ML
Mogale L
1 reviews | Active since Jan 2020
30 Sept 2020, 14:11
Not completely impartial, biased in favor of insurance.
L5/20 I do appreciate that OSTI initially requested the insurance to pay my valid claim but they refused and stated some reasons and from those reasons OSTI sided with the insurance and it’s very disappointing because those reasons already were disproved by the insurance own expert. But now when OSTI they never considered that evidence.. .1. OSTI says the insurance expert evidence is realiable on the other hand they have oral evidence where the same expert states that he determined the final resting position based on pictures they very same pictures that he says it doesn’t matter to him when they were captured even after he was advised that one of the vehicle was moved before captured...What do you call these ? They sided with the insurance without questioning these Or asking comments from the insurance... they totally ignored my submission.
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Ombudsman for Short Term Insurance's replyOfficial
01 Oct 2020, 12:10Dear Mogale Lekoloane
I have reviewed the file under the noted reference number, and find no basis on which to overturn the finding made by the Assistant Ombudsman who dealt with the merits of the complaint.
I will not go into the details of the claim in detail on this platform in the interests of protecting personal information and confidentiality.
In our adjudication of the matter, this office must determine to what extent the findings and conclusions put forward by the insurer’s expert were founded on logical reasoning. After reviewing the report, photographs, and description of the loss, we find that the insurer made out a case on which to contest liability based on the policy exclusion it re**** on. Put differently, that the insurer discharged its onus of proof on a balance of probability. The expert, in our view, has given a reasonable opinion on the subject matter.
The expert report you provided did not put forward a compelling argument on which to challenge the findings set out by the insurer’s expert on the material aspects of the rejection. What it did, at best, was create a factual dispute which must be determined by a court and tested through oral evidence including the cross-examining of the expert witnesses to test the veracity of their version. This office has a limited adjudicative function, and as such, has the no power to hold a formal hearing, or take witnesses’ evidence under oath. The determination made by the Assistant Ombudsman was based purely on the evidence filed in the matter.
Accordingly, and to the extent that you have raised arguments that give rise to a dispute of fact, this office cannot resolve those disputes. We refer in this regard to articles 5.1 and 7.3 of our terms of reference, which respectively and essentially state that the ombudsman may at his/ her discretion decide that a matter be referred to a court or a more appropriate forum; and that the ombudsman does not have the jurisdiction to deal with material disputes of fact.
The decision in this matter is maintained.
Yours faithfully,
Ayanda Mazwi
Senor Assistant Ombudsman.
I have reviewed the file under the noted reference number, and find no basis on which to overturn the finding made by the Assistant Ombudsman who dealt with the merits of the complaint.
I will not go into the details of the claim in detail on this platform in the interests of protecting personal information and confidentiality.
In our adjudication of the matter, this office must determine to what extent the findings and conclusions put forward by the insurer’s expert were founded on logical reasoning. After reviewing the report, photographs, and description of the loss, we find that the insurer made out a case on which to contest liability based on the policy exclusion it re**** on. Put differently, that the insurer discharged its onus of proof on a balance of probability. The expert, in our view, has given a reasonable opinion on the subject matter.
The expert report you provided did not put forward a compelling argument on which to challenge the findings set out by the insurer’s expert on the material aspects of the rejection. What it did, at best, was create a factual dispute which must be determined by a court and tested through oral evidence including the cross-examining of the expert witnesses to test the veracity of their version. This office has a limited adjudicative function, and as such, has the no power to hold a formal hearing, or take witnesses’ evidence under oath. The determination made by the Assistant Ombudsman was based purely on the evidence filed in the matter.
Accordingly, and to the extent that you have raised arguments that give rise to a dispute of fact, this office cannot resolve those disputes. We refer in this regard to articles 5.1 and 7.3 of our terms of reference, which respectively and essentially state that the ombudsman may at his/ her discretion decide that a matter be referred to a court or a more appropriate forum; and that the ombudsman does not have the jurisdiction to deal with material disputes of fact.
The decision in this matter is maintained.
Yours faithfully,
Ayanda Mazwi
Senor Assistant Ombudsman.
Ombudsman for Short Term Insurance's reply01 Oct 2020, 12:10
Official
Dear Mogale Lekoloane
I have reviewed the file under the noted reference number, and find no basis on which to overturn the finding made by the Assistant Ombudsman who dealt with the merits of the complaint.
I will not go into the details of the claim in detail on this platform in the interests of protecting personal information and confidentiality.
In our adjudication of the matter, this office must determine to what extent the findings and conclusions put forward by the insurer’s expert were founded on logical reasoning. After reviewing the report, photographs, and description of the loss, we find that the insurer made out a case on which to contest liability based on the policy exclusion it re**** on. Put differently, that the insurer discharged its onus of proof on a balance of probability. The expert, in our view, has given a reasonable opinion on the subject matter.
The expert report you provided did not put forward a compelling argument on which to challenge the findings set out by the insurer’s expert on the material aspects of the rejection. What it did, at best, was create a factual dispute which must be determined by a court and tested through oral evidence including the cross-examining of the expert witnesses to test the veracity of their version. This office has a limited adjudicative function, and as such, has the no power to hold a formal hearing, or take witnesses’ evidence under oath. The determination made by the Assistant Ombudsman was based purely on the evidence filed in the matter.
Accordingly, and to the extent that you have raised arguments that give rise to a dispute of fact, this office cannot resolve those disputes. We refer in this regard to articles 5.1 and 7.3 of our terms of reference, which respectively and essentially state that the ombudsman may at his/ her discretion decide that a matter be referred to a court or a more appropriate forum; and that the ombudsman does not have the jurisdiction to deal with material disputes of fact.
The decision in this matter is maintained.
Yours faithfully,
Ayanda Mazwi
Senor Assistant Ombudsman.
I have reviewed the file under the noted reference number, and find no basis on which to overturn the finding made by the Assistant Ombudsman who dealt with the merits of the complaint.
I will not go into the details of the claim in detail on this platform in the interests of protecting personal information and confidentiality.
In our adjudication of the matter, this office must determine to what extent the findings and conclusions put forward by the insurer’s expert were founded on logical reasoning. After reviewing the report, photographs, and description of the loss, we find that the insurer made out a case on which to contest liability based on the policy exclusion it re**** on. Put differently, that the insurer discharged its onus of proof on a balance of probability. The expert, in our view, has given a reasonable opinion on the subject matter.
The expert report you provided did not put forward a compelling argument on which to challenge the findings set out by the insurer’s expert on the material aspects of the rejection. What it did, at best, was create a factual dispute which must be determined by a court and tested through oral evidence including the cross-examining of the expert witnesses to test the veracity of their version. This office has a limited adjudicative function, and as such, has the no power to hold a formal hearing, or take witnesses’ evidence under oath. The determination made by the Assistant Ombudsman was based purely on the evidence filed in the matter.
Accordingly, and to the extent that you have raised arguments that give rise to a dispute of fact, this office cannot resolve those disputes. We refer in this regard to articles 5.1 and 7.3 of our terms of reference, which respectively and essentially state that the ombudsman may at his/ her discretion decide that a matter be referred to a court or a more appropriate forum; and that the ombudsman does not have the jurisdiction to deal with material disputes of fact.
The decision in this matter is maintained.
Yours faithfully,
Ayanda Mazwi
Senor Assistant Ombudsman.