mempermudahkan tuntutan insurans hayat life insurance claims

LIFE INSURANCE ASSOCIATION OF MALAYSIA

Mempermudahkan Tuntutan Insurans Hayat

Life Insurance Claims Made Easy

Teman Anda Sepanjang HayatYour Friend For Life

Mempermudahkan Tuntutan Insurans Hayat

Life Insurance Claims Made Easy

LIFE INSURANCE ASSOCIATIONOF MALAYSIANo. 4, Lorong Medan Tuanku SatuMedan Tuanku, 50300 Kuala LumpurTel: 2691 6168, 2691 6628, 2691 8068Fax: 2691 7978E-mail: [email protected]: //www.liam.org.my

Teman Anda Sepanjang Hayat

Your Friend For Life

PRAKATA

Babak terakhir setiap polisi insurans hayat adalah tuntutan nilai yang diinsuranskan.Ini dilakukan oleh sama ada penama orang yang diinsuranskan yang telah meninggaldunia atau orang yang diinsuranskan itu sendiri sekiranya dia masih hidup semasapolisi insuransnya matang.

Membuat tuntutan insurans adalah mudah tetapi rumit. Ia memerlukan berbagaijenis dokumentasi, khususnya untuk membuktikan bahawa orang yang berhak keatas wang polisi adalah orang yang dinyatakan dalam polisi insurans tersebut danterdapat prosedur-prosedur penting yang perlu dipatuhi. Industri insurans hayattelah menetapkan peraturan-peraturan membuat tuntutan untuk memastikantiada sebarang implikasi undang-undang terhadap syarikat insurans hayat.

Buku kecil ini menjelaskan langkah-langkah yang perlu diambil oleh penama atauorang yang diinsuranskan itu sendiri untuk membuat tuntutan insurans. Ia jugamenerangkan cara-cara membuat tuntutan untuk bayaran bil perubatan atauhospital bagi kes kemalangan.

Buku ini adalah sebahagian daripada projek yang telah dilaksanakan oleh PersatuanInsurans Hayat Malaysia (LIAM) untuk mendidik orang ramai tentang berbagaiaspek insurans hayat. Ia merupakan kompilasi rencana-rencana yang telahditerbitkan bersama Utusan Malaysia, New Sunday Times dan Nanyang SiangPau.

L. MeyyappanPresidenPersatuan Insurans Hayat MalaysiaKuala Lumpur

Februari 2002

(i)

PREFACE

The final chapter of any life insurance policy is claiming the sum insured. Thisis done either by the nominee of the person insured who has passed away, or bythe insured himself/herself if he/she is still alive on the date of the maturity of thelife insurance policy.

Claims for sums insured are easy, and yet not so easy, to make. Variousdocumentations are involved, mainly to prove the person entitled to the moneyis really the person mentioned in the life insurance policy. Above all there areprocedures to follow; rules that have been set down by the life insurance industryto ensure that there would be no legal backlash on the life insurance companyconcerned.

This booklet explains the various steps to be taken by the beneficiary, or theinsured himself/herself, to make a proper claim for the sum insured. It alsoexplains how claims are made for payment of medical bills or hospitalisation incases of accident.

This booklet is part of an ongoing programme undertaken by the Life InsuranceAssociation of Malaysia (LIAM) to educate Malaysians in various aspects of lifeinsurance. It is a compilation of articles that first appeared in the New SundayTimes, Utusan Malaysia and Nanyang Siang Pau newspapers.

L. MeyyappanPresidentLife Insurance Association of MalaysiaKuala Lumpur

February 2002

(ii)

Kandungan/ Contents/

Diterbitkan di Utusan Malaysia:

1. Isu Tentang Kes-kes Aduan 1

2. Pemegang Polisi Mesti Faham Hak Tuntutan 4

3. Kepentingan Pemegang Polisi Diutamakan 7

4. Memahami Cara Membuat Tuntutan 11

Published in the New Sunday Times:

1. IMB An Extra Avenue for Policyholders To Settle Disputes 16

2. Scope of IMB Confined To Claims Up To RM100,000 Against Firms 19

3. Reducing IMB’s Workload Through Education 21

4. Dealing With Clients Who Are More Aware of Rights 23

5. Self-Regulatory Measures In Insurance Industry 25

6. Making Accident and Hospitalisation Claims 27The Simple and Easy Way

7. Looking at Ways of Filing Death and Maturity Claims 30

1. 32

2. 35

3. 37

4. 39

5. 41

6. 43

7. 45

8. 48

• Contents of the articles in Bahasa Malaysia, English and Mandarin may differ due toupdating of information or editing by the respective media at the point of publishing.

• Whilst every endeavor has been made to ensure the information provided is correct,the Life Insurance Association of Malaysia (LIAM) is not responsible for anymisstatement expressed in the booklet.

• LIAM welcome the reproduction of any section of the booklet without prior permission.

16 Y O U R F R I E N D F O R L I F E

CASE ONE:

Angie Tan was diagnosed as sufferingfrom “mitral stenosis”. She underwent asurgery known as “precutaneoustransvenous mitral commisurotomy orPMTC” to correct the heart valve defect.

Tan submitted her claim under theliving assurance rider benefit, whichstates: In the event of either the death ofthe Life Assured or the Life Assured beingdiagnosed as suffering from any majorillness as defined in section IV, thecompany shall pay the amount ofbenefits....

Under Section IV is the definition ofmajor illness, where one of it is “HeartValve Surgery” which is defined as “Theactual undergoing of open-heart surgeryto replace and/or dilate cardiac valvesas consequence of heart valve defects”.

The insurance company repudiated theclaim on the ground that the definitionof “Heart Valve Surgery” has not beenfulfilled.

It was not disputed that Tan wasdiagnosed as suffering from heart valvedefect. The issue was whether her lifeinsurance policy intended to providethe benefits based on the illness sufferedby the assured or on the surgeryperformed. Under the heading“Definition of Major Illnesses”, it wasincluded “Heart Valve Surgery”. Butheart valve surgery is not an illness. Itis a form of treatment. The illness whichrequires surgery is “Heart Valve Defect”.

In the absence of such an expression as“.... as shall include either the diagnosisof any of the following illnesses orperformance of any of the coveredsurgeries included therein....” under thedefinition of “Major Illnesses”, theInsurance Mediator was sceptical as towhether the insurance company couldinsist on the payment of the policy basedon the surgery performed instead of theillness suffered, that is heart valve defect.

The insurance company conceded thatcertain ambiguity of intention mighthave arisen from the preamble

ARTICLE 1

IMB AN EXTRA AVENUE FORPOLICYHOLDERS TO SETTLE DISPUTES

MEDIATION BUREAU AND DISPUTE RESOLUTION

17Y O U R F R I E N D F O R L I F E

description of “diagnosis of majorillness”. The insurance companysubsequently revised its decision andaccorded the benefit of the doubt toTan, and settled the claim on an ex-gratia basis.

CASE TWO:

K. Nathan bought a life insurance policywith a supplementary accidentalcoverage. A few years later he was founddead by the roadside not far from hishome. The nominee under the policysubmitted a death claim to his insurancecompany.

But the insurance company repudiatedthe claim on the ground that accordingto a toxicology report the alcohol contentin the blood of the deceased was 332milligram ethanol/100 millilitre and thedeceased was thus considered to beintoxicated at the time of his death.

The insurance company relied on aprovision in the supplementaryaccidental contract which stipulates thatthe insurance company would not beliable for injury or death resultingdirectly or indirectly caused oraccelerated by (iii) being under theinfluence of intoxicating liquor or anynarcotic or drug.

A post-mortem was carried out, andaccording to the report the cause of

death of the deceased was asphyxia dueto manual strangulation. Thus, the causeof death was not due to or acceleratedby being under the influence ofintoxicating liquor which is excludedunder the policy. The InsuranceMediator ruled in favour of the lateNathan’s nominee, and the insurancecompany paid the claim.

CASE THREE:

Mohd Razlan bought a personalaccident policy. One day he submitteda claim under the policy alleging thathe accidentally knocked himself againsthis car’s side mirror, injurying his eyeand bleeding from the nose. He wasadmitted to the hospital.

According to the medical report,Razlan was found to havethrombocytopenia on admission and thedoctor reported that the nose bleedingwas probably the result ofthrombocyltopenia as no mass lesionor other abnormality was noted in thenose and the nasopharynx.

The insurance company repudiatedthe claim on the ground thatRazlan’s condition did not satisfythe requirement of the policy, whichis bodily injury affected directlyor independently of all other causes byviolent accidental external and visiblemeans.


The Insurance Mediator ruled infavour of the insurance company basedon the medical report that thethrombocytopenia condition of Razlanwould constitute “other causes”.

The above are three of the manyexamples of disputes involving holdersof life insurance policies and theirrespective insurance companies thathave come before the InsuranceMediation Bureau (IMB) last year.

Set up by the insurance industry in1992, the IMB is an alternative channelto resolve claims disputes betweenpolicyholders and their insurancecompanies.

Bank Negara already has a CustomerService Bureau (CSB) within itsInsurance Regulation Department thathandles complaints and enquiries oninsurance matters from the public.

The CSB works closely with insurancecompanies and insurance associationsto resolve grievances against insurancecompanies. It also analyses trends

emerging from complaints received inorder to identify and address persistentproblems in insurance practices.

The CSB’s functions are furtherenhanced by a computerised databasesystem on public complaints againstfinancial institutions, which enablesexpeditious handling of publiccomplaints.

However, the CSB is a departmentunder the administration of BankNegara. The IMB, which is not adepartment under Bank Negara, is anadditional avenue for policyholders tosettle their disputes with their respectiveinsurance companies.

IMB is headed by an InsuranceMediator, who oversees the operationsand reports to a Council. Above theCouncil is a Board of Directors. TheIMB has 53 life and general insurancecompanies as members.

• New Sunday Times, 11 November2001.


As mentioned previously, the InsuranceMediation Bureau (IMB) was set up bythe insurance industry in 1992 as analternative channel to resolve claimsdisputes between policyholders and theirinsurance companies.

According to Bank Negara, the scopeof the IMB is confined to claims bypolicyholders against their owninsurance companies (excluding thirdparty claims) for claims of amounts upto RM100,000 per claim.

The Insurance Mediator’s functions arelisted as:

1) To act as a counsellor or conciliatorin order to facilitate the satisfaction,settlement or withdrawal of thecomplaint;

2) To act as an investigator andadjudicator in order to determinethe complaint by upholding orrejecting it wholly or in part;

3) Where the complaint is upheld,wholly or partially, to make amonetary award against the

insurance company (which is amember) binding up toRM100,000 and being arecommendation only as to anyexcess; and

4) To make such recommendationsor such representations as he thinksfit to the complainant, to theinsurance company or to theCouncil. However, neither thecomplainant nor the Councilshall be informed of anyrecommendation or representationas to any payment (ex gratia orotherwise) being made by theinsurance company unless thatcompany agrees to divulge theinformation.

The IMB has come out with a standardprocedure how policyholders can makea complaint against their respectiveinsurance companies.

Any policyholder who is not satisfiedwith the decision of the seniormanagement of an insurance companywhich is a member of the IMB maywrite to the Insurance Mediator giving

ARTICLE 2

SCOPE OF IMB CONFINED TO CLAIMS UPTO RM100,000 AGAINST FIRMS


details of the dispute, the name of theinsurance company and the policynumber.

Copies of correspondence between thepolicyholder and the insurancecompany may be sent to facilitatetracing the case file kept by thecompany.

However, before the complaint isreferred to the Insurance Mediator, itmust be considered first by a seniorofficer of the insurance company.

When the offer or observations of thesenior officer are not accepted by thepolicyholder, the matter can then bereferred to the Insurance Mediator; butwithin six months after the senior officerhas made his offer or observations.

The policyholder does not have to paya single sen to refer his case to theInsurance Mediator

After the case is heard, and when theInsurance Mediator makes an awardagainst an insurance company, thepolicyholder is required to inform himwhether he accepts the award within14 days, so that the company can beinformed of his decision.

There is no appeal procedure withinthe IMB. If the policyholder does notwish to accept the award, he may rejectthe decision of the Insurance Mediator,and he is free to institute civil courtproceedings against the insurancecompany or refer it to arbitration.

On the other hand, once the InsuranceMediator directs that a claim must bepaid, the insurance company is boundby that decision.

The IMB is not responsible for handlingpayment following the decision of theInsurance Mediator.

The insurance company when informedof the acceptance of the award isrequired to remit the amount direct tothe claimant within 30 days.

At present, the IMB does not chargeany fees for services provided to resolvethe dispute.



In buying a life insurance policy, aconsumer must know what he is gettinginto. He must take the initiative tostudy the terms and conditions of hispolicy, and to take precaution to complywith them.

Consumers are advised to ask theservicing agents to explain details ofthe policy coverage, its benefits and theexclusion/limitations in the policy.

This is important to enable theconsumers to fully understand what iscovered and not covered under thepolicies.

So when a policyholder complainsagainst his life insurance company, thereis always a likelihood that thepolicyholder may not have fullyunderstood the terms and conditionsof his policy that he has signed.

Despite the fact that some timesthe policyholder may be in the wrong,life insurance companies do have a heartin ensuring that they provide the bestof services to their respectivepolicyholders.

After all the policyholders are theircustomers, and by giving them goodcustomer services, word of mouth willhelp spread the good image of that lifeinsurance company.

Due largely to the fact that lifeinsurance companies are handlingamicably the complaints of theirrespective policyholders, the increase inthe number of complaints against lifeinsurance companies has slowedconsiderably.

For instance in year 2000, the numberof complaints against life insurersrecorded at 290 cases out of a total of1,783 complaints received throughoutthe insurance industry.

However, if we compare the numberof complaints received to policies inforce, this figure is a negligible 0.004per cent.

Most of the complaints last year werewith regards to agency matters, delayin settling claims and repudiation ofliability with reference to conditions ofpolicy contract.

ARTICLE 3

REDUCING IMB’S WORKLOADTHROUGH EDUCATION


But not all the complaints against lifeinsurance companies reached theInsurance Mediation Bureau (IMB),though, the number of cases handledby IMB has risen four-fold from 110in 1996 to 463 in 1999. Last year theIMB handled 515 complaints, anincrease of only 11.2 per cent.

The Insurance Mediator in his reportfor 2000 said that the reduction in thepercentage of the number of referencehandled by the IMB might provide anindication that the policyholders weresatisfied with the decisions of theirinsurance companies.

It also indicated that the internalcomplaint procedures of the insurancecompanies and the Guidelines onClaims Settlement Practices had beencomplied with.

At the same time, the IMB also heldmeetings with claims managers on howto resolve complaints with anunderstanding of what would happenif the disputes were to be referred tothe IMB.

Discussions were also held on how todeal more effectively with cases beforethey become formal complaints.

Of the 515 cases the IMB handled,only 170 were complaints against lifeinsurance companies.

They comprised mainly death claims(47 cases), hospital surgical benefit claim(38 cases), total and permanentdisability benefit claim (27 cases), dreaddiseases (16 cases), comprehensiveaccident benefit/accident indemnityclaim (14 cases), enhanced payor waiverof premium benefit claim (eight cases)and comprehensive/personal accidentand hospitalisation benefit claim (sevencases).

And of the 170 complaints, the IMBcompleted and resolved 146 cases lastyear. The bulk of the cases were mainlydeath claims and hospital surgicalbenefit claims.

Policyholders must also fully understandtheir rights as consumers when buyinglife insurance products from insurancecompanies, like they would whenbuying perishable products.



It has always been said thatThe Consumer is the King. And when aconsumer complains, the provider of aservice or seller of a product listens.

However, buyers of a service or productdo complain most of the time for onereason or another. And sometimessuch complaints are genuine, sometimesnot.

Malaysian consumers today are moreeducated, knowledgeable and aware oftheir rights, and have become lesshesitant to pursue their rights.

There seems to be an awakening amonglocal consumers, specifically lifeinsurance policyholders of what theywant of their policies that. This is agood sign, not just for the policyholdersin general but also for the life insuranceindustry at large, as insurancecompanies are now able to deal moreintelligently with policyholders.

Policyholders, as consumers, essentiallyhave eight basic rights: Satisfaction,information, choice, basic goodsand services, need to be heard, seekredress, consumer education and safe

and clean environment.

Apart from Malaysian consumers beingknowledgeable about their rights, theinsurance industry, which itselfunderwent a change in the last 10 to20 years, also saw the problems ofinsolvent insurers, unfair trade practicesand inefficient operations as the maincatalyst in boosting growing pressuresand criticisms from policyholdersagainst the life insurance companies.

In 1987, nine insurance companies werefound to be have failed to meet theminimum solvency requirements. Theproblem has since been resolved.Complaints against the life insuranceindustry can be categorized as:

1) Unreasonable delays in settlingclaims

2) Unfair claims settlement3) Operating at high marketing costs4) Collusion and price fixing5) Poor service to policyholders6) Providing incomplete and false

information7) Resorting to pressure selling8) Lack of professionalism

ARTICLE 4

DEALING WITH CLIENTS WHO AREMORE AWARE OF RIGHTS


From the statistics provided by BankNegara it is clear that there is growingdissatisfaction of policyholders not onlywith life insurance companies but alsogeneral insurance companies.

Last year Bank Negara received a totalof 1,783 complaints from the publicagainst insurance companies, of which290 were against life insurancecompanies. In 1997, the total numberof written complaints amounted to1,259, which was the lowest receivedby Bank Negara.

To resolve this growing consumerpressure, Bank Negara on July 1, 1998set up a dedicated Customer ServicesBureau (CSB) within its InsuranceRegulation Department, which acts asa central point of reference for allcomplaints from the public.

• New Sunday Times, 9 December2001.


In addition to Bank Negara’s CustomerServices Bureau, the insurance industryhas set up the Insurance MediationBureau (IMB) as an alternative channelfor the public to refer their disputeswith their respective life (and general)insurance companies for settlement.

Despite this move, the life insuranceindustry is not sitting idle. It has beenresponding on its own to the growingconsumer pressures by having self-regulatory measures, which have beenintroduced with the objectives of:

1) Instilling discipline and promotinghealthy competition amongcompanies in the industry; and

2) Providing an element of protectionto policyholders.

Many have argued the pros and consfor self-regulation, but self-regulatorymeasures are essentially to instil greaterself-discipline among the life insurancecompanies, thus avoiding the need forstricter legislations.

While laws can be passed by Parliamentto ensure that the rules and regulations

are followed, a sort of a top-down legalcommand, self-regulatory measureswhich are really bottom-up way ofmanaging can therefore respond tochanging circumstances faster thanlegislations. Self-regulatory measures arenot cast in stone somewhat unlikelegislations, where the process ofamending a small aspect of the law isvery tedious.

True, self-regulatory measures do nothave the power of the law, as they aremerely voluntary. Thus in the event oflife insurance companies breachingthem, policyholders cannot resort tothe courts to address such shortcomings.

Laws are interpreted by the courts butstatements of practices are interpretedby those who drafted them.

One very significant self-regulatorymeasure is the setting up of the LifeInsurance Association of Malaysia(LIAM), where the Insurance Act 1996has made it mandatory for all lifeinsurance companies to be members.(For general insurance, there is theGeneral Insurance Association of

ARTICLE 5

SELF-REGULATORY MEASURES ININSURANCE INDUSTRY


Malaysia, or commonly known asPIAM).

LIAM is vested with the powers toenforce the rules and regulations thathave been formulated by the authorities,so as to ensure among others, the lifeinsurance companies are conducting theirbusinesses in a professional manner.

LIAM has also initiated on its ownmeasures such as various inter-companyagreements and guidelines that help toregulate the proper conduct ofbusinesses by its members, and to ensureethical conduct and professionalismbetween insurers and agents.

In 1991, as a further step towardsgreater self-regulatory, LIAM formulated

a Code of Ethics and Conduct for itsmembers that deals with life insuranceselling and practices.

The IMB is really a self-regulatorymeasure that was set up in response toan increasing number of disputesbetween policyholders and theirrespective insurance companies. Therole of the IMB dovetails very neatlywith the CSB and the self-regulatorymeasures of LIAM (and PIAM), andits significance cannot be under-estimated.

• New Sunday Times, 16 December2001.


When a policyholder buys a lifeinsurance policy he is buying anintangible product, meaning somethingthat is hard to define or measure andnot physical.

The policyholder is really buying a“promise” by the life insurance companyto pay him/her upon a certain eventoccurring, namely death, injuriessustained in an accident or hospitaliseddue to illness.

To receive a certain agreed value, thepolicyholder pays an annual premium,and thus depends on the integrity andreputation of the life insurance companyto fulfill its obligations.

The Government therefore maintains astrict control over the life (and general)insurance companies simply because ofthis purchase of an intangible productby the policyholder who has to dependon the integrity and reputation of theinsurance company to fulfill itsobligations.

Insurance is by no means an easy subjectfor the ordinary man to understand, as

the contract for the purchase of a lifeinsurance policy is usually in legallanguage and jargon. Precisely due tothis fact that the Government has strictregulations governing trade practices oflife insurance companies.

The insurance industry is also strictlyregulated because life (and general)insurance affects the interests of thepublic. Life insurance is a form offinancial protection for an individual,his family and/or his business.

If life insurance companies fail tohonour their “promise” to pay after theregular premiums have been paid andwhen the policies mature, then thisfailure would adversely affect manypolicyholders.

Premiums for life insurance are usuallyseen as a form of long-term savings.And for the life insurance company notto honour its obligations would bedisastrous to the individual’s futurelivelihood.

Thus the Insurance Act 1996 governslife (and general) insurance companies,

ARTICLE 6

MAKING ACCIDENT ANDHOSPITALISATION CLAIMS THE SIMPLE

AND EASY WAY


the way they operate, how they managetheir businesses, and provides adequateprotection to policyholders andpenalties for the insurance companiesin cases of breaches of the obligations.

The Act also provides procedures forclaims to be made against life (andgeneral) insurance companies in case ofthe policyholder meeting with anaccident and needs hospitalisation, ordeath due to illness or accident, andmaturity of the policy. Claimants areadvised to contact their insurancecompanies or servicing agents forassistance to lodge the different typesof claims.

Procedures for accident claims:

1) A written notice of the injurysustained to be given to the lifeinsurance company within 20 daysafter the date of the accident.Failure to do so within thestipulated time would require anexplanation letter.

2) The policyholder must completethe Claim form truthfully and incomplete details. The Claim formcomes in two sections - Section 1to be completed by thepolicyholder, and section 2 bythe attending doctor. Thepolicyholder will pay for themedical report fees.

3) Documents that are to besubmitted to support the Claimare:• Medical certificates.

• Medical reports.

• X-ray film or radiologist reportif there is a fracture.

• Outpatient follow-up card.

• Discharge notes.

• Police reports for motor vehicleaccidents.

• Newspaper cuttings of theaccident, if any.

• For dismemberment cases,coloured photographs of the siteof injury, if any.

Procedures for hospitalisation claims:

1) A written or verbal notice of Claimmust be given to the life insurancecompany within a reasonableperiod (as according to theinsurance company’s contractualprovisions in the contract thatthe policyholder signed) ofthe commencement of theconfinement in the hospital.

2) Proof of hospitalisation to befurnished to the insurancecompany at the expense of thepolicyholder within a specifiedperiod mentioned in the policycontract.


3) The policyholder must completeand signed the Claim form.

4) The Hospitalisation Report mustbe completed by the attendingdoctor, and the policyholder paysfor the report fee.

5) The policyholder must submit theoriginal bills and receipts to claimfor reimbursements. In the eventof a hospital and surgical benefit

claim, certified true copies of thebills and receipts would suffice.

NEXT WEEK: Procedures for DeathClaims and Maturity Claims

• New Sunday Times, 23 December2001


ARTICLE 7

LOOKING AT WAYS OF FILING DEATHAND MATURITY CLAIMS

Continuing from the week before last,today’s article will look at how to filedeath claims and maturity claims.

Procedures for Death Claims:For life policies the death claims caneither be contestable or incontestable.

Contestable claims are for deathoccurring within two years from thedate of issue of the policies or date oflatest reinstatement of the policieswhichever is later. There are two typesof contestable death claims:

• For natural deaths, the documentsto be furnished by the deceased’sclaimant are: physician’s statement,death certificate, claimant’sstatement, five copies of ClinicalAbstract Application forms (dulysigned and witnessed), proof ofrelationship, the policy the deceasedsigned with the life insurancecompany. And proof of age (if thereis any discrepancy).

If there is additional accidental deathcoverage, in addition to the above,post mortem report, toxicology

report and coroner’s inquest wouldalso be required.

• For accident deaths, the documentsto be furnished by the deceased’sclaimant are: All the documents asin cases of natural deaths, plus post-mortem report, police report andnewspaper cuttings (if any).

For incontestable death claims for deathoccurring within two years from the dateof issue of the policies or date of latestreinstatement of the policies whicheveris later, there are again two types:

• For natural deaths, the documentsto be furnished are: Death certificate,claimant’s statement, proof ofrelationship and proof of age (if thereis a discrepancy).

• For accident deaths, the documentsneeded are: All the documents as incases of natural deaths, plus post-mortem report, police report andnewspaper cuttings (if any).

For personal accident policies, thebeneficiary of the insured (or the


deceased) can make a death claim bysubmitting the following documents:• Death certificate, original or certified

true copy.• Claimant’s statement duly signed

and witnessed by a person who hasno interest in the claims.

• The policy contract the deceasedsigned with his/her insurancecompany.

• A police report.• Post-mortem report or physician

statement duly completed by thephysician who last attended theinsured, if a post-mortem report isnot available.

• Proof of relationship such as amarriage certificate or birthcertificate.

Procedures for Maturity Claims:For endowment life insurance policies,the insurance company pays the amountinsured upon maturity of the policy inthe event the policyholder survives tothe end of the maturity period.

The insurance company would usuallyinform the policyholder of theimpending maturity of his/herendowment policy, and would requestthe policyholder to follow the followingprocedures:

• The insurance company will forwardan identity form, a survival formand a discharge form to thepolicyholder for completion andreturned with the policy contract.

• If the policyholder is the life insured,then he/she must provide proof ofage, proof of survival, complete adischarge voucher and submittogether with the policy document.

• If the policyholder is not the lifeinsured, then he/she must give adeed of assignment or any other titledocument, and a simple statementstating that the person insured isalive but unable to sign the survivalcertificate.

Endowment life insurance policiesusually provide a few settlement options,which the policyholder can exerciseupon maturity of the policies. Thereare four common options:• Full amount of the cash proceeds.• Convert the proceeds into an

annuity, either as an annuity certainor a life annuity.

• Leave the proceeds as a deposit withthe insurance company on agreedterms.

• Draw the proceeds by installmentsover a number of years. Interest willbe credited to the outstandingbalances.

• New Sunday Times, 13 January2002.

1T E M A N A N D A S E P A N J A N G H A Y A T

KES PERTAMA:

Rabiah Talib menandatangani borangpolisi insurans hayat pada 14 Oktober1994. Beliau mengesahkan bahawabeliau tidak menghidapi sebarangpenyakit.

Syarikat insurans hayat meluluskanpermohonannya pada 27 Oktober 1994dengan syarat: Perlindungan akanbermula apabila kami menerima bayaranpremium yang pertama dengan sepenuhnyaiaitu RM5,244.50. Dan sewaktupembayaran premium keadaan kesihatananda hendaklah sama seperti pada masaanda memohon polisi insurans ini.

Syarikat insurans menerima premiumdaripada Rabiah pada 30 September1996. Pada 5 November 1996, Rabiahtelah meninggal dunia akibat daripadakanser gastrik yang teruk. Pewarisnyatelah membuat tuntutan kematiandengan syarikat insuransnya.

Laporan perubatan mendapati arwahRabiah telah didiagnosis menghidapkanser gastrik yang teruk semenjakSeptember 1996.

BAHAGIAN 1

ISU TENTANGKES-KES ADUAN

Syarikat insurans menolak liabilitituntutan kematian tersebut atas alasanbahawa keadaan kesihatan arwahRabiah sewaktu premium dibayar tidaksama dengan borang permohonan yangdiserahkan kepada syarikat insurans.Berdasarkan ini, surat kelulusan yangdikeluarkan pada 27 Oktober 1994adalah tidak sah.

Pengantara Insurans telah membuatkeputusan berpihak kepada syarikatinsurans berdasarkan penerimaanbersyarat permohonan arwah Rabiahdan maklumat yang diperolehi daripadalaporan perubatan.

KES KEDUA:

K. Nathan telah membeli sebuah polisiinsurans hayat. Beberapa tahunkemudian, Nathan dijumpai mati ditepi jalan tidak jauh daripada rumahnya.Pewaris polisinya pun membuattuntutan kematian daripada syarikatinsurans berkenaan.

Syarikat insurans telah menolaktuntutan tersebut atas alasan bahawa

2 T E M A N A N D A S E P A N J A N G H A Y A T

laporan toksikologi menunjukkankandungan alkohol di dalam darahmendiang Nathan adalah 332 miligramethanol/100 mililiter. Mendiang Nathandikatakan mabuk semasa dia meninggaldunia.

Berpegang

Syarikat insurans berpegang padaperuntukan di dalam polisi yangmengatakan bahawa syarikat adalahtidak bertanggungjawab di atas sebarangkecederaan yang diakibatkan secaralangsung atau tidak langsung ataudipengaruhi oleh keadaan seseorangyang mabuk atau khayal akibat daripadapengaruh alkohol, narkotik atau dadah.

Suatu post-mortem dijalankan danlaporan mengatakan punca kematianadalah asfiksia akibat dicekik. Oleh itu,punca kematian bukanlah disebabkanatau dipengaruhi oleh keadaan mabukyang tidak termasuk dalam polisiinsurans.

Pengantara Insurans telah membuatkeputusan berpihak pada pewarisNathan dan tuntutan tersebutdiluluskan oleh syarikat insurans.

KES KETIGA:

Mohd Raslan yang membeli polisiinsurans kemalangan diri telah

membuat tuntutan insurans terhadappolisinya. Beliau mendakwa bahawabeliau telah terlanggar cermin tepikeretanya dan mengakibatkan matanyatercedera dan hidungnya berdarah.Beliau terpaksa dimasukkan ke wad dihospital besar untuk mendapatkanrawatan.

Mengikut laporan perubatan,Razlan didapati mempunyai“thrombocytopenia” sewaktu beliaudimasukkan ke hospital. Doktormelaporkan bahawa hidungnyaberdarah berkemungkinan besardisebabkan oleh “thrombocytopenia”kerana tidak terdapat kecederaan yangteruk atau keadaan yang tidak normalpada bahagian hidung atau nasofarinks.

Syarikat insurans telah menolaktuntutan tersebut atas dasar bahawakecederaan Razlan tidak memenuhisyarat polisi iaitu kecederaan anggotaakibat daripada sebab-sebab lain melaluicara luaran yang nyata dan ganas secaratidak sengaja.

Pengantara insurans telah membuatkeputusan memihak kepada syarikatinsurans berdasarkan laporan perubatanyang menyatakan keadaan“thrombocytopenia” Razlan adalahakibat “sebab-sebab lain”.

Ketiga-tiga kes di atas adalah merupakancontoh kes-kes pertikaian di antarapemegang polisi dengan syarikat


insurans yang telah dikendalikan olehBiro Pengantaraan Insurans pada tahunlepas.

Biro telah ditubuhkan oleh industriinsurans pada tahun 1992. Iamerupakan saluran alternatif untukmenyelesaikan pertikaian di antarapemegang polisi dan pihak syarikatinsurans.

Bank Negara juga ada menubuhkanBiro Perkhidmatan Pelanggan di bawahJabatan Pengawalan Insurans. BiroPerkhidmatan Pelanggan inimengendalikan kes-kes aduan danpertanyaan daripada orang awammengenai hal-hal insurans.

Biro Perkhidmatan bekerjasama rapatdengan syarikat insurans serta Persatuaninsurans untuk menyelesaikan rungutandan aduan terhadap pihak syarikatinsurans. Ia juga menganalisis aduan-aduan yang diterima untuk mengenalpasti dan mencari jalan penyelesaianbagi masalah yang sering dihadapiberkaitan dengan amalan industri ini.

Fungsi Biro Perkhidmatan telahdipertingkatkan dengan adanya sistempangkalan data berkomputer yangmengandungi maklumat-maklumattentang aduan-aduan orang ramaiterhadap institusi kewangan. Ini

membolehkan Biro mengendalikanaduan tersebut dengan lebih pantas.

Biro ini adalah satu jabatan di bawahpentadbiran Bank Negara. Tetapi BiroPengantaraan Insurans bukan di bawahpentadbiran Bank Negara. Iamerupakan saluran tambahan untukpemegang polisi menyelesaikanpertikaian mereka dengan syarikatinsurans yang terlibat.

Biro Pengantaraan Insurans diketuaioleh Pengantara Insurans yangbertanggungjawab ke atas operasi Birodan beliau melapor kepada pihak Majlisyang dikawal oleh Lembaga Pengarah.Biro Pengantaraan Insurans mempunyaitataurusan persatuannya sendiri. Buatmasa kini, Biro mempunyai seramai 53ahli yang terdiri daripada syarikatinsurans hayat dan am.

Bank Negara menetapkan, skop BiroPengantaraan Insurans terhad padatuntutan pemegang polisi terhadapsyarikat insuransnya (tidak termasuktuntutan pihak ketiga) dan jumlahmaksimum setiap tuntutan adalahRM100,000.

• Utusan Malaysia, 13 Ogos 2001.


BAHAGIAN 2

PEMEGANG POLISI MESTI FAHAMHAK TUNTUTAN

Semasa membeli polisi insurans hayat,setiap pengguna haruslah mengambiltahu lebih mendalam tentang polisiyang akan dibeli. Dia hendaklahmengambil inisiatif mengkaji syarat danterma polisi dengan teliti danmengambil langkah-langkah untukmemenuhi syarat-syarat tersebut. Sepertiyang selalu dikatakan, anda hendaklahsentiasa membaca huruf-huruf bercetakhalus.

Apabila sesorang pemegang polisimembuat aduan terhadap syarikatinsurans, ada kemungkinan dia tidakbegitu memahami syarat-syarat polisidengan sepenuhnya.

Meskipun ada kemungkinan bahawapemegang polisi itu tersilap, namunsyarikat insurans hayat tetapmemastikan bahawa perkhidmatan yangterbaik diberikan kepada pemegangpolisi mereka.

Ini adalah kerana pemegang polisiadalah pelanggan mereka. Denganmemberikan perkhidmatan yangterbaik, ia akan membantumeningkatkan imej dan nama baik

syarikat insurans hayat tersebut.

Memandangkan syarikat insurans hayatmampu menangani aduan-aduandaripada pemegang polisi merekadengan baik, jumlah kes aduan terhadapsyarikat insurans hayat telah banyakmenurun.

Mengikut statistik daripada BankNegara Malaysia (BNM) jumlah aduanterhadap syarikat insurans hayatmeningkat sebanyak 19.8 peratus padatahun 1998. Tetapi kadar ini turun ke6.2 peratus pada tahun lepas.

Pada tahun 2000, hanya terdapat 290kes atau 16.26 peratus daripada jumlahkeseluruhan 1,783 kes aduan yangdilaporkan terhadap syarikat insuranshayat dan am.

Sebahagian besar daripada aduan padatahun lepas adalah berkaitan hal-halagensi, kelewatan menyelesaikantuntutan dan penolakan liabiliti atassyarat-syarat kontrak polisi.

Namun begitu, bukan semua kes aduanterhadap syarikat insurans hayat


diterima oleh Biro PengantaraanInsurans.

Jumlah kes aduan yang dikendalikanoleh Biro telah meningkat sebanyak 4kali ganda daripada 110 pada tahun1996 kepada 463 pada tahun 1999.Walau bagaimanapun kes yangdiuruskan oleh Biro pada tahun lepashanya berjumlah 515, iaitu peningkatansebanyak 11.2 peratus sahaja.

Dalam laporan tahunan 2000,Pengantara Insurans berkatapengurangan dalam kes aduan yangdikendalikan oleh Biro mungkinmenunjukkan pemegang polisi telahberpuas hati dengan keputusan syarikatinsurans mereka.

Ia juga menunjukkan bahawa syarikat-syarikat insurans telah mematuhiprosedur aduan dalaman syarikatmasing-masing dan juga Garis PanduanMengenai Amalan PenyelesaianTuntutan.

Pada masa yang sama, Birojuga mengadakan mesyuaratdengan pengurus-pengurus tuntutanmembincangkan cara bagaimana aduandiselesaikan jika pertikaian tersebutdirujuk kepada pihak Biro.

Biro juga sentiasa mengadakanperbincangan tentang bagaimanamenguruskan kes aduan dengan lebihefektif sebelum pemegang polisi

memutuskan untuk memfailkan aduanmereka secara rasmi.

Insurans

Daripada jumlah 515 kes yangdikendalikan oleh Biro, hanya 170 kesyang membabitkan syarikat insuranshayat.

Kes-kes aduan ini terdiri daripadatuntutan kematian (47 kes), tuntutanfaedah hospital dan bedah (38 kes),tuntutan faedah hilang upayamenyeluruh dan kekal (27 kes),penyakit kritikal (16 kes), tuntutanfaedah kemalangan komprehensif/indemniti kemalangan (14 kes),tuntutan faedah penepian premium (8kes) dan tuntutan faedah komprehensif/kemalangan diri dan hospital (7 kes).

Daripada 170 aduan tersebut, Biro telahmenyelesaikan 146 kes iaitu 85.49peratus daripada jumlah kes yangdiselesaikan pada tahun lepas.Kebanyakan kes tersebut adalahtuntutan kematian dan tuntutan faedahhospital dan bedah.

Dalam laporan tahunan pada tahunlepas, Pengantara Insurans berkatamendidik pengguna merupakankomponen yang penting dalammeningkatkan perkhidmatan pelanggan.Pemegang-pemegang polisi hendaklahfaham sepenuhnya tentang polisi


insurans dan apakah tuntutan yang akandipenuhi oleh polisi tersebut.

Yang lebih penting pemegang-pemegangpolisi mestilah faham sepenuhnya akanhak-hak mereka sebagai penggunaketika membeli produk insurans hayatdaripada syarikat insurans, sama juga

seperti mereka membeli barang yangmudah rosak daripada syarikat-syarikatproduk pengguna.



“Pengguna adalah Raja”. Itulah yangsering diperkatakan. Apabila penggunamembuat aduan, si pembekalperkhidmatan atau penjual produkhendaklah memberi perhatian terhadapaduan tersebut. Sudah menjadikebiasaan para pengguna merunguttentang suatu perkhidmatan ataupunproduk atas berbagai-bagai sebab. Diantara sungutan-sungutan tersebut adayang berasas dan benar dan ada jugayang tidak.

Pada masa kini, para pengguna diMalaysia adalah lebih berpendidikan,berpengetahuan dan sedar akan hak-hak mereka. Mereka tidak akan teragak-agak untuk mempertahankan hakmereka jika keadaan memerlukan.

Nampaknya, para pengguna pada masakini terutamanya di kalangan pemegangpolisi hayat adalah lebih yakin tentangapa yang mereka inginkan daripadapolisi insurans yang telah mereka beli.Ini adalah petunjuk yang baik, bukansahaja untuk pemegang polisi padaumumnya tetapi juga bagi industriinsurans hayat. Ini adalah keranasyarikat insurans boleh berurusan

BAHAGIAN 3

KEPENTINGAN PEMEGANG POLISIDIUTAMAKAN

dengan lebih cekap dan bijak denganpara pemegang polisi yang sedar dansedia tahu apa yang mereka inginkan.

Pemegang polisi seperti para penggunapada umumnya mempunyai lapan jenishak asasi iaitu kepuasan, infomasi,pilihan, barangan dan perkhidmatanasas, kebebasan bersuara, kebebasanmenuntut tebus rugi, pendidikankonsumer serta suasana yang bersih danselamat.

Selain daripada para pengguna yanglebih berpengetahuan akan hak-hakmereka, industri insurans, yang telahmengalami keadaan ‘pembetulan’sepanjang 10 hingga 20 tahun yang lalu,juga mendapati bahawa masalah-masalah penginsurans yang tidak solven,amalan perniagaan yang tidak adil danoperasi yang tidak cekap adalah faktormangkin utama yang menyumbangkepada peningkatan tekanan dankritikan daripada pemegang polisiterhadap syarikat insurans hayat.

Pada tahun 1987, sembilan buahsyarikat insurans didapati gagalmemenuhi keperluan minimum


kesolvenan. Masalah tersebutbagaimanapun telah dapat diselesaikan.

Aduan-aduan terhadap industri insuranshayat boleh dikategorikan sepertiberikut:

1) kelewatan yang tidak munasabahdalam menyelesaikan suatutuntutan.

2) penyelesaian tuntutan yang tidakadil.

3) menjalankan operasi dengan kospemasaran yang tinggi.

4) pakatan sulit dan penetapan harga.5) perkhidmatan yang tidak

memuaskan kepada pemegangpolisi.

6) memberi maklumat yang palsu dantidak lengkap.

7) mengguna taktik jualan yangmendesakkan.

8) kurang profesionalisme.

Statistik daripada Bank Negara jelasmenunjukkan bahawa perasaan tidakpuas hati di kalangan pemegang polisikian bertambah bukan sahaja terhadapsyarikat insurans hayat tetapi jugaterhadap syarikat insurans am.

Pada tahun lepas, Bank Negara telahmenerima sebanyak 1,783 jumlah kesaduan daripada orang ramai terhadapsyarikat insurans. Daripada jumlah ini,290 aduan adalah terhadap syarikatinsurans hayat dan 1,493 terhadapsyarikat insurans am. Pada tahun 1997,

jumlah aduan bertulis yang diterimaadalah sebanyak 1,259 kes, suatu jumlahyang terendah yang pernah diterimaoleh Bank Negara.

Untuk menangani tekanan daripadapengguna yang kian meningkat, BankNegara telah menubuhkan BiroPerkhidmatan Pelanggan di dalamJabatan Pengawalan Insurans pada 1Julai 1998. Biro ini bertindak sebagaipusat rujukan bagi semua aduan yangditerima daripada orang ramai.

Pada awal tahun 1992, industri insuranstelah menubuhkan Biro PengantaraanInsurans sebagai saluran alternatif bagiorang ramai untuk menyelesaikanpertikaian mereka dengan syarikatinsurans hayat ataupun am.

Walaupun dengan langkah-langkahyang telah diambil ini, pihak industriinsurans hayat tidak berpeluk tubuhsahaja. Industri insurans telahmengambil langkah-langkah kawalansendiri bagi menangani tekanandaripada para pengguna yang kianbertambah. Langkah-langkah inidiperkenalkan dengan tujuan untuk:

1) memupuk disiplin danmengalakkan persaingan sihat dikalangan syarikat-syarikat dalamindustri insurans.

2) memberi elemen perlindungankepada para pemegang polisi.


Ramai telah mempertikaikan tentangkebaikan dan keburukan kawalansendiri. Langkah-langkah kawalansendiri pada asasnya adalah untukmemupuk tahap disiplin diri yang lebihtinggi di kalangan syarikat insuranshayat demi mengelakkan kawalanperundangan yang lebih ketat.

Undang-undang diluluskan olehParlimen untuk memastikan orangramai mematuhi undang-undang danperaturan. Ini merupakan perintahundang-undang dari peringkat atas kebawah.

Manakala langkah-langkah kawalansendiri adalah cara pengurusan dariperingkat bawah ke atas dan berupayabertindak balas terhadap keadaanyang berubah-ubah dengan lebihpantas berbanding dengan sistemperundangan.

Langkah-langkah kawalan sendiri adalahlebih senang dirangka berbandingdengan pengubalan undang-undang dimana proses mengubal sebahagian kecildaripada aspek undang-undang adalahrumit dan memakan masa yangpanjang.

Memang benar, langkah-langkahkawalan sendiri tidak mempunyai kuasaundang-undang kerana ia adalahtindakan secara sukarela. Oleh itu, jikasyarikat-syarikat insurans melanggarperaturan tersebut, para pemegang polisi

tidak boleh mengambil tindakanmahkamah untuk menanganikelemahan itu. Undang-undangditafsirkan oleh pihak mahkamah tetapikenyataan amalan ditafsirkan olehmereka yang mengubalnya.

Salah satu langkah kawalan sendiri yangpaling penting adalah denganpenubuhan Persatuan Insurans HayatMalaysia (LIAM) di mana Akta Insurans1996 telah mewajibkan semua syarikatinsurans hayat untuk menjadi ahlipersatuan ini. (Bagi insurans am,terdapat Persatuan Insuran AMMalaysia, atau lebih dikenali sebagaiPIAM).

LIAM telah diberi mandat untukmenguatkuasakan peraturan-peraturanyang telah dirangka oleh pihak berkuasa.Di antara tujuannya adalah untukmemastikan bahawa syarikat insuranshayat menjalankan perniagaan merekasecara profesional.

LIAM juga telah mengambil inisiatifmemperkenalkan memorandumperjanjian di antara syarikat-syarikat danmerangka garispanduan bagi membantumengawal pengurusan perniagaanyang lebih teratur. Ia juga bertujuanuntuk memastikan tingkah laku yangberetika dan profesional di kalanganpenginsurans dan para ejen.

Pada tahun 1991, sebagai langkah kearah kawalan sendiri yang lebih


berkesan, LIAM telah merangka KodEtika dan Tingkah Laku yangmerangkumi amalan dan jualaninsurans hayat untuk ahli-ahlinya.

Biro Pengantaraan Insurans jugamerupakan langkah kawalan sendiriyang telah ditubuhkan untukmenangani pertikaian di antarapemegang polisi dan syarikat insuransyang kian bertambah. Peranan Biro

Pengantaraan Insurans bertepatan sekalidengan Biro Perkhidmatan PelangganBank Negara dan langkah-langkahkawalan sendiri oleh LIAM (danPIAM), di mana kepentingannya tidakboleh dipertikaikan lagi.



BAHAGIAN 4

MEMAHAMI CARAMEMBUAT TUNTUTAN

Apabila seorang pemegang polisimembeli polisi insurans hayat, diamembeli suatu produk yang tidak ketaraiaitu suatu yang sukar didefinisikanataupun disukat dan tidak mempunyaibentuk fizikal.

Pemegang polisi sebenarnya membeli‘janji’ syarikat insurans hayat yangmenjanjikan bayaran jikalau berlakunyakematian, kecederaan akibat daripadakemalangan atau dimasukkan kehospital kerana penyakit.

Untuk menerima sejumlah bayaranyang telah ditentukan nilainya,pemegang polisi akan membayarpremium tahunan dan bergantung padakejujuran dan reputasi syarikat insuranshayat untuk memenuhi kewajiban dantanggungjawab mereka.

Oleh sebab itu kerajaan terpaksamengenakan kawalan yang ketat ke atassyarikat insurans hayat (dan am) keranapembelian produk yang tidak ketara inidi mana pemegang polisi terpaksabergantung pada kejujuran dan reputasisyarikat insurans hayat untukmemenuhi tanggungjawab mereka.

Insurans bukanlah subjek yang mudahdifahami oleh orang biasa keranakontrak pembelian insurans hayatlazimnya ditulis dalam bahasa danistilah undang-undang. Disebabkan inijugalah kerajaan mengenakan kawalanyang ketat ke atas amalan perniagaansyarikat insurans hayat.

Industri insurans juga dikawal seliadengan ketat kerana insurans hayat (danam) mempengaruhi kepentingan orangramai. Insurans hayat adalah salah satubentuk perlindungan kewangan bagiindividu, keluarganya dan/atauperniagaannya.

Jikalau syarikat insurans hayat gagalmenunaikan ‘janji’ mereka untukmenunaikan bayaran setelah menerimapremium-premium tahunan dan apabilapolisi matang, kegagalan ini akanmenjejaskan ramai pemegang polisi.

Premium insurans hayat dianggapsebagai suatu simpanan jangka panjang.Jikalau syarikat insurans hayat gagalmemenuhi kewajiban mereka, ia akanmembawa akibat buruk terhadappendapatan masa depan seseorang.


Akta Insurans 1996 mengawal seliasyarikat insurans hayat (dan am) tentangcara mereka beroperasi, cara bagaimanamereka menguruskan perniagaan danmemastikan perlindungan yangdiberikan mencukupi demi menjagakepentingan pemegang polisi danmengenakan penalti terhadap syarikatinsurans yang gagal memenuhikewajiban mereka.

Akta juga menyediakan prosedurtuntutan terhadap syarikat insuranshayat (dan am) untuk keadaan di manapemegang polisi telah terlibat dalamkemalangan dan dimasukkan kehospital, atau meninggal dunia keranasakit atau kemalangan, dan apabilapolisi matang.

Prosedur Tuntutan Kemalangan

1) Suatu notis bertulis tentangkecederaan yang dialami hendaklahdiserahkan kepada syarikat insuranshayat dalam tempoh 20 hari selepaskemalangan berlaku. Jika gagalberbuat demikian dalam tempohyang ditetapkan, surat penjelasanadalah diperlukan.

2) Pemegang polisi hendaklahmengisikan borang tuntutan secarajujur dan memberikan segalamaklumat secara terperinci. Borangtuntutan dibahagikan kepada duabahagian. Bahagian 1 untuk

dilengkapkan oleh pemegang polisidan Bahagian 2 oleh doktor.Bayaran laporan perubatanditanggung oleh pemegang polisi.

3) Dokumen-dokumen berikut perludisertakan untuk menyokongtuntutan:• Sijil perubatan dan sijil tugas

ringan.• Filem x-ray atau laporan pakar

radiologi jikalau terdapat tulangyang patah.

• Kad rawatan susulan pesakitluar.

• Nota dibenarkan keluardaripada hospital.

• Laporan polis bagi kes-keskemalangan kenderaan.

• Keratan akhbar tentangkemalangan tersebut, jika ada.

• Gambar foto menunjukkankecederaan yang dialami, jikaada.

Prosedur Tuntutan Hospital

1) Suatu notis secara bertulis atau lisantentang tuntutan hendaklahdiberikan kepada syarikat insuranshayat dalam jangka masa yangmunasabah (mengikut peruntukankontraktual syarikat insurans dalamkontrak yang ditandatangani olehpemegang polisi) tentang tarikhbermulanya dimasukkan kehospital.


Pemegang polisi

2) Bukti-bukti pemegang polisi telahdimasukkan ke hospital hendaklahdiserahkan kepada syarikat insuransdengan perbelanjaan sendiripemegang polisi dalam tempoh30 hari selepas pemegang polisidibenarkan keluar daripadahospital.

3) Pemegang polisi hendaklahmelengkapkan borang tuntutan.

4) Laporan hospital hendaklahdilengkapkan oleh doktor dankosnya dibiayai oleh pemegangpolisi.

5) Pemegang polisi hendaklahmenyerahkan resit dan bil asaluntuk menuntut pembayaran balik.

Prosedur Tuntutan Kematian

Bagi polisi insurans hayat, tuntutankematian boleh ditanding ataupun tidakboleh ditanding.

1) Tuntutan boleh ditanding adalahuntuk kes kematian yang berlakudalam tempoh dua tahun daripadatarikh polisi dikeluarkan atau tarikhpolisi dikuatkuasakan semula,mana-mana yang terkemudian.

Terdapat dua jenis tuntutankematian boleh tanding:

a) Bagi kematian secara normal,dokumen-dokumen yang mestidiserahkan oleh pihak menuntutadalah: kenyataan doktorperubatan, sijil kematian,kenyataan pihak menuntut, limasalinan borang Aplikasi AbstrakKlinikal (yang ditandatanganidan disaksikan), bukti talipersaudaraan, polisi yangditandatangani oleh pemegangpolisi yang telah meninggaldunia dengan syarikat insuranshayat. Dan bukti umur (jika adapercanggahan).

b) Bagi kematian akibatkemalangan, dokumen-dokumen yang diperlukanadalah: sama seperti dokumenyang diperlukan untuk kematiansecara normal dengan laporanbedah siasat, laporan polis dankeratan akhbar (jika ada).

2) Kematian tidak boleh ditandingjuga mempunyai dua jenis:

a) Bagi kematian secara normal,dokumen yang perlu diserahkanadalah: sijil kematian, kenyataanpihak menuntut, bukti talipersaudaraan dan bukti umur(jika ada percanggahan).

b) Bagi kematian akibatkemalangan, dokumen yangdiperlukan adalah: semua


dokumen yang diperlukanuntuk kematian secara normal,termasuklah laporan bedahsiasat, laporan polis dan keratanakhbar (jika ada).

Bagi polisi kemalangan diri, pewarisbagi orang yang diinsuranskan (atauyang telah meninggal dunia) bolehmembuat tuntutan denganmenyerahkan dokumen-dokumen yangberikut:

1) Sijil kematian, asal atau salinanyang disahkan.

2) Kenyataan si penuntut yangditandatangani dan disaksikan olehseorang yang tidak mempunyaikepentingan terhadap tuntutantersebut.

3) Kontrak polisi yang ditandatanganioleh orang yang telah meninggaldunia dengan syarikat insuransnya.

4) Laporan polis.

5) Laporan bedah siasat ataukenyataan doktor perubatan yangdilengkapkan oleh doktor yangterakhir merawat orang yangdiinsuranskan itu, jika laporanbedah siasat tidak dapat diperoleh.

6) Bukti tali persaudaraan seperti sijilperkahwinan atau sijil suratberanak.

Prosedur Tuntutan Kematangan

Bagi polisi insurans hayat endowmen,syarikat insurans akan membayarjumlah yang diinsuranskan apabila polisimatang jika pemegang polisi masihhidup pada penghujung tempohkontrak.

Syarikat insurans lazimnya akanmenghubungi pemegang polisi tentangpolisi endowmennya yang akan matang,dan meminta pemegang polisi mengikutprosedur berikut:

1) Syarikat insurans akan menghantarborang pengenalan, borangmandiri (survival) dan borangpelepasan kepada pemegang polisiuntuk dilengkapkan. Borang-borang ini hendaklah dikembalikankepada syarikat insurans bersamadengan kontrak polisi.

2) Jika pemegang polisi adalah orangyang diinsuranskan, beliauhendaklah memberikan buktiumur, bukti masih hidup, baucarpelepasan yang lengkap danmenyerahkan semua ini bersamadengan dokumen polisi.

3) Jikalau pemegang polisi bukanorang yang diinsuranskan, beliauhendaklah menyerahkan surat serahhak atau dokumen hak milik yanglain dankenyataan ringkas yangmenyatakan bahawa orang yang


diinsuranskan masih hidup tetapitidak dapat menandatangani sijilmandiri (survival).

Polisi insurans hayat endowmenlazimnya memberikan beberapa pilihanpenyelesaian yang boleh dilaksanakanoleh pemegang polisi apabila polisimereka matang. Biasanya terdapatempat pilihan:

a) Perolehan kematangan tunai.

b) Menukarkan perolehan kematangankepada anuiti, sama ada anuiti pastiatau anuiti hayat.

c) Membiarkan perolehan kematangansebagai deposit dengan syarikatinsurans mengikut terma-termayang dipersetujui.

d) Mengeluarkan perolehankematangan secara beransuran bagitempoh beberapa tahun. Faedahakan dikreditkan ke atas baki dalamakaun.

• Utusan Malaysia, 3 September 2001.

51

Ahli-Ahli Persatuan Insurans Hayat Malaysia

Member Companies of the LifeInsurance Association of Malaysia

1. Aetna Universal Insurance Berhad

2. AMAL Assurance Bhd

3. American International Assurance Company Limited

4. Arab-Malaysian Assurance Berhad

5. Asia Life (M) Berhad

6. EON CMG Life Assurance Berhad

7. Great Eastern Life Assurance (Malaysia) Berhad

8. Hannover Life Re, Malaysian Branch

9. Hong Leong Assurance Berhad

10. John Hancock Life Insurance (Malaysia) Berhad

11. Malaysia National Insurance Berhad

12. Malaysian Assurance Alliance Berhad

13. Malaysian Life Reinsurance Group Berhad

14. Mayban Life Assurance Berhad

15. MBA Life Assurance Berhad

16. MCIS Insurance Berhad

17. Prudential Assurance Malaysia Berhad

18. Talasco Insurance Berhad

February 2002