CR17 Delay – exclusions – late submission of claim


• Delay – exclusions – late submission of claim – is the insurer entitled to rely on the exclusion clause?

Mr A suffered a stroke on 29.07.2002. His doctor suggested that he wait “close to a year and only than (sic) it would be possible for him to say if damage is permanent or temporary.” He approached his brokers during mid July 2003, but they were no longer representing the insurer. He alleged that nobody informed him that the brokerage had changed.

On 15.07.2003 (before the expiry of 365 days) he wrote directly to the insurer, requesting claim forms. He received no response and approached another broker for assistance. Only after the intervention of this broker, did Mr A find out who the new brokers were that dealt with these policies.

His second letter was sent via registered mail and reached the insurer. However, the claim was declined due to late submission. Their decision was based on the following wording in their contract:

“notice must be given to Us in writing within 365 days of any occurrence which may give rise to a claim under this Policy.

All certificates, information and evidence required by Us shall be furnished in the form prescribed and without expense to Us and must be submitted to Us within 365 days following notification. After 365 days the onus shall rest with the claimant to prove that We were not prejudiced in any way as a result of the late notification.”

We requested details regarding the prejudice that the insurer may have suffered as a result of the late submission of the claim. The insurer informed us that the renewal date of the scheme was on 01.04.2003 and that “renewal terms are negotiated according to the loss ratio.” We concluded that the 365 day period in which Mr A had to notify the insurer of the claim only ended on 28.07.2003, so the renewal terms would not have been a factor, as he could still have submitted his claim after the renewal date of 01.04.2003. We also took into consideration that Mr A wrote to the insurer on 15.07.2003 regarding this matter, but it appears as if the letter got lost in the mail.

We suggested to the insurer that it should meet the claim, which it did.