Page 7 - Claims Binders Mandates and Guidelines

General Procedures
barriers to change or replace a policy, submit a claim or make a complaint”. You are obliged, by law, to comply with all PPR requirements for applicable policies. The PPR applies to any short-term insurance policy where a policyholder is a natural person or where a policyholder is a juristic person like a company, with a turnover or gross asset value of less than R2 000 000 (two million rand).
“Treating Customers Fairly” has been designed to regulate the market conduct of financial service providers. The initiative seeks to ensure that specific, clearly articulated fairness outcomes for financial services claimants are demonstrably delivered by regulated financial institutions.
The Regulatory Guideline stipulates certain requirements and timeframes that must be adhered to in respect of all claims, and the time frames below apply to all sections.
3.1 Every claim needs to be recorded, irrespective of whether the notification is received late, or whether the policy exists or whether liability will be admitted. No temporary claim numbers are permitted. In the event of the claims system being offline, the first notification of loss (FNOL) must be recorded using alternative methods other than the standard system recording.
3.2 All claims supporting information and documentation including, communication, progress and status updates must be recorded on the system and system notes made on the claims system.
3.3 All claims documents must be stored with a clear audit trail and must be access/password protected, preferably electronically on the system claim record, if it is in paper files, it needs to be clearly marked and safely secured in a fireproof safe or at a procured document management supplier for a period of 5 (five) years. All data containing claimant personal information must be destroyed or de-identified and a record of evidence must be made available, upon request. Claims documents may be destroyed after 5 (five) years from the date of finalization, provided there is no pending legal action. No physical documents may lie around on desks and must be stored away in a fireproof safe. No policyholder or claimant information may be shared with another party without the policyholder and or claimant’s consent. Refer to the Protection of Personal Information Act (POPIA), Promotion of Access to Information Act (PAIA) and frequently asked questions (FAQ) sections in the Regulatory Guideline for more details.
3.4 Acknowledgement of a claim received
The PPR requires an insurer to ensure that its claims processes and procedures are transparent, visible, and accessible through channels that are appropriate, in plain language and that do not impose any unreasonable barriers to its policyholders and claimants.
3.4.1 A claim must be recorded within 1 (one) business day after the date of receipt of the initial claim. There must be no delay recording the claim if information is still outstanding.
3.4.2 A claim is deemed to have been received on the day the binder holder, receives notification thereof.
3.4.3 A formal acknowledgement of receipt of a claim must be extended to the claimant, within 24 (twenty-four) hours, and must contain:
• the claim handler’s details (name, surname, contact number and email address
• the preliminary excess amount, with a note stating: "to be confirmed in the final settlement offer/agreement/release"
• the process and timelines that will be followed in processing the claim
• any outstanding information and/or documents.
(Please make use of the ‘Acknowledgement of claim’ letter, available on the Binder Library, under the Claims templates section)
3.4.3 Claims received under period of grace:
PPR Rule 15.1: An insurer shall ensure that a policy contains a provision for a period of grace for the payment of premiums of not less than 15 (fifteen) days after the relevant due date provided that in the case of a monthly policy, such provision must apply with effect from the second month of the currency of the policy.
PPR Rule 17.12.1: If a claimant submits a valid claim in respect of an event that occurred during the period referred to in Rule 15, the value of the claim may be reduced by the sum of the unpaid premium.
Claims Binder Holders Mandates and Guidelines – V6: 2022 Page | 5