Genoa Underwriting Managers has compiled a useful Claims handling and incident reporting manual to take the stress out of dealing with a claim or notifying 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?
- First and foremost, keep calm as there are experts available to help you through the process 24/7.
- Consult the Claims Triage table to check the urgency of the matter to direct the notification via the correct channel for prompt and appropriate assistance.
- Compile all documentation as quickly and concisely as possible and send them along to your broker.
- Your broker will then make contact with the in-house legal team at Genoa Underwriting Managers which is headed up by Ms Inge Sieberhagen. The claims team can be contacted on claims@genoa.co.za or via telephone at 010 590 9449. Should you wish to speak to an Attorney, when you dial the telephone follow the necessary voice prompts.
- Should you wish to speak to a Medico-Legal consultant instead of an Attorney, then please dial 010 590 9449 and follow the necessary voice prompts.
- In the instance that urgent guidance and assistance is required after hours, then please dial the emergency number 010 594 9777.
Note: Please view the post on the Claim Triage for guidance on urgency.
What is a claim notification?
A Claim notification is the process of informing your broker / insurance company that a risk event has occurred and that the policyholder intends to call on its policy for assistance now or possibly in the near future for legal defence costs and/or to pay a claim covered by the policy wording.
Is there any time limit to notify my Insurer of a claim?
Yes. When 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 broker.
The summary should be accompanied by any correspondence or documents relevant to the matter.
What documents should I provide with a claim notification?
The information and documentation is dependent on the nature of the Circumstance and/or Claim.
At notification it is best to provide a brief summary of the incident that includes the date, location, details of complainant, details of incident and the claims team will revert with further guidance.
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 renotify the Insurer that the Circumstance has become a Claim.
Any Claim or loss arising from such Circumstance or Claim shall be deemed to have been made in the Period of Insurance in which the event giving rise to the Circumstance or Claim occurred.
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:
(a) 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;
(b) 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;
(c) any notification of penalty or intention to levy a penalty against you for Medical Malpractice or alleged Medical Malpractice indemnified under this Policy; or
(d) notice of complaint made to a Regulatory Body or notice to attend an inquiry by a Regulatory Body
Record Retention
Keep all 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?
Should there be a failure to comply with the claims notification clause then the Insurer shall not be obliged to indemnify you in respect of the Claim.
Repetitive late claim may cause the Insurer to cancel your policy.
The notification obligation enables insurers to respond promptly to the incident. Time is of the essence in mitigation of a matter escalating and ensuring that legislative timelines are adhered to, which if not adhered to may lead to increased legal defence costs or a fine against the insured.
Defence Costs
Where the policy triggers and provides legal defence costs indemnity, 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 a 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 paid.
Do I owe the Insurer any duty?
Yes. The Insured must give such assistance as the Insurer may require. This includes attending 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.
The Insured bears 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 complaints procedure.
Ombudsman dispute resolution procedure
Should you not be satisfied with the response received from the Insurer after representations have been made via the
complaints procedure, you shall be at liberty to refer the dispute to the National Financial Ombud.
Payment of Excess
The Insured is responsible for the Excess stated in the Policy Schedule.
The Excess is the first amount borne by you for your own account and applies per Claim or series of Claims arising from one originating cause or source.
The Excess applies 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 dependent 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 Claim.
