Background
The deceased had a policy which provided cover in the event of accidental hospitalization. The deceased had been hospitalized for an extended period from 16 June 2016 to 18 August 2016. The complainant who is the deceased’s son, phoned the insurer to enquire whether he could claim under the policy. The complainant advised the call center consultant that the insured was hospitalized for difficulty with breathing. The complainant was given a claim number and had to obtain claim information. The call center consultant did not inform him that this was only an accident policy.
The following claim requirements were sent to the complainant via e-mail:
- identity document
- detailed hospital account
- confirmation of bank details
- discharge summary report
- motivation letter from doctor explaining why it was necessary to be hospitalized for more than 3 days.
The complainant had to incur costs and had trouble obtaining this information, which he submitted to the insurer on 22 September 2016. He then followed up with the insurer on 11 October 2016.
On 17 October 2016 the insurer advised him that the claim was declined as the policy only covers:
- bone fractures
- second degree burns
- dislocation requiring surgery
Discussion
We raised the following with the insurer:
- why did the call center consultant not inform the complainant that the policy only provided cover in the event of an accident?
- why could the author of the e-mail message listing the claim requirements also not do so?
The insurer informed us that the relevant staff members could not give advice and therefore could not advise the complainant on the outcome of the claim.
Result
Although the complaint could not be upheld, the insurer agreed to pay compensation amounting to R5 000.00 for putting the complainant to unnecessary trouble and inconvenience to provide documentation in a claim that could never succeed.
