The switch from law to insurance has led Edite Teixeira-McKinon down the path of becoming the Lead Ombud of the Non-life Insurance Division of the National Financial Ombud Scheme South Africa NPC (NFO).
In the first of the “IOL Big Interviews” with industry leaders and executives from various sectors, Teixeira-McKinon revealed that she had initially studied law, completed her articles and became an admitted attorney, before she realised that a legal career in that form was not for her.
She then joined the insurance firm Mutual & Federal, thereafter joined the office of the ombudsman as an assistant, before working her way up to become the chief executive of the Ombudsman for Short-Term Insurance.
These days, Teixeira-McKinon is the Lead Ombud of the Non-life Insurance Division of the NFO, dealing mostly with vehicle and household insurance related disputes. The disputes are many, she adds, adding that some are complex in nature.
The NFO is a free, one-stop, all-in-one dispute resolution service made up of four former industry ombud schemes: the Ombudsman for Short-Term Insurance, the Ombudsman for Life Insurance, the Credit Ombud, Ombudsman for Banking Services.
While Reana Steyn is the head Ombud of the NFO, these are the leads for each of the schemes.
- Banking Division Lead Ombud: Nerosha Maseti
- Credit Division Lead Ombud: Howard Gabriel
- Lead Ombud of the Non-life Insurance Division: Edite Teixeira-McKinon
- Life Insurance Division: Denise Gabriels
Teixeira-McKinon, who most South Africans would be counting on to find against the insurers during disputes, has offered advice to people who seek the help of the NPO and on how to manage the challenges of the insurance industry.
Seeking help from the ombudsman
If people are experiencing issues with their insurer, the ombud has encourage members of the public to take up any disputes with their insurer first, before seeking the help of the ombudsman.
“Insurance companies by law need to have mechanisms in place to escalate these issues and handle them internally,” Teixeira-McKinon notes.
In the event that insured members of the public do not find common ground with their insurer, Teixeira-McKinon explains that their doors are open to help register these disputes and complaints, for no fee.
People also have the option to go the legal route, but this can be costly and time consuming, Teixeira-McKinon warns.
Complaints process
Teixeira-McKinon said: “As long as people are policy holders of an insurance policy then the doors of the ombudsman are open to them.”
Those who have complaints can start the process by completing the application form that can be found on the ombudsman website. Documents like a letter of rejection can be handed in at a later stage, if people don’t want to upload them.
People can also email the ombudsman with details like claim numbers or the date of the incident.
Teixeira-McKinon said that the pressures of the job can range from making sure that in every complaint the correct decision is made and that an efficient service is provided to handling the fluctuating volume of claims.
“As an adjudicator the biggest challenge is to make correct quality decisions but also efficiently. We are supposed to provide a service to that is an alternative to court that is supposed to be efficient, so bringing efficiency with quality decisions is a challenge,” Teixeira-McKinon said.
Another challenge is that more and more complaints are becoming complex in their nature, according to Teixeira-McKinon.
These complaints require a lot of effort not only on the part of the adjudicator but also the team of seniors that weigh in to ensure that the right decision is made for all the parties.
According to Teixeira-McKinon, there are currently a high volume of complaints, however, the number of complaints that they do receive does fluctuate.
She said that there have been periods of a high number of complaints and sometimes the number of complaints decrease.
Rejection of claims
Claims can be rejected due to non-compliance or specific situations that are not covered by the insurers.
Teixeira-McKinon said: “Claims can be rejected for a number of reasons based on what is in the contract, but insurers cannot create reasons to reject claims.“
People that have insurance need to meet certain conditions in their contract.
For example, if a vehicle is stolen and the policy holder does not have the necessary tracker required by the insurer even though it was communicated to them then the claim can be rejected.
Certain exclusions may also result in an insurance claim being rejected.
For example, if a person that has been involved in an accident and they have been driving under the influence and the insurer discovers this information during their investigation, then their claim can be rejected.
Protect yourself against the inclement weather
Teixeira-McKinon advises people need to heed weather warnings and not ignore communications from their insurers to seek shelter if there is bad weather.
If there is hail, people need to ensure that they have hail cover. However, some insurers have cut back as it used to be apart of comprehensive cover. If hail cover is not covered, then people will need to pay extra to get cover for it.
Homeowners need to maintain their properties as well as repair any wear and tear. Many people forget to do the repairs or they don’t have the funds to take care of the maintenance.
If insurers can show lack of maintenance to the ombudsman, then the ombudsman would not be able to help them.
Replacement cover
“It is important to check the wording on the policy because if the payout for the claim is accepted, then the insurer will payout for the current value of the items not what they were valued at five years go,” Teixeira-McKinon said.
If the items are not insured for their correct replacement value, then people become the co-dependent and they will have to pay for it out of their own pockets.
It essential that people do an annual re-evaluation which could result in the premium going up but it will be worth in the log run. People need to also check their policies annually.
Cancelling insurance
Due to the cost of living, people may consider cancelling their insurance but they should not do it.
Teixeira-McKinon said: “Instead of cancelling your insurance you can scale back your cover. Consider third-party insurance, because if there is an accident people will still be covered.”
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