Balancing the scales of justice is often a tricky job. Often, when we read the reports and cases coming out of the offices of the ombudsmen, we see insurers and brokers getting dragged over the coals for what the relevant ombudsman deems poor advice on the part of the broker, or negligent activities on the part of insurers.
Do the scales of justice ever work in the broker or insurer’s favour? The following case from the Office of the Short Term Industry Ombudsman (Osti) suggests that it does, but there are some issues of contention that need to be considered.
Mrs Z submitted a claim to her insurer for damage caused as a result of rising damp. Relying on an exclusion in the policy for damage caused as a result of gradual deterioration or operating causes or as a result of defective workmanship, the insurer rejected the claim on the grounds that no insured peril had occurred in terms of the policy.
Following the rejection of her claim, Mrs Z lodged a complaint with the Osti. Mrs Z did not contest the actual basis on which the insurer declined liability nor did she argue that the damage was the result of a cause other than that stated by the insurer. Instead she disputed the rejection of the claim on the ground that the insurer had not supplied her with the policy documents containing the above exclusions.
She argued that, in the absence of receipt of such documents, and owing to her lack of knowledge of the policy exclusions, the insurer could not rely on the provisions of the policy wording.
Taking a chance
It was also Mrs Z’s contention that she had previously held a policy with another insurer, where she would have enjoyed the said cover. She stated that she would have kept her previous policy if she had been properly informed of the policy exclusions by the current insurer.
The relevant policy documentation in this matter included the policy wording, the policy schedule, the proposal form and its supporting documents. The insurer contended that the documents were sent to Mrs Z as a complete set, including the policy wording. Mrs Z had confirmed receipt of the schedule and other documents but not the policy wording.
All the evidence suggested that a policy wording was provided to her or that she could have even requested the policy wording prior to accepting the policy.
According to the insurer, it was also clear from the evidence that even if it were accepted that the policy had not been received, Mrs Z still had a duty to request the policy wording from the insurer. It appeared that there had not been any effort on the part of Mrs Z to request the policy wording during a period of approximately two years.
Furthermore, the insurer argued that Mrs Z had submitted a previous claim in which the policy wording had been discussed.
Osti pointed out that even if it were accepted that the insurer had failed to provide the policy wording, this would not necessarily mean that the claim must be honoured by the insurer.
It was further pointed out that in terms of South African law, and more specifically what is known as the Expedition Theory, if the insurer can prove that it sent documentation to the insured’s correct address, then the documents will be presumed to have been received by the insured within a reasonable period…unless the insured can prove the contrary.
The Ombudsman upheld the rejection of the claim by the insurer.
Issues to consider
There is no doubt that the Osti made the correct ruling. Outright fraud cannot be tolerated in any form.
This case does raise a few questions though. In a technology driven world, where there are emails and interactive platforms where a policyholder can access all of the details concerning their policy, why are we still using the postal service to deliver key documents such as policy schedules and policy wording?
The reality of South Africa is that letters often gets lost in the post. How would this ruling then change? The insurer can prove that the documents were sent to the correct address in a timely manner and the policyholder can pose a legitimate argument that they never received it. This leads us to an interesting debate as to what is the acceptable way, from a legal standpoint, to receive a policy schedule. We will follow up with the Financial Services Board on this issue.
But when does reliance on a broker or insurer border on spoon feeding? If a client is mature enough to take out a policy, they should be mature enough to ask for documents that take long in getting to them. Brokers and insurers are not policeman. Please comment below, interact with us on Twitter at @fanews_online or email me your thoughts firstname.lastname@example.org.