further argument (of 26 July 2010) that “it seems the member’s issue is with the employer for not submitting the claim timeously”.11.
These related to the confusion which prevailed after the conclusion of the settlement agreement as to when and whether the policy was reinstated (as it clearly would eventually have to be, given that the reinstatement overrode the dismissal). It appeared from letters he furnished from the employer’s attorneys that correspondence on this issue was ongoing between the employer and Old Mutual (whether via the intermediary or directly) until at least June 2009.

The claim ends up at the Ombudsman with the insurer screaming “refute for non-disclosure” and the claimant asking “what about the PMA waiver?”“Pressure is being brought to bear on underwriters to accept business that they are in the first instance reluctant to accept – and then because of the pressure they do accept,” says Pearce. Her concern is that this trend will lead to a sharp spike in disclosure-related complaints in the future.
Having considered the arguments at an adjudicators’ meeting, we made a provisional ruling on 18 August 2010.13. Her fear is confirmed by global Ombudsmen bodies that say complaints are becoming more complex and complainants more persistent with time! We pointed out in the provisional ruling that the date on which the claim arose would be the date upon which Mr B’s disabling illness would have caused his absence from work. That date is not clear; at the earliest it would be after 5 May 2008 (the dismissal date) and at the latest, 23 September 2008, when Old Mutual paid him an occupational disability accelerator benefit under his Greenlight policy. Even at best for the complainant, if one were to calculate the six months waiting period from 23 September 2008, plus the 4 weeks thereafter, the expiry date for submitting the claim would be 23 April 2009. Have you had any dealings with the Ombudsman for long-term insurance, and if so, were you satisfied with the outcome?
Our office has the power to apply equity if a strict legal approach gives rise to an unfair result. Long term is the oldest Ombudsman office and shows the greatest level of experience, knowledge and application of the law the way it is. In this case we considered whether the circumstances were such that fairness to both parties required that we exercise our equity jurisdiction in Mr B’s favour.15.
The other two seem not to produce the same quality decisions, often made with no reference to the law the way it is but rather to the way they would like it to be. We took into account that the complainant had, in his latest submission, provided reasons for the late submission.16.
In our view the confusion surrounding the confirmation of reinstatement on the policy, as well as the fact that up to date supporting medical information could only be obtained in June 2009, constituted good reasons for the delay in the policyholder submitting the claim. There was also confusion as to the commencement date of the waiting period, and hence the expiry date of the time allowed for lodging claims. This confusion was understandable given the dismissal and retrospective reinstatement, and the fact that the policy does not regulate such unusual situations.
The meeting did not consider that a delay of between two and seven months was a considerable delay in these circumstances.17. The meeting considered the point about general prejudice to the insurer if employers did not face severe consequences for late submissions, but was of the view that this could not be an overriding consideration. It did not appear that there would be any specific prejudice to Old Mutual if this specific claim was assessed. The amount of time which had elapsed did not appear to preclude a proper evaluation of the medical evidence. On the other hand there would be considerable prejudice to the complainant if he were denied assessment of his claim as a result of a technicality, arising out of the unusual circumstances of his dismissal from employment and subsequent reinstatement.18.
It was therefore our provisional determination that the late lodging should be condoned on grounds of equity, and the claim should be assessed.Further submissions from Old Mutual19.
In response to the provisional ruling the Internal Arbitrator sent us a Memorandum by Mr S of Old Mutual. The Internal Arbitrator stated that he had nothing to add to his previous responses, save to note that nothing prevented the submission of Mr B’s claim within four weeks after his re-instatement, as he need not have consulted a doctor again, considering that Old Mutual had already admitted his Greenlight claim.
The Internal Arbitrator remained of the view that his recourse should be against his employer, not the insurer.20.
Mr S of Old Mutual in his Memorandum stated that the contract was between the employer and Old Mutual, not between Mr B and Old Mutual, and that it is the policyholder (the employer) that must institute a claim on behalf of the employee.
For this reason he was of the view that it was important not to underestimate the conduct of the employer when considering a claim on grounds of equity.
He argued that if the employer were allowed to submit claims beyond the time limits, there would be potential for anti-selecting against the insurer, as the employer could withhold claims until after the premium review date to ensure that it received a more favourable premium rate compared to what it would have been if the claims had been submitted timeously.
While the insurer could then impose a much larger premium increase at the next review, the employer could avoid this by moving its business to another insurer. Mr S stated that the annual premium income for the company concerned was R20 697, and that a single disability claim could quickly exceed the premiums received from this employer.21.
Mr S stated that he took note of the unique circumstances we pointed out in this case, but was of the view that as the employer was aware from the reinstatement date (3 February 2009) that Mr B might well be classified as disabled, the employer should have instituted a disability claim at the same time as reinstating the employee. He also speculated that Mr B could have told the employer about the medical examination he used for his Greenlight claim in August 2008, which would mean there would have been no need for him to wait for a further medical appointment before the claim on the group scheme was submitted in July 2009.Final determination22.
It was the view of the meeting that the special circumstances in this case apply to the policyholder (the employer) as well as the member, Mr B. There was confusion surrounding when and whether the insurance cover had in fact been reinstated alongside the reinstatement of employment. As mentioned in the provisional ruling, correspondence on this issue continued between the employer and Old Mutual (via the intermediary or directly) until at least June 2009.
There was also confusion after the member was reinstated in his employment as to when the waiting period should commence. This meant there was no certainty as to the expiry date of the time allowed for lodging a claim. The policy does not regulate such unusual situations, and all parties were therefore uncertain about the issues, including the employer. It is the general practice of insurers to require up to date medical evidence when a claim is submitted, and it was not for the policyholder to surmise that Old Mutual might be satisfied with medical information that would have been a year old, if indeed the policyholder was aware of this information. It was therefore reasonable that Mr B set about obtaining up to date information from his specialist physician, especially as he was still waiting, until at least June 2009, for confirmation that his policy had been reinstated.25. The meeting was of the view that Old Mutual has not demonstrated that there would be any specific prejudice to it if this specific claim was assessed.
If the claim had not been lodged a few months late, the insurer would in all likelihood have been obliged to pay the claim, given the favourable prospects for the success of this claim on its merits.
In our view the prejudice that would inure to the complainant if he were denied assessment of this claim as a result of a technicality, arising out of the unusual circumstances of his dismissal from employment and subsequent reinstatement, far outweighs any general prejudice to the insurer if this claim were to be assessed.26. For the reasons set out in the provisional ruling and here, it was the decision of the meeting that, on grounds of equity, the late lodgement should be condoned and the claim assessed.27.

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Comments to “Long term life insurance ombudsman lucknow”

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