INSURANCE CLAIMS PROCEDURE
Shoprite Checkers (Pty) Ltd trading as OK Furniture and House & Home (“The Company”)
"repudiate" in relation to a claim means any action by which an insurer repudiates or refuses to pay a claim or any part of a claim, for any reason, and includes instances where a claimant lodges a claim -
(a) in respect of a loss event or risk not covered by a policy; and
(b) in respect of a loss event or risk covered by a policy, but the premium or premiums payable in respect of that policy are not paid.
(c) For the purposes of this framework, the word “repudiate” and “repudiate” will attach the same meaning.
"claimant" means a person who makes a claim.
"the Insurer" means Centriq Insurance Company Limited, a licensed Non-Life insurer and FSP 3417, and Centriq Life Insurance Company Limited, a licensed Life insurer and FSP 7370.
The Company is a registered Financial Services Provider in terms of the Financial Advisory and Intermediary Services Act and has been appointed by the Insurer to act as a non-mandated Intermediary and to accept and manage all claims for policyholders.
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 Claims Process
The Company maintains transparent claims procedures and ensures that customers are kept informed of the progress of their claim, causes of any delay in the finalisation of a claim and details of any outstanding requirements. All communications with claimants are in plain language and are clear and easy to understand. The Company is committed to comply with the requirements set out in Rule 17 of the Policyholder Protection Rules (Claims Management) and all related regulations. Any claims must be submitted within 60 days of an occurrence of an event.
When any claim is received, it is referred to the Company’s competent claims handling department, with trained staff in claims handling. Claims are handled according to a Claims Procedure, which is can be viewed in store or by sending an e-mail to firstname.lastname@example.org.
To submit a claim, a Customer must attend the nearest OK Furniture / House & Home branch. Once a claim is reported at a retail store, a store employee will immediately capture all of the relevant details onto the applicable claim form on the computer system. The Customer will receive a claim form and a claim number once the claim is submitted.
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 within 30 days. The Customer will receive an SMS notification every 14 days to remind the Customer that documentation is outstanding.
Upon receipt of all the requested documentation, the documentation will be scanned into 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 is automatically saved on the computer system at the time that it was submitted to the branch.
A claims assessor at the Company’s insurance department will verify the claim and view all of the supporting documents for its accuracy within 2 business days. If the insurance department has any queries or require any additional documentation, it will be sent back to the branch for urgent attention. The Customer will receive an SMS notification every 14 days to remind the Customer that documentation is outstanding. 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. The turnaround time for assessment of the claim after the documentation is submitted is 2 business days.
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:
- Once the claim is approved the full account balance will be settled.
- settle three consecutive monthly instalments in the case of a retrenchment claim within 2 business days;
- account for the applicable number of confined days in respect of a temporary disability claim within 2 business days;
- replace the item/s (within the limitations of the insured amount) immediately in the case of all risks or warranty protection claims. The Customer must attend the branch to collect the replacement item and will receive an SMS reminder every 7 days until the item is replaced. In the event that the branch has to source the replacement item/s from another branch the replacement turnaround time will be affected, however we will strive to replace the item within a reasonable time.
- the timeline relating to repairs will be dependent on the availability of spares/parts but will be repaired within a reasonable time. The repair of a unit will be done by an approved repair agent. In the event of all risks or warranty protection claims, should the unit be found to be irreparable, the unit will be replaced.
2.2 Repudiation Process
If the claim is considered outside the scope of the policy, the assessor will refer the claim to the Insurer for review and once in receipt of an approved repudiation from the Insurer the assessor will issue a “Repudiation Letter” on behalf of the Insurer 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 Insurer’s decision.
2.3 Repudiated Claims
When a claim is repudiated, the policyholder shall be notified by the Company on behalf of the Insurer within ten (10) days of submitting their claim. A claim can only be repudiated once all required documents are received. Full reasons for why the claim is repudiated 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 repudiation, by approaching any OK Furniture or House and Home store. Such appeal shall be communicated to an Insurance Representative in store, or by sending the appeal on e-mail to the following address: email@example.com, who shall respond to such appeal within fifteen (15) days of receipt of the appeal.
The appeal may be successful and consequently the original decision to repudiate will be overturned or the appeal may be unsuccessful and in which event the original decision to repudiate will be upheld. Whichever the outcome, the same procedures and time limits as detailed in 2.1 and 2.2 above shall apply.
Should the claim still be repudiated, the claimant may still have recourse by lodging a complaint, in accordance with the Company’s Complaints Policy and may refer the claim to the insurer’s complaints department for further review and decision. The insurer’s complaints department may be contacted at firstname.lastname@example.org.
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.
2.5 Record Keeping
In accordance with Rule 17 of the Policyholder Protection Rules (as amended from time to time) the Company shall ensure accurate, efficient and secure recording of all claims received, irrespective of whether the claims are valid or not. All claims received, assessed and finalised will be kept for a minimum of 5 years.
Information that will be recorded in respect of each claim is:
- all relevant details of the claimant and the subject matter of the claim;
- copies of all relevant evidence, correspondence and decisions; and
- Progress and status of the claim, including whether such progress is within or outside any set timelines.
The Company shall also maintain the following claims related data on an ongoing basis:
- number and quantum of claims received;
- number and quantum of claims paid;
- number and quantum of repudiated claims and reasons for repudiation;
- number of claims escalated by claimants to the internal claims escalation and review process and their outcome
- number of claims referred to the ombudsman and their outcome; and
- total number of claims outstanding.
2.6 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 a 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, via SMS.
2.7 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.
2.8 Escalation process
There will be a Claims & Complaints Resolution Committee/Claims & Complaints Forum that deals with any repudiations or claim disputes where consensus cannot be reached between the customer and claims team, as well as any complex claims and related claims and complaints that might be received. The Claims & Complaints Resolution Committee/forum will consist of nominated representatives.
The representatives for the Company will be as follows:
Name & Surname : Mirandi du Bruyn Designation: Legal and Compliance Manager
Name & Surname : Christian Markgraaff Designation: Legal and Compliance Officer
The representatives for the Insurer will be as follows:
Name & Surname : Theodor Jordaan Designation: Claims specialist
Name & Surname : Shivani Naidoo Designation: Complaints specialist
This policy shall take effect on adoption of the Board of Directors and shall apply to all staff of the binder holder or contracting party with the Company, , which shall be stipulated in any outsourcing or binder agreements.
4. Responsibility of Claims staff:
Any person that is responsible for making decisions or recommendations in respect of claims generally or on a specific claim must-
(a) be adequately trained;
(b) be experienced in claims handling and be appropriately qualified;
(c) not be subject to a conflict of interest; and
(d) be adequately empowered to make impartial decisions or recommendations.
A claim received by an independent intermediary, binder holder or any other service provider that has been mandated by the Insurer to manage claims on its behalf, or a claim received by a representative of the Insurer, is deemed to have been received by the Insurer itself.
This policy must be followed by any parties involved in the claims process, including binder and outsource parties.
4.1 Ex gratia payments
Ex gratia payments are made where all parties concerned (i.e. Insurers, reinsurers, the broker and the customer) agree that the Insurer is not contractually liable to indemnify the customer, but where Insurer agrees to a so-called “goodwill” payment to the customer (Ex gratia letter).
All ex- gratia requests must be referred to the Insurer, for consideration and same will be reviewed in line with the agreed ex gratia process.
Summonses received must be treated as high priority and attended to immediately: An attorney to be appointed to enter appearance to defend, claim to be registered and estimate to be held, the Insurer to be notified.
4.3 Prohibited claims practices
The Company and the Insurer may not dissuade a claimant from obtaining the services of an attorney or adjustor; deny a claim without performing a reasonable Investigation; or deny a claim based solely on the outcome of a polygraph, lie detector, truth verification or similar test or procedure referred. The Company may not decline a claim based solely on the outcome of a polygraph, lie detector, truth verification, or any similar test or procedure which is furnished or made available by the Insurer or any person in terms of an arrangement with the Insurer and which is conducted under the control of the Insurer or such other person.
The Company should permit the use of a layered voice analysis (LVA) during claims stage and the analysis should be used solely as a segmentation tool.
The outcome of the LVA should be used solely to segment claims for actual merit investigation and not to repudiate a claim or void a policy. The outcome of the LVA should not be made available to the merit investigators. No claim will be repudiated on the basis of the outcome of the LVA test and the outcome of the LVA test will have no bearing on the decision on the claim.
This policy is hereby adopted by the Board of Directors on September 2021
Version History: 2022/05/05
Shoprite Checkers (Pty) Ltd (“The Company”)
When an insurance claim is submitted, you (“The Customer”) must follow the following procedure:
- Report the incident at the information counter at the closest OK Furniture or House & Home store and obtain a claim form.
- A store employee will capture all of the relevant details onto the applicable claim form on our computer system.
- The Customer must complete the claim from and attach the relevant supporting documentation.
- When supporting (extra) documentation is needed from you, the store employee will inform you of what documents are needed and that you must bring this to the store as soon as possible in order to process your claim.
- Once the documentation is returned to the store our staff will scan it into the computer system.
- Our branch management will then do a final check to see that everything is in order and will then send the claim to the insurance department on your behalf. If there are any queries, the store will contact you.
- If your claim is approved, the claim will immediately be settled according to the terms and conditions of your policy document which were provided to you when you signed up for the Insurance Cover (you may request an additional copy of the policy document at any local store).
- When a claim is repudiated, the policyholder shall be notified by the Company, on behalf of the Insurer, within ten (10) days of submitting their claim, provided all documentation has been submitted by the policyholder as required under the policy. This repudiation letter will include the following details:
- You 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, the outcome of the claim and when to approach your closest retail store.
- You can direct any queries to email@example.com or by approaching the information counter at your nearest store.
- If you are unhappy with the decision relating to your claim, you can appeal by e-mailing all relevant details to firstname.lastname@example.org or by approaching the information counter at your nearest store.
- If you have any complaints, you may e-mail all relevant details to email@example.com or by approaching the information counter at your nearest store. In addition, the Customer may send a formal complaint to the Insurer (Centriq Insurance Company Limited) via email to: firstname.lastname@example.org.
a) A clear explanation detailing the reason of the outcome; and
b) Steps to be taken should the Customer wish to appeal the outcome of the assessor’s decision.
|For Death Claims||For Disability Claims||For Retrenchment Claims||For All Risk Claims|
Autopsy Report (for unnatural deaths
Proof Boarded from Duty
|Claim form confirming unemployment
(thereafter to be provided every 3 months)
Retrenchment letter by employer
UIF form (in the absence of
a Retrenchment letter)
Police Case number