Dealing with Insurance Disputes and Complaints

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In South Africa, handling disputes and complaints related to insurance involves several steps.

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The process is overseen by the Ombudsman for Short-Term Insurance and the Ombudsman for Long-Term Insurance, independent bodies investigating and resolving disputes between policyholders and insurers.

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Here’s a quick overview of the process for handling said disputes and complaints:

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Contact the insurer

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The first step in resolving a dispute or complaint is to contact the insurer directly. You can do this by contacting their customer service department, claims department, or broker.

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Submit a formal complaint

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If you aren’t satisfied with the outcome of your discussion with your insurer provider, you have the right to submit a formal complaint to the insurer. They’ll provide you with the necessary forms and instructions for complaint submission.

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Call in the big guns

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If the complaint is not resolved satisfactorily, you can contact the relevant Ombudsman. 

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The Ombudsman for Short-Term Insurance handles complaints related to short-term insurance, such as car and household insurance. In contrast, the Ombudsman for Long-Term Insurance operates complaints related to long-term insurance, such as life insurance and disability insurance.

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Provide information

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To get the help you need, you’ll have to provide the Ombudsman with detailed information about your complaint. Be sure to include any relevant documentation and correspondence with the insurance company.

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Investigation

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The OSTI (The Ombudsman for Short-term Insurance) will investigate the complaint and attempt to mediate a settlement between you, the policyholder, and the insurance provider.

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Decision

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If both parties can’t settle, the OSTI will decide based on the evidence provided. The decision will bind the insurance company but not the policyholder.

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Legal action

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If you are still unsatisfied with the outcome, the next step would be to take legal action against the insurer.

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And that’s the process of handling an insurance dispute in a nutshell. 

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Though, it's worth noting that the process may vary depending on the type of insurance and the specific circumstances of the complaint.

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However, the steps outlined above provide a general overview of the process in South Africa.

The role of the Ombudsman for Short-term Insurance

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The Ombudsman for Short-term Insurance is an independent body that provides an impartial service to consumers who complain about short-term insurance products, such as car insurance, home insurance, and travel insurance. 

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The office of the OSTI is an independent non-profit industry scheme whose role is to investigate complaints and make recommendations for fair and reasonable settlements.

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Essentially, their role is facilitating conflict resolution between parties by offering advice and mediation. 

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They provide a remedy where outcomes between a company or organisation failed, and the person who filed the complaint wasn't in the wrong.

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Before you can approach the OSTI, try to resolve your complaint with your insurance company first. 

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Although you don't need to complain to your insurance company before submitting a complaint to OSTI, it is suggested that you first try to resolve your issue with your insurer before submitting a complaint. 

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Complainants are given this advice because;

• It’s helpful if the insurer can look into any complaint to ensure it has made the right decision.
  

• Many complaints are caused by a misunderstanding, either on your part or on the part of your insurer. The insurer can quickly and easily fix these complaints once the problem is understood.
  

• When you complain to the insurer, your claim will usually be looked at by a different person at the insurer. You will get a second opinion from the insurer and may have your issue resolved.
  

• Even if your issue is not resolved by the insurer, submitting a complaint to the insurer may give you more information about your matter which will assist you in making your complaint to OSTI.

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Call the insurer and ask for the name of the person you speak to, keeping note of this information; it may be required later.

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Suppose you’re unsatisfied with the insurer's response; in that case, you can proceed to the next step.

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Gather all the information relevant to your complaint, including your policy documents, correspondence with your insurance provider, and other relevant information.

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With these documents and information, you can then file an official complaint.

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You can obtain a complaint form from the OSTI website or by contacting the OSTI directly. 

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The complaint form requires you to provide details about your complaint, including the name of your insurer, policy number, and a description of the complaint.

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It is usually best to complain in writing, but a phone call will work just as well. You can complain in writing, but the OSTI also provides a telephonic or walk-in service.

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When you write a letter of complaint, set out the facts as clearly as possible, write down the facts logically, stick to what is relevant, and keep a copy of any letters between you and the insurance company.

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Afterwards, submit the complaint form to the OSTI via email (info@osti.co.za), fax (011 726 5501), or post (PO Box: 32334, Braamfontein, 2017. 

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The Ombudsman will investigate your complaint and recommend a fair and reasonable settlement. The investigation process can take several weeks or months, depending on the complexity of the complaint.

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During the complaint process, you can expect the OSTI to:

• Be impartial. Being an independent body,  the OSTI will approach your complaint objectively.
  

• Investigate thoroughly. There will be an investigation into your complaint's relevant facts and circumstances.
  

• Communicate findings with you. The OSTI will keep you informed of the progress of your complaint and any recommendations made.
  

• Make recommendations. You will receive recommendations for a fair and reasonable settlement of your complaint from the OSTI.
  

• Act as a mediator. Trust the OSTI to mediate between you and your insurer to help resolve the complaint.
  

• Uphold the law. The OSTI will uphold the law, ensuring all parties comply with the relevant legislation and regulations.

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Overall, the role of the OSTI is to provide an accessible and effective dispute resolution service for consumers with complaints about short-term insurance products. 

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If you have a complaint, it's essential to follow the steps above and to provide all the relevant information to the OSTI to ensure that your complaint is investigated thoroughly and fairly.

Preparing for a complaint or dispute, including gathering relevant documentation and evidence

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Gathering as much relevant documentation and evidence as possible will help you to present a clear and convincing case. It may even improve your chances of resolving the dispute in your favour.  

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But before filing a complaint, review the Ombudsman's procedures and guidelines to ensure you understand the process and requirements for filing a complaint.

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Afterwards, collect any documents relevant to your complaint, such as contracts, receipts, invoices, correspondence, and any other records related to the transaction. 

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Be sure to make copies of these documents and keep the originals in a safe place.

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Once you have collected your documents, organise them logically to support your case. For example, you may want to group them by date or by the different stages of the transaction.

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Review your documents to identify any critical evidence supporting your case, including emails, text messages, or other forms of communication that help clarify the transaction details.

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Make notes of other vital details, such as the dates and times of critical events, the names of people involved in the transaction, and any promises or commitments made by the other party.

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If disputing a technical matter or needing an expert opinion, consider obtaining a report or statement from a qualified professional.

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If you do not have enough direct evidence to support your case, think about alternative types of evidence, such as witness statements or other indirect evidence, that could help to prove your case.

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Next, submit your complaint to the Ombudsman along with a cover letter or summary that outlines your case.

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The Ombudsman will have specific time limits for complaints, ensure that you file your complaint within the stipulated timeframe.

Tips for effectively communicating with insurance companies and the Ombudsman to resolve disputes

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Here are a few helpful tips for communicating during this process.

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Remain calm and professional

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Regardless of how frustrated or angry you may be, it is vital to remain calm and professional when communicating with insurance companies and the Ombudsman. 

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Doing this will help you stay focused on the issues and avoid worsening the situation.

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Be clear and concise

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When explaining your complaint or dispute, be clear and concise. Avoid using technical language or jargon that the other party may not understand. Use simple, direct language that is easy to understand.

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Focus on the facts

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Stick to the facts when presenting your case. Avoid speculation or exaggeration, and back up your claims with evidence and documentation.

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Practice active listening

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Listen carefully to what the other party has to say. Make sure you understand their viewpoints and the reasons behind their decisions. 

This can help you identify common ground areas and potentially resolve disputes more quickly.

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Be persistent but patient

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Dealing with disputes can be slow, so remember to be patient while persistently pursuing a resolution. Keep following up with the insurance company or Ombudsman and keep track of all communications.

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Be prepared to negotiate

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When dealing with disputes, it is essential to be prepared to negotiate. This may involve finding a compromise or alternative solution to which both parties can agree.

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And if all else fails,

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Consider seeking professional advice

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If you are struggling to resolve a dispute, consider seeking professional advice from a lawyer or another expert. 

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They can help you navigate the legal process and advise you on the best action.

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With these tips and communicating effectively with insurance companies and the Ombudsman, you can increase your chances of resolving disputes in your favour.

The legal options available in case of unresolved disputes

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The Ombudsman’s services are free and informal; they are not a court. But that doesn’t mean you don’t have the right to use someone else’s services to act on your behalf. 

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If you use someone else to help you, you must file a power of attorney and send this to the OSTI, and note that to appoint a specialist or an attorney; you must pay those costs yourself. 

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When it comes to unresolved disputes, there are several legal options that you can pursue depending on the nature of the dispute.

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For example,

• Negotiation.
• Mediation.
• Arbitration.
• Small Claims Court.
• Civil Lawsuit.
• Administrative Agency.

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It's also recommended that you consult with a lawyer to help you understand your legal rights and the best course of action for your situation.

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The outcome of complaints remains the same - whether you do it on your own or pay someone to do it for you.