Image
Icon

Directory

IconActuaries
IconAssociations & Institutes
IconAuditors
IconBBBEE Consulting and Verification Agencies
IconBusiness Chambers
IconBusiness Process Management
IconBusiness Process Outsourcing
IconCall Centre Outsourcing & Sales
IconCompliance
IconConsumer Protection
IconCorporate Governance
IconCredit Bureaus
IconDebit Order Collection Facilities
IconEducation and Training
IconFAIS
IconHuman Resources
IconInformation Technology and Software Partners
IconLegal
IconLife Insurance Companies
IconLife Insurance Products
IconOmbud
IconOutbound Sales
IconPolicy Administration
IconPolicy Trading
IconPublications
IconRe-insurance Companies
IconRegulatory Authorities
IconSales and Sales Management
IconSocial Grants (Government)
IconSurveys and Research
IconTraining Courses & Workshops
IconWellness Programs
Image
  Subscribe To »

What keeps the Long Term Ombudsman awake at night? Part 1

Published

2017

Wed

17

May

 

From the Long-term Ombud’s 2016 annual report:

The Assessors and Adjudicators in the Long-term Ombud’s office were canvassed about the issues that currently fall into this category. The following are some of the matters raised.

1. Bad bargains

These include products that do not provide value for money or do not deliver on promises and expectations.

  • Policies that provide very limited cover. E.g. a policy termed a “Cancer policy” which in effect only provides cover for female cancers or male cancers, but it is only by reading one particular clause in the policy that the policyholder will discover that the cover is limited in this way.
  • Unexpected or unusual provisions in policies. These are terms and conditions that are not part of standard policy terms or conditions and that we have seldom or never encountered previously. The question then arises whether policyholders, or even intermediaries, were aware of these unusual provisions when the policies were purchased. E.g. policies that reverse the normal onus of proof; whole life risk policies that give the insurer a right to cancel the policy.
  • Policies which are unsuitable for their target market. E.g. capital protector policies with premium reviews sold to pensioners. Although the concept of a capital protector policy has distinct advantages, if there is a premium review which results in a high increase in the premium it could make the premium unaffordable for a pensioner who is on a fixed annuity. We have had many complaints about such premium increases following premium reviews.
  • Legacy products that have become outdated. E.g. critical illness policies with outdated definitions which are difficult to apply because of advances in medical science.
  • Policies that are sold that raise expectations that have no chance of being fulfilled. The Ombud quotes a case where a terminally ill client, who disclosed this, was sold a life policy, and died the day after acceptance. The claim was declined as, at the date of death, the policy only provided accidental cover because the “underwriting process” (three months) had not been completed.
  • Investment policies that do not provide good value for money because of high costs. The charges are disclosed in the contractual documentation but it is unlikely that the policyholder fully appreciates the eroding effect of such charges. E.g. we have seen some policies where the charges amount to up to 33% of the premium or where the Reduction in Yield was illustrated as 10% which reflects the impact of costs on the return of the investment. The chances of a policyholder getting a real return on such a policy are slim.

2. Complex products

  • There are some extremely complex products in the market. The majority of these policies are critical illness and disability policies with cover for a myriad of conditions. Some of these policies consist of more than 100 pages. We find it difficult to interpret and understand the policies. The question is how many policyholders would be able to understand these policies? We have cases where legal experts differ on the interpretation of policy wording as the drafting is not always clear, particularly where there are medical or actuarial terms involved.
  • There are products that have design flaws. This can lead to difficulty at claim stage when applying the wording in the policies to the conditions they are supposed to cover. These are products that have not been tested in the “real world” or have not been “thought through”. E.g. a benefit that pays out if the insured suffers from four grand mal epileptic seizures during a specified period. However, the insurer had not indicated in what manner the insured would have to prove the incidence of such seizures. Funeral policies covering “cousins”. It is of course not that easy to prove that someone is a cousin. In certain indigenous languages there is no distinction drawn between a cousin and a second cousin. We have had a number of complaints where a policyholder covered a second cousin but described the insured as a cousin” because of this difference in terminology.
  • Products that provide perverse incentives that then lead to unintended consequences. The problem of excessive claims on the hospital cash plans is an example of this.

From the above it becomes evident why Treating Customers Fairly is an essential foundation on which future regulation will be built. With greater emphasis on accountability for product design and outcomes, product providers will no longer be able to get away with the issues outlined above.

The question one has to ask is why this is not already happening. If the basis of an insurance contract is “mutual trust”, should providers not set the ethical example, rather than try to avoid their contractual obligations?

Next week we discuss complainant behaviour, insurer behaviour and systemic issues.

 
Source: Paul Kruger: Moonstone Compliance (Pty) Ltd
 
« Back to previous page Print this page » |
 

Breaking News »

Too many eggs in one basket?

“Catch-22 is any paradoxical, circular reasoning that catches its victim in its illogic and serves those who have made the law. ” One of the options in the Merriam-Webster dictionary reads: “A ...
Read More »

  

Hannover Re expects its large loss budget to be exceeded

Hannover: The insurance industry currently finds itself faced with a number of severe natural catastrophe events, the losses from which cannot as yet be precisely quantified; they include Hurricanes Harvey and ...
Read More »

  

Collaboration is the best way to combat fraud

Speakers concur that collaboration is the best way to combat fraud at the SAFPS and ICB Inaugural International Fraud Conference “It’s a Bring and Braai,” said Manie van Schalkwyk head of ...
Read More »

  

What will the amended Compliance Officer regulation changes mean in practice?

In 2010, the Regulator published Board Notice 127 which governed the services provided by Compliance Officers. Section 4. 4 of that Board Notice demanded that in respect of category 1 FSPs, an external compliance ...
Read More »

 

More News »

Image

Healthcare »

Image

Investment »

Image

Retirement »

Image

Short-term »

Advertise Here
Image
Image
Image
Image
Advertise Here

From The Glossary »

Icon

Switching:

The transfer of money between investment portfolios.
More Definitions »

 
 
By using this website you agree to the Terms of Use.
Copyright © Stoker Risk & ICT (Pty) Ltd 2004 - 2017.
All Rights Reserved.
Icon

Advertise

  Icon

eZine

  Icon

Contact IG

Icon

Media Pack

  Icon

RSS Feeds