Genoa Underwriting Managers has compiled a useful Insurance Claim handling and incident reporting manual to take the stress out of how to deal with a claim or a notification of a potential claim.

What do I do if I receive a notification of a circumstance which may give rise to a claim or a notification of a claim?

  1. First and foremost, keep calm as there are experts available to help you through the process 24/7.
  2. Compile all documentation as quickly and concisely as possible and send them along to your
  3. Your broker will then make contact with the in-house legal team at Genoa Underwriting Managers which is headed up by Mrs Jacqueline She may be contacted on claims@genoa.co.za or on her cellphone which is 079 580 9883
  4. Should you wish to speak to a Medico-Legal consultant instead of an Attorney, then please dial 010 286 1915 and follow the necessary voice

What is a claim notification?

A Claim notification is the process of informing your broker / insurance company that a risk event/ a loss has occurred and that the policyholder intends to call on its policy for assistance either with defence costs or to pay a claim covered by the policy wording.

Is there any time limit to notify my Insurer of a claim?

If a Circumstance or Claim should exist or arise, you shall as soon as possible, but in any event not later than 30 (thirty) days of becoming aware thereof, give notice of the Circumstance or Claim to the Insurer in writing.

Who shall I notify if I have moved Insurers recently?

The claim may arise now, but the error may have occurred on an earlier date. It is important to check whether you have cover for earlier errors. If not, you should notify the Insurer which covered you at the time when the error arose. If you are ever confused with the process, then simply contact your Med-Mal broker at Shackleton Risk Management of 011- 784 5373 or email medmal@srisk.co.za

What documents should I provide with a claim notification?

You shall provide the Insurer with all documents and details relating to a Circumstance or a Claim as soon as possible with or shortly after notification.

It is always best to provide the Insurer will all information so that it does not have further queries.

Types of documents the Insurer will seek are any demand, notice letter, summons, writ, process or any other document relating to a Claim (whatever you have received including documents which may suggest a claim will arise).

Not a Claim yet just a Circumstance?

Both a Circumstance and a Claim are reportable. Should a Circumstance become a Claim then you are obliged to re- notify the Insurer that the Circumstance has become a Claim, in which case the date on which the Circumstance became a Claim shall be date of the Claim for the purposes of this Policy.

What is a Circumstance?

“Circumstance” means knowledge of facts which ought reasonably to lead to the conclusion that a Claim may be made against you.

What is a Claim?

“Claim” means the receipt by you of:

  • any written demand for Medical Malpractice compensation or liability to pay compensation indemnified under this Policy, made by or on behalf of a third party against you;
  • any statement of claim, summons, writ, application or other originating legal or arbitral process, or third-party notice served upon you which contains a demand or prayer for Medical Malpractice compensation or compensation indemnified under this Policy;
  • any notification of penalty or intention to levy a penalty against you for Medical Malpractice or alleged Medical Malpractice indemnified under this Policy; or
  • notice of complaint made to a Regulatory Body or notice to attend an inquiry by a Regulatory Body

Record Retention

Do not discard any evidence. Ensure proper and legible records are kept.

Keep a written record of all communications (telephonic or otherwise) with the client, the client’s legal representatives, ourselves, your insurers, and anyone else who may be involved and make sure that you also keep this record for at least 5 years from the date of the incident.

What happens if I submit my claim late?

If you do not comply with the claims notification clause then the Insurer shall not be obliged to entertain and /or indemnify you in respect of the Claim.

Where it is established that you have known about an error /incident for some time and only notified the Insurer when you received a formal complaint from the regulatory body or third party, the Claim stands to be rejected because the terms of the Insurance have been breached by you.

Repetitive late insurance claim may cause the Insurer to cancel your policy.

Reserves need to be established by your insurance company and their reinsurers need to be notified within days of your claim notification.

Defence Costs

Do not appoint your own attorney. Your insurers reserve the right to appoint an attorney on your behalf. Most Insurers have a panel which they instruct in the event that Defence of an Insurance Claim is required. If you appoint your own attorney and start taking steps to defend the matter, Insurers are not obliged to proceed with those attorneys or approve their costs as they did not instruct the attorneys.

Where the Insurer has agreed attorneys and their fees, the Insurer will pay all reasonable, relevant and necessary costs, fees and expenses incurred by you in order to assist with the investigation, defence, or settlement of any claim made against you including:

  • representation at any inquest or inquiry held at the instance of a Regulatory Body or disciplinary committee in relation to any conduct of your performance in connection with Professional Services rendered;
  • representation at any administrative tribunal or court in relation to the breach of any privacy law or duty of confidentiality owed to any patient; or
  • defence of any civil proceedings made or brought against you in the course of the provision of Health Care Services;
  • defence of criminal proceedings made or brought against you where the allegations giving rise to such proceedings have arisen in the course of the provision of Health Care Services,

provided that the defence or representation has direct relevance to any claim made or which might be made against you, provided such Claim or Claims are the subject of indemnity by this Policy and the Insurers prior written consent is obtained.

Should it emerge during the course of the defence or investigation of the matter that the Claim made against you is a claim which is excluded under the Exclusions clause or is not a Claim which attaches to the Policy for any reason:

  • the Insurer will not be liable to indemnify you against any loss (including Defence Costs);
  • you might remain personally liable for such amount; and
  • you will be required to refund the Insurer any Defence Costs which may have already been

Do I owe the Insurer any duty?

You shall give all such assistance as the Insurer may require.

You shall if required by the Insurer attend all court proceedings and enquiries scheduled at the instance of the disciplinary committee of a Regulatory Body governing your conduct and assist the Insurer in the giving of evidence and / or the securing the attendance of witnesses.

You shall be required to bear any other costs not covered by the Insurer.

You may not make any admissions, offers, promises or payment without the written consent of the Insurer.

If you do, the Insurer shall be under no obligation to provide indemnity or Defence Costs in connection with the admitted Claim.

What if I complete a claim form dishonestly?

If you knowingly, intentionally or fraudulently make any claim knowing it to be false or fails to disclose any material fact as regards amount or otherwise this Policy shall become void and all claims hereunder shall be forfeited.

If my claim is rejected do I have any rights to dispute this?

Should you wish to dispute the rejection of a claim or the quantum of a claim, you will have 90 days following the Insurer’s decision, to make representations to the Insurer in respect of such decision before following the Arbitration procedure.

Ombudsman dispute resolution procedure

Should you not be satisfied with the response received from the Insurer after representations have been made, you shall be at liberty to refer the dispute to the Ombudsman for Short Term Insurance.

Payment of Excess

You shall at all times be responsible for the Excess stated in the Policy Schedule.

The Excess shall be the first amount borne by you for his own account and shall apply per Claim or series of Claims arising from one originating cause or source.

The Excess shall apply to all Claims including Claims relating to Regulatory Body complaints and inquiries, provided that in such cases the Insurer will have a discretion as to when and how much of the Excess (if any) shall be payable by you to the Insurer dependant on the nature and extent of the complaint made against you.

The Excess is payable by you towards Defence Costs upon the request of the Insurer and is payable regardless of the outcome of the insurance claim.

Recovery by the Insurer

The Insurer shall be subrogated (substituted) to all your rights of recovery against any person or organisation before or after any payment under this insurance, whether payment or compensation has been affected or not. You shall execute and deliver instruments and papers and do whatever else is necessary to secure such rights. You shall do nothing to prejudice such rights.

Any recovery made shall be applied first to the outstanding uninsured loss and then to the Insurer’s outlay and then to the Excess in the absence of agreement to the contrary.

It is agreed that the Insurer shall not exercise such rights against any Employee of yours unless such claim has been brought about or contributed to by the dishonest, fraudulent, criminal or malicious act or omission of such Employee.