INSURANCE CLAIMS PROCEDURES
The Company receives personal lines and commercial lines claims from its policyholders on a continual and regular basis. The Company ensures that it has sufficient funds in order to settle claims in a timely manner, while still maintaining the solvency margins specified by regulatory requirements.
The Company strives to achieve
- Customer satisfaction;
- Meeting contractual obligations;
- Fair treatment of customers and policyholders;
- Accurate and complete claims handling and settlement;
- Timely and fair response to all claims received.
It is the Company’s policy to meet the abovementioned goals by ensuring that all contracting parties which handle claims adopt and maintain user friendly claims system and follow fair and appropriate claims procedures. The Company commits to timely settlement of claims, however is aware of the practical delays that may result from failure by the customer to report the claim with all supporting documents, and further delays which may result from unavailability of repair parts or replacement products in respect of all risks and warranty policies. The Company addresses these specific risks with a view to implement certain procedures so as to mitigate these risks in so far as it is possible to do so.
2.1 Receipt and processing of claims
When any claim is received, it is referred to a competent claims handling department, with trained staff in claims handling.
Claims are handled according to a Claims Handling Procedure, which is displayed by the binder holder at each retail store.
Once a claim is reported at a retail store, a store employee will capture all of the relevant details onto the applicable claim form on the computer system. The computer system will automatically do an immediate and compulsory check to verify the existence of the furniture account; whether this account is in arrears or not and whether the insurance policy is still applicable to the account. If these conditions are not met, a “Notice of Decline” will be given to the customer, in writing, which will advise the customer of what to do next.
When supporting documentation is required, the store employee will inform the customer of what documentation is needed and that the customer must bring this documentation to the store as soon as possible.
Upon receipt, the documentation will be scanned in to the computer system. Branch management will then do a final verification and thereafter submit the claim electronically to the insurance department on behalf of the customer. The claim automatically goes into the computer system on the time basis that it was submitted to the branch.
A claims assessor at the insurance department will verify the claim and view all of the supporting documents for its accuracy. If the insurance department has any queries, it will be sent back to the branch for urgent attention. Once the store responds to the query, the necessary information will be sent back to the insurance department, and this claim will receive priority in the queue of claims.
Once finally assessed, an outcome is determined and if the claim is approved, the assessor will immediately settle the claim by settling the full account in the case of death or permanent disability; settle three consecutive monthly instalments in the case of a retrenchment claim; account for the applicable number of confined days in respect of a temporary disability claim; replace the item/s (within the limitations of the insured amount) in the case of all risks or warranty protection claims; or arrange for the repair of a unit by an approved repair agent in the case of all risks or warranty protection claims (should the unit be found to be irreparable, the unit will be replaced).
If the claim is rejected, the assessor will issue a “Final Declined Letter” to the customer, which will include a clear explanation detailing the reason of the outcome; and steps to be taken should the customer wish to appeal the outcome of the assessor’s decision.
The customer will receive SMS updates in respect of the claims process, including confirmation of receipt of the claim, regular reminders to provide outstanding documents, the status of the claim and the outcome of the claim.
2.2 Payment/ settlement of claims
Settlement of the claim shall be made immediately on confirmation of acceptance of the claim, unless (in terms of Warranty Protection or All Risks Cover) a product which needs to be replaced must be sourced from an alternative store. In this case the claim settlement could take a longer period, as is reasonable in the circumstances. Claims that are upheld in terms of warranty protection policies are also subject to repair agent availability and parts, however, time delays are strictly monitored by the Company to ensure that these are not unreasonable and that the interests of the policyholder are promoted.
The Company may settle the claim in favour of any of the following parties, depending on the nature of the insurance contract:
- The policyholder;
- The credit provider;
- Third party supplier.
Where the Company accepts the claim, the policyholder is notified in writing, via SMS.
2.3 Repairs, workmanship and materials
Where property is repaired or replaced, the following standards will apply:
- Appropriately skilled, certified or professionally skilled repair agents are used;
- A repair agent shall be instructed within a reasonable time period, but no later than within three (3) days of receipt of the claim and all relevant information;
- The Company shall make a decision regarding repair or replacement, within 48 hours of receiving the relevant information from the repair agent;
- The Company accepts responsibility for the quality of materials and workmanship of the repair agent which repairs or replaces the property.
2.4 Rejected Claims
When a claim is rejected, the policyholder shall be notified within fourteen (14) days of submitting their claim, provided all documentation has been submitted by the policyholder as required under the policy. Full reasons for why the claim is rejected shall be provided to the policyholder, in writing and in plain and understandable language.
The policyholder shall have an opportunity to appeal the decision for rejection, by approaching any OK Furniture or House and Home store. Such appeal shall be communicated immediately to Chris van der Walt, of Shoprite Insurance Company Limited, who shall respond to such appeal within fifteen (15) days of receipt of the appeal.
The appeal may then be upheld, or again rejected. Whichever the outcome, the same procedures and time limits as detailed above shall apply mutatis mutandis.
Should the claim still be rejected, the claimant may still have recourse by lodging a complaint, in accordance with the Company’s Complaints Policy.
This policy shall take effect on adoption of the Board of Directors and shall apply to all staff of any binder holder or contracting party with the Company, which may handle such claims, which shall be stipulated in any outsourcing or binder agreements.
This policy must be followed by any parties involved in the claims process, including binder and outsource parties.
This policy is hereby adopted by the Board of Directors on:
Date: 17th May 2016