getclosure! is publishing a series of interviews to increase consumer awareness about various remedy providers and the valuable role which they play. Our next interview is with Mr Justice Brian Galgut, the Ombudsman for Long-term Insurance.
1. What is the primary function of the office of the Long-term Insurance Ombudsman?
To provide, at no cost to consumers, out of court dispute resolution of their complaints against insurance companies arising from long-term insurance policies.
2. Is the Long-term Insurance Ombudsman’s Office a voluntary organisation?
Yes, it is a purely voluntary scheme, and as such the office does not therefore administer or operate in terms of any legislation. As a voluntary scheme it needs to be recognised, however, in terms of the Financial Services Ombud Schemes Act of 2004, which was duly applied for and granted.
The scheme is answerable only to an independent Council, which is likewise not appointed and does not operate in terms of any legislation. It is a body whose members are drawn, for their skills and expertise in the consumer field, from prominent members of the public. The Council monitors the performance and independence of the office, and for this purpose the scheme operates subject to a set of Rules fixed by the Council.
3. When should a consumer lodge a complaint with the Office of the Long-term Insurance Ombudsman?
As soon as possible. It is advisable, however, that the complaint should first be taken up with the relevant insurer itself, and that the complainant should resort to the Ombudsman’s office if he or she has not obtained satisfaction via that route.
4. When was the Office of the Ombudsman for Long-term Insurance established?
In 1985.
5. Describe a brief anecdote or case study to illustrate how your office operates.
We had a case recently where, in a transplant operation, the complainant donated one of her kidneys to her brother. The brother’s life was otherwise in danger and she had been the only suitable donor. She spent a month away from work, without income, and made a claim under a policy for sick pay benefits. The insurer declined the claim on the basis of a policy term that it would not be liable if the policyholder’s sickness or injury is self-inflicted. She lodged a complaint with the Ombudsman’s office. Because she had agreed to the donation of her kidney, the office accepted that her injuries had been self-inflicted, but because the complainant’s motive had in fact been to help save the life of her brother, the office indicated to the insurer that, although an application of the law would lead to the opposite result, equitable considerations should be applied and the claim should be met. The insurer agreed to pay the benefit and the matter was thereby settled.
6. How long have you been the Long-term Insurance Ombudsman and what do you enjoy most about your position?
I was appointed with effect from 1 June 2007. In the present economic climate most consumers are not financially able to sue an insurer in court so that the service the office provides enables consumers to achieve justice that would otherwise have been beyond their reach. I derive satisfaction from being able to help.
7. What does your average work day entail?
I do adjudications, give advice on legal questions to members of my adjudicating staff, attend meetings of various bodies, and attend seminars and conferences at some of which I am required to speak.
8. What qualifications and qualities do you need to be an ombudsman?
Nothing is prescribed in these regards. What is necessary, however, is that the incumbent should have a legal background, which is why all five of the office’s ombudsmen since its inception in 1985 have been retired judges.
9. How many complaints did your office handle last year?
7923 complaints were received by the office in 2007, of which 4494 were full cases, the balance being mini cases, out-of-scope cases (cases over which my office has no jurisdiction), or cases that have to be referred to the insurer (being Old Mutual and Sanlam, who have their own internal arbitrators, and with whom the office has an agreement that such internal arbitrator will deal with the matter first and my office only thereafter should the complainant still be dissatisfied).
10. What is the average time taken to deal with complaints?
83% of the complaints received by the office in 2007 were finalised within six months. The balance are cases that of necessity take time e.g. where a complainant’s incapacity requires to be proved to be permanent, and for this purpose reports have to be obtained or time is taken, with or without treatment, to see whether the condition at issue clears up.
11. What is the average cost per complaint handled?
Our cost per case, being the amount charged to subscribing members per standard case, was R1560.00 in 2007. The unit cost, which is the total cost of the office divided by the number of full cases finalised, was R1842.
1. What is the primary function of the office of the Long-term Insurance Ombudsman?
To provide, at no cost to consumers, out of court dispute resolution of their complaints against insurance companies arising from long-term insurance policies.
2. Is the Long-term Insurance Ombudsman’s Office a voluntary organisation?
Yes, it is a purely voluntary scheme, and as such the office does not therefore administer or operate in terms of any legislation. As a voluntary scheme it needs to be recognised, however, in terms of the Financial Services Ombud Schemes Act of 2004, which was duly applied for and granted.
The scheme is answerable only to an independent Council, which is likewise not appointed and does not operate in terms of any legislation. It is a body whose members are drawn, for their skills and expertise in the consumer field, from prominent members of the public. The Council monitors the performance and independence of the office, and for this purpose the scheme operates subject to a set of Rules fixed by the Council.
3. When should a consumer lodge a complaint with the Office of the Long-term Insurance Ombudsman?
As soon as possible. It is advisable, however, that the complaint should first be taken up with the relevant insurer itself, and that the complainant should resort to the Ombudsman’s office if he or she has not obtained satisfaction via that route.
4. When was the Office of the Ombudsman for Long-term Insurance established?
In 1985.
5. Describe a brief anecdote or case study to illustrate how your office operates.
We had a case recently where, in a transplant operation, the complainant donated one of her kidneys to her brother. The brother’s life was otherwise in danger and she had been the only suitable donor. She spent a month away from work, without income, and made a claim under a policy for sick pay benefits. The insurer declined the claim on the basis of a policy term that it would not be liable if the policyholder’s sickness or injury is self-inflicted. She lodged a complaint with the Ombudsman’s office. Because she had agreed to the donation of her kidney, the office accepted that her injuries had been self-inflicted, but because the complainant’s motive had in fact been to help save the life of her brother, the office indicated to the insurer that, although an application of the law would lead to the opposite result, equitable considerations should be applied and the claim should be met. The insurer agreed to pay the benefit and the matter was thereby settled.
6. How long have you been the Long-term Insurance Ombudsman and what do you enjoy most about your position?
I was appointed with effect from 1 June 2007. In the present economic climate most consumers are not financially able to sue an insurer in court so that the service the office provides enables consumers to achieve justice that would otherwise have been beyond their reach. I derive satisfaction from being able to help.
7. What does your average work day entail?
I do adjudications, give advice on legal questions to members of my adjudicating staff, attend meetings of various bodies, and attend seminars and conferences at some of which I am required to speak.
8. What qualifications and qualities do you need to be an ombudsman?
Nothing is prescribed in these regards. What is necessary, however, is that the incumbent should have a legal background, which is why all five of the office’s ombudsmen since its inception in 1985 have been retired judges.
9. How many complaints did your office handle last year?
7923 complaints were received by the office in 2007, of which 4494 were full cases, the balance being mini cases, out-of-scope cases (cases over which my office has no jurisdiction), or cases that have to be referred to the insurer (being Old Mutual and Sanlam, who have their own internal arbitrators, and with whom the office has an agreement that such internal arbitrator will deal with the matter first and my office only thereafter should the complainant still be dissatisfied).
10. What is the average time taken to deal with complaints?
83% of the complaints received by the office in 2007 were finalised within six months. The balance are cases that of necessity take time e.g. where a complainant’s incapacity requires to be proved to be permanent, and for this purpose reports have to be obtained or time is taken, with or without treatment, to see whether the condition at issue clears up.
11. What is the average cost per complaint handled?
Our cost per case, being the amount charged to subscribing members per standard case, was R1560.00 in 2007. The unit cost, which is the total cost of the office divided by the number of full cases finalised, was R1842.
12. Do you have statistics about levels of consumer satisfaction?
Yes, here is a complaints survey which was conducted in 2004 and 2006:
Yes, here is a complaints survey which was conducted in 2004 and 2006:
