CR180

Delay- group funeral scheme- late submission- exceptional circumstances that can be taken into consideration for late submission- equity considerations

Background

The complainant submitted a claim for his deceased wife a year and a half after the event. The insurer declined the claim on the basis that the policy document makes provision for a claim to be submitted within a period of six months.

Discussion

In dealing with this matter we considered the reasons given by the complainant for late submission, i.e:

• he is illiterate;
• he was unaware of the benefit due to him;
• he is a farm worker living in a remote rural area;
• he only became aware of the benefit due to him through the help of trade union officials who read the policy on his behalf.

We also considered that the policy premiums were paid, on his behalf, by the trade union to which the complainant belonged. This indicated that the complainant did not have first hand dealings with this policy.

We pointed out to the insurer that we regarded these reasons for late submission as compelling and justifiable to the extent that they presented special circumstances.

In the light thereof we recommended that it would be equitable that the complainant’s special circumstances be accommodated and that the insurer should assess the claim on its merits.

Result

Following our recommendation the insurer agreed to review its decision and accepted the claim.

TS
November 2006