The ombudsman for long-term insurance has ordered Clientele Life to compensate a policy holder whose claim for hospitalisation costs was rejected.

The claim related to an insurance plan against unforeseen costs for hospitalisation. The daily cash benefit amount was R2‚000.

According to the office of the ombudsman‚ the complainant’s policy commenced on 1 April 2015‚ with the mandatory six-month waiting period ending on October 1 of the same year.

“The complainant was admitted to a Margate hospital as an emergency patient on 10 September 2015. He was subsequently transferred to another hospital on October 5 2015‚ and stayed a total of 26 days in hospital. In terms of the policy conditions‚ this was regarded as one continuous period in hospital‚” the office said.

The ombud's report card on how the country’s short-term insurers fared in handling claims in 2016Insurers MiWay‚ Outsurance and Momentum have reason to crow after the release of the Ombudsman for Short-Term Insurance’s (OSTI) annual report for 2016 on Tuesday‚ which revealed that they were found to have handled claims more fairly than most of their competitors. 

Clientele Life declined the claim on the basis that the man was hospitalised during the waiting period.

According to the policy: “No claims as a consequence of illness will be considered during the waiting period.”

But the ombudsman pointed out that there was no requirement in the definition of the waiting period that claims would only be considered if the date of admission to hospital was after the expiry date of the waiting period.

“As the complainant was discharged from hospital on 8 October 2015‚ we advised Clientele Life that we believed it should pay for eight days of hospitalisation‚” ombudsman Judge Ron McLaren said.

Clientele Life maintained that the claim arose during the waiting period‚ however the ombudsman made a final determination ordering that the complainant should be paid for eight days of his hospital stay.

Clientele Life spokesman Mada Miller said: “We received a complaint from the Ombudsman regarding a claim that was turned down due to a clause in the client’s policy contract‚ a legal document. The matter was regarding the interpretation of the waiting period provision.

“While we are comfortable that our decision was legally correct‚ the Ombudsman interpreted the provision differently‚ making use of their discretionary authority. We accepted this interpretation‚ and made payment as a result‚” said Miller.