“OSTI remains an independent organisation. It continues to deliver fair and just outcomes,” the chairman of OSTI’s board, Haroon Laher, recently noted. Understanding the Ombudsman for Short-term Insurance’s (OSTI) role in resolving disputes is essential to developing a better relationship between OSTI, insurers and policyholders. Amid a possible increase in disputes as a result of the current pandemic and possible consequences, a recent article published in OSTI’s Briefcase addresses its independent and impartial role.
“The general expectation of almost every complainant in our office is that, because they are paying their premiums, their claims, which are true and honest, should be honoured by the insurers,” according to the article. We have, of course, seen many instances where claims are not so “true and honest” as they would have us believe.
A quick overview of the roles:
Insured (Complainant’s) role
|For an insured to have a valid complaint against the insurer, the insured is required to demonstrate that she/he has a valid claim in terms of the insurance policy.
|The insured is required, not only to allege, but also to prove the claim, which involves the presentation of substantive evidence.
|The onus is on complainants to provide OSTI with the evidence on which they rely to support their claims.
|The outcome of a complaint is determined by weighing the version of events on a balancing scale of fairness, reasonableness and human experience to establish what is more likely or probable.
|This exercise is called deciding a case on a “balance of probabilities” and refers to the standard test used when deciding civil disputes.
OSTI cannot give legal advice to the parties about a specific complaint, as this would compromise its ability to act independently in resolving the dispute.
|Insurers are also required to provide evidence to support their stance and defences on each matter.
|The cooperation of the insurer also has a bearing on the time it takes to resolve a complaint against it.
|In circumstances where the insurer avoids liability because of an exclusion or exception in the policy, the duty to prove the exclusion or exception lies with the insurer.
OSTI therefore gives both parties a chance to present their case and tell their story which mitigates against the escalation of the conflict.
Click here to read the article as published in the latest OSTI Briefcase.
Source: Moonstone Compliance