CR373
Late submission / Equity

Claim submitted late as complainant forgot she had covered the deceased; equity considered; decision in favour of the insurer

Background

1. The complainant forgot that she had covered her aunt on her employer’s group funeral scheme policy. She was reminded when a consultant visited her office with a printout of her policy document. Her aunt had died just over a year previously, on 4 February 2014. The time limit for lodging a claim was one year. She then lodged a claim on 23 March 2015, some six weeks late. The claim was declined and she lodged a complaint with our office.
2. The insurer had sent a benefit statement to the complainant in June 2013, showing all the persons she had covered, but she maintained that she had not received it. She also stated that she never received a policy. She did however receive a copy of the original application form which she completed in 2009 – this stated at the top “Claims must be fully submitted within 180 days of death”. She had added cover on her aunt’s life some time later, in about 2011 or 2012.

3. The insurer’s response to our office stated that they had changed the notification period from 6 to 12 months “to accommodate clients and to be fair in the dealings with them, however on the other hand insurance companies cannot be open-ended in this regard, it has a big effect on the business model as a whole from solvency calculations and reserves, to actuarial calculations of premiums and profitability”.

4. We asked the insurer what specific prejudice it would suffer if it were to pay this claim. The insurer could not provide information of specific prejudice, but maintained that equity jurisdiction should only come into play “where unique circumstances are present which explain the delay, other than forgetfulness, especially if the insurer allows for ample time for submissions of claims”.

Discussion

5. The matter was referred to a meeting of the adjudicative staff to consider whether, weighing up all the circumstances, we could invoke equity in the complainant’s favour.

6. The meeting considered that it would be the complainant’s responsibility, if she did not receive a copy of the policy, to make enquiries at that time, but it appeared that she did not do so. She did however receive a copy of the original application form, which indicated a six month (180 days) time limit for lodging a claim.

7. Although the complainant stated that she did not receive the benefit statement in June 2013, the meeting accepted the evidence that this was sent by the insurer, to the correct postal address. The insurer could not be held responsible if it did not reach her through the post.

8. The meeting noted the insurer’s explanation that it had changed the notification period from six to twelve months “to accommodate clients and to be fair in the dealings with them”.

9. A time limit for lodging claims must in principle be enforced by our office, the only exception being if the circumstances of the case are such that fairness to both parties requires that we exercise our equity jurisdiction in favour of the complainant.

10. In deciding whether to exercise our equity jurisdiction, relevant circumstances to be taken into account would include the degree of lateness, the reasons for the delay in lodging the claim, and whether the insurer would suffer prejudice by receiving the claim beyond the prescribed period.

11. In this case the degree of lateness, some six weeks, was not great. However the meeting took account of the fact that the time limit for lodging funeral claims was generous, having been extended from six months to one year.

12. The insurer could not point to any specific prejudice, but did state that open-ended time periods for lodging claims would have a significant effect on its business model.

13. The meeting considered that the reason for the delay, that the complainant had forgotten about the cover, was not a sufficiently compelling circumstance in this case.

14. The meeting also considered that it could be expected of the complainant to remember that she had applied for cover for her aunt, whose name, date of birth, etc. she would have provided to the insurer when she applied to cover her in 2011 or 2012.

15. The complainant had not mentioned whether she had paid for her aunt’s funeral, nor had she provided any proof of such payment. In the view of the meeting, if she had paid for her aunt’s funeral, this would in all likelihood have reminded her of the fact that she had funeral cover on the life of her aunt.

16. The meeting also took into account that the insurer had made an effort to inform and remind members of the cover they had by sending out benefit statements, including one to the complainant in June 2013, showing all the persons she had covered. Although she stated that she did not receive the benefit statement, we had to consider in the insurer’s favour that it made this effort.

Result

17. The meeting considered that there were not sufficiently compelling reasons in this case, such that we could require the insurer to pay the claim on grounds of equity. The complaint was dismissed.

18. We asked the insurer to ensure that premiums the complainant paid after the date of her aunt’s death be refunded to her.

SM
April 2016