ASISA STANDARD ON THE CLAIMS REGISTER
(October 2015)
CONTENTS
Para
Title
1.
Introduction: Purpose and Status
2.
Definitions
3.
Scope
4.
The Basic Rules
5.
Access by ASISA members
6.
Access by the Public
7.
The right to privacy
8.
Security of information
9.
Suspension of rights to access
Annexure A - Claims Register Enquiries Protocol
1.
INTRODUCTION: PURPOSE AND STATUS
1.1
The insurance risks which insurers are asked to cover, and the claims they are asked to
pay, must be properly assessed. To do proper claims assessment and to discourage fraud,
insurers must be able to obtain all information relevant to those risks and claims.
1.2
The Claims Register is a data base through which insurers can share information about
persons who are the lives assured under policies and who have made “notifiable claims”
that are relevant to the assessment of future claims.
1.3
It is important to note that:
1.3.1
1.3.2
1.3.3
1.3.4
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the exchange of information is necessary to achieve certain objectives, such as
facilitating the rating of risks;
the information shared comprises a compilation of information rather than
calculations;
the exchange of information does not contain any indication of the level of
commercial premiums; and
the information is made available free of charge and on reasonable and nondiscriminatory terms to the consumer.
2.
DEFINITIONS
In this Standard, the following definitions apply:"Group scheme" means a scheme under which individuals belonging to a group are insured.
"Notifiable claim" is defined in paragraph 4.5
"The Republic" is South Africa
"The SADC States" are Angola, Botswana, Lesotho, Malawi, Mozambique, Namibia, Swaziland,
Tanzania, Zambia and Zimbabwe.
3.
SCOPE
3.1
Territory
The Claims Register relates to policies sold in South Africa and Namibia.
3.2
Business
The Claims Register relates solely to Life policies issued in respect of -
4.
2
(a)
group schemes
(b)
death benefits
(c)
disability benefits
(d)
dread disease benefits
(e)
medical lifestyle benefits
THE BASIC RULES
4.1
Direct writing offices shall populate the register on notification, of any notifiable claim.
4.3
Reinsurance offices have only read access.
4.4
Single notifications should be submitted for each life under group scheme policies.
4.5
A member office may not base a decision to repudiate or honour a claim solely on the
information listed in the Claims Register.
4.5
"Notifiable claims" are risk claims that meet the following criteria:
4.5.1
Early claims

Individual or group scheme death claims:
o

Individual or group scheme disability or functional impairment claims:
o

4.5.2
on policies in force for less than 3 years from date of entry, revival or
ad hoc increase.
on policies in force for less than 3 years from date of entry, revival or
ad hoc increase. This includes both functional and physical
impairment and both lump sum and income disability (PHI) claims.
Hospital Cash Cover:
o on policies in force for less than 3 years from date of entry, revival or
ad hoc increase.
Claims under special investigation
Claims that are under forensic investigation.
4.5.3
Fraudulent claims
Claims that have been found to be fraudulent.
4.5.4
Claims that have been repudiated/declined
Claims that have been repudiated.
4.5.5
Dread Disease benefit
All claims in respect of dread disease benefits.
4.5.6
Claims originating outside South Africa
All claims that arise from outside the SADC countries.
4.5.7
Disability Income Claims/Sickness Benefits
Individual or group scheme disability income claims or sickness benefits where:



4.5.8
the disability income or sickness benefit is greater than R 35 000.00 per
month, per policy, or
the insurer has cancelled the benefit due to non-disclosure or
the benefit was paid for longer than 6 months.
Beneficiary
For individual or group scheme death claims:

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where the beneficiary is not a close family relation of the life insured or

4.5.9
where the beneficiary is an intermediary.
Retrenchment
All claims in respect of retrenchment benefits.
5.
4.6
An office shall update the Claims Register within 48 hours after seeing a notifiable claim.
4.7
The life office concerned must correct or withdraw incorrect entries within 48 hours of
realising their mistake.
4.8
Notifications to the Claims Register shall be effected by means described in the “Life and
Claims Register User Manual” which is provided to member offices by Astute. The Claims
Register is hosted and maintained by Astute.
ACCESS BY MEMBER OFFICES
5.1
Access to the Register
Access by member offices to the Claims Register is restricted to the Claims Assessors and
Medical Underwriters of that member and to senior personnel expressly authorised in
writing by either of those two officers. Member offices are required to keep a register of
personnel that have access to the Register to ensure that access is terminated when a
staff member resigns or moves to a different position within the organisation.
5.2
Access to supporting documentation:
A member office may obtain supporting documentation from other members.
A member asked to furnish information in terms of this paragraph, shall do so within three
working days to enable the enquiring office to come to a decision.
6.
ACCESS BY THE PUBLIC
Should an enquiry be made by a member of the public to Astute or to the member office about an
entry on the Claims Register, the enquiry must be dealt with in accordance with the protocol
contained in Annexure A which may be amended by the ASISA Claims Standing Committee from
time to time and a replacement circulated by ASISA.
7.
THE RIGHT TO PRIVACY
Members must at all times ensure that they are compliant with the provisions of the Protection of
Personal Information Act (PPI) as well as any industry Code of Conduct approved under PPI. PPI
aims to give effect to the constitutional right to privacy by safeguarding personal information and
regulates the manner in which personal information must be processed. Members must clearly
disclose to the client why the information is needed and what it will be used for and that in order
to assist with underwriting and assessment of claims it may be exchanged with other insurers or
reinsurers through a shared database.
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Guidance on wording of the disclosures and consent is set out below:
PROTECTION OF PERSONAL INFORMATION DISCLOSURES
I understand that:

my insurer requires access to my personal information, including medical information, in order
to assess this (or any other) application for insurance made by me for underwriting purposes
and consideration of any claim for benefits;

my personal information may be shared with other insurers or reinsurers either directly or
through a data base for the same purposes of underwriting risks and assessing claims and my
insurer may also collect my personal information from other insurers - exchange of
information helps to save costs and combat fraud;

my personal information will be treated in accordance with applicable law, for example it
will be safeguarded and treated as confidential;

the provision of this information is a compulsory requirement from my insurer to provide me
with this insurance product. If I choose not to provide this information my insurer will not be
able to assess my application for insurance;

I can request details of the information held by my insurer and request its correction where
appropriate.
and I authorise a doctor, hospital or any other person to provide this information to my insurer.
-----------------------------------------------------------------Written or electronic signature of applicant (and life assured if different person)
8.
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SECURITY OF INFORMATION
8.1
In view of the important aspects of privacy and the Authorisation in respect of the limited
information gathering, use and sharing must be strictly limited as set out in this
paragraph.
8.2
Information obtained from the Claims Register shall be used only for the bona fide
purposes of member offices, and shall not be made available to any office which is not a
member of ASISA.
8.3
Offices shall be responsible for ensuring 8.3.1
that any information that has been obtained from the Claims Register, is kept
entirely private and confidential;
8.3.2
that all system/computer access to the Claims Register data be limited to bona
fide claims assessors and medical underwriters;
8.3.3
that the information held on the Claims Register is complete and accurate.
9.
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8.4
The data contained on the Claims Register is the property of the participating members of
ASISA.
8.5
When an office ceases to be an ASISA member it shall destroy all Claims Register data held
on its computer systems and files and confirm (within 7 days after its membership ceases)
that this has been done.
8.6
Member offices may make use of the services of Information Technology provided that
they ensure that the confidential nature of the Claims Register is maintained.
SUSPENSION OF RIGHTS TO ACCESS
9.1
A member shall at the written request of ASISA subject itself to an inspection aimed at
determining whether the member has fully complied with the provisions of this Standard,
particularly the member’s obligations in respect of notifiable claims.
9.2
Without derogating from the generality of paragraph 9.1, the members shall9.2.1
grant the nominated party and/or its auditors access to all relevant policies and
other documentation;
9.2.2
provide the nominated party with all information reasonably required; and
9.2.3
generally fully co-operate with the nominated party in order to achieve an
effective inspection.
9.3
ASISA may, subject to the provisions of paragraph 9.4, at any time suspend or revoke the
right of access of a member office to the Claims Register if it is satisfied that the member
failed to fully comply with its obligations in terms of this Standard, including the
provisions of clause 9.1 and 9.2.
9.4
Before suspending the right of access of a member office, ASISA must inform the member
office of its intention to suspend or revoke its right of access and afford the member
office a reasonable opportunity to respond to the allegation of non-compliance.
Annexure A
CLAIMS REGISTER ENQUIRY PROTOCOL
When an enquiry is made to a member office by a member of the public (or anyone else on behalf of such a
person) about the possible existence and/or the nature of entries relating to that person that might appear
on the Claims Register, the member office should take the action as set out below:
1. Provide the enquirer with a copy of the "Notice for the benefit of consumers" as well as the enquiry
form, as set out in the attachment to this Annexure.
2. The listing member office shall, on receipt of a written enquiry (in the prescribed format) advice the
person making the enquiry whether there are any entries on the Claims Register relating to him/her.
Should no entries exist on the Claims Register relating to that person that will be the end of the matter.
3. Should the Register show that an entry does exist, the person making the enquiry will at the same time
be advised by Astute or the particular member office that life office A/B/C has activated an entry on the
Register and that the relevant information about the entry will shortly be supplied to the person to
whom the information relates.
4. Should the accuracy of the information on the Register be questioned by the person to whom the
information relates, this issue is to be dealt with between that person and the relevant life office.
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ASSOCIATION FOR SAVINGS AND INVESTMENT (ASISA)
Notice for the benefit of consumers
It is critical for present and future policyholders that insurance companies remain financially healthy so
that their products remain affordable. To achieve this, all underwriting and claims applications must be
assessed using information that is available to both applicant and their insurance company. This includes
information from a variety of sources including that of other insurance companies.
ASISA has developed a Register which allows the exchange of information between insurance companies,
to ensure information can be accessed by all ASISA members. The Register is not only beneficial to
insurance companies, but also to the client in cases such as the unintentional non-disclosure of
information. In some instances clients forget to disclose relevant information which will then be picked
up when performing an enquiry on the Register. This in turn will limit the repudiation of claims.
The Register contains information such as medical conditions, information pertaining to your occupation
and details of any previous claims.
The process is as follows:
Insurer A obtains medical, financial underwriting or claim related information during application
underwriting or assessing a claim. It is put into an electronic database shared by all ASISA members.
Confidentiality is strictly observed in each company by ensuring that access to this information is limited
to certain authorised personnel only. Insurer B, if it needs this information to assess a risk or claim, may
access it from the database or from insurer A.
Details regarding this information may be obtained by submitting a request to the insurance company
responsible for the listing on the Register. The company responsible for the listing will then arrange for
non-medical information to be disclosed directly to the person to whom the information relates, and
medical information to be disclosed to a nominated medical attendant.
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CLAIMS REGISTER ENQUIRY FORM
INFORMATION ON THE RECORDS OF THE CLAIMS REGISTER
Kindly provide me with information about any entry relating to myself which might appear on the Claims
Register.
I hereby supply you with the following information which you require to enable you to ascertain with
certainty that the information does in fact relate to me:
1. Surname:
_______________________________________________
2. First name:
_______________________________________________
3. Initials of other names: _______________________________________________
4. Date of birth: _____________ (Day) _________ (Month) _______________ (Year)
5. Current address:
_______________________________________________
_______________________________________________
_______________________________________________
6. Fax and/or telephone
number:
_______________________________________________
Signature:
_________________________
Date:
_________________________
Note: Should this enquiry be made on behalf of another person, please attach the written authorisation of such person.
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