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Teman Anda Sepanjang Hayat Your Friend For Life

Mempermudahkan Tuntutan Insurans Hayat Life Insurance Claims Made Easy

LIFE INSURANCE ASSOCIATION OF MALAYSIA

Teman Anda Sepanjang Hayat Your Friend For Life

Mempermudahkan Tuntutan Insurans Hayat Life Insurance Claims Made Easy

LIFE INSURANCE ASSOCIATION OF MALAYSIA
No. 4, Lorong Medan Tuanku Satu Medan Tuanku, 50300 Kuala Lumpur Tel: 2691 6168, 2691 6628, 2691 8068 Fax: 2691 7978 E-mail: [email protected] Http: //www.liam.org.my

PRAKATA
Babak terakhir setiap polisi insurans hayat adalah tuntutan nilai yang diinsuranskan. Ini dilakukan oleh sama ada penama orang yang diinsuranskan yang telah meninggal dunia atau orang yang diinsuranskan itu sendiri sekiranya dia masih hidup semasa polisi insuransnya matang. Membuat tuntutan insurans adalah mudah tetapi rumit. Ia memerlukan berbagai jenis dokumentasi, khususnya untuk membuktikan bahawa orang yang berhak ke atas wang polisi adalah orang yang dinyatakan dalam polisi insurans tersebut dan terdapat prosedur-prosedur penting yang perlu dipatuhi. Industri insurans hayat telah menetapkan peraturan-peraturan membuat tuntutan untuk memastikan tiada sebarang implikasi undang-undang terhadap syarikat insurans hayat. Buku kecil ini menjelaskan langkah-langkah yang perlu diambil oleh penama atau orang yang diinsuranskan itu sendiri untuk membuat tuntutan insurans. Ia juga menerangkan cara-cara membuat tuntutan untuk bayaran bil perubatan atau hospital bagi kes kemalangan. Buku ini adalah sebahagian daripada projek yang telah dilaksanakan oleh Persatuan Insurans Hayat Malaysia (LIAM) untuk mendidik orang ramai tentang berbagai aspek insurans hayat. Ia merupakan kompilasi rencana-rencana yang telah diterbitkan bersama Utusan Malaysia, New Sunday Times dan Nanyang Siang Pau.

L. Meyyappan Presiden Persatuan Insurans Hayat Malaysia Kuala Lumpur Februari 2002

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PREFACE
The final chapter of any life insurance policy is claiming the sum insured. This is done either by the nominee of the person insured who has passed away, or by the insured himself/herself if he/she is still alive on the date of the maturity of the life insurance policy. Claims for sums insured are easy, and yet not so easy, to make. Various documentations are involved, mainly to prove the person entitled to the money is really the person mentioned in the life insurance policy. Above all there are procedures to follow; rules that have been set down by the life insurance industry to ensure that there would be no legal backlash on the life insurance company concerned. This booklet explains the various steps to be taken by the beneficiary, or the insured himself/herself, to make a proper claim for the sum insured. It also explains how claims are made for payment of medical bills or hospitalisation in cases of accident. This booklet is part of an ongoing programme undertaken by the Life Insurance Association of Malaysia (LIAM) to educate Malaysians in various aspects of life insurance. It is a compilation of articles that first appeared in the New Sunday Times, Utusan Malaysia and Nanyang Siang Pau newspapers.

L. Meyyappan President Life Insurance Association of Malaysia Kuala Lumpur February 2002

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Kandungan/ Contents/ Diterbitkan di Utusan Malaysia: 1. Isu Tentang Kes-kes Aduan 2. Pemegang Polisi Mesti Faham Hak Tuntutan 3. Kepentingan Pemegang Polisi Diutamakan 4. Memahami Cara Membuat Tuntutan

1 4 7 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 27 The Simple and Easy Way 7. Looking at Ways of Filing Death and Maturity Claims 30

1. 2. 3. 4. 5. 6. 7. 8.
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32 35 37 39 41 43 45 48
Contents of the articles in Bahasa Malaysia, English and Mandarin may differ due to updating 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 any misstatement expressed in the booklet. LIAM welcome the reproduction of any section of the booklet without prior permission.



ARTICLE 1

IMB AN EXTRA AVENUE FOR POLICYHOLDERS TO SETTLE DISPUTES
MEDIATION BUREAU AND DISPUTE RESOLUTION
CASE ONE: Angie Tan was diagnosed as suffering from “mitral stenosis”. She underwent a surgery known as “precutaneous transvenous mitral commisurotomy or PMTC” to correct the heart valve defect. Tan submitted her claim under the living assurance rider benefit, which states: In the event of either the death of the Life Assured or the Life Assured being diagnosed as suffering from any major illness as defined in section IV, the company shall pay the amount of benefits.... Under Section IV is the definition of major illness, where one of it is “Heart Valve Surgery” which is defined as “The actual undergoing of open-heart surgery to replace and/or dilate cardiac valves as consequence of heart valve defects”. The insurance company repudiated the claim on the ground that the definition of “Heart Valve Surgery” has not been fulfilled.
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It was not disputed that Tan was diagnosed as suffering from heart valve defect. The issue was whether her life insurance policy intended to provide the benefits based on the illness suffered by the assured or on the surgery performed. Under the heading “Definition of Major Illnesses”, it was included “Heart Valve Surgery”. But heart valve surgery is not an illness. It is a form of treatment. The illness which requires surgery is “Heart Valve Defect”. In the absence of such an expression as “.... as shall include either the diagnosis of any of the following illnesses or performance of any of the covered surgeries included therein....” under the definition of “Major Illnesses”, the Insurance Mediator was sceptical as to whether the insurance company could insist on the payment of the policy based on the surgery performed instead of the illness suffered, that is heart valve defect. The insurance company conceded that certain ambiguity of intention might have arisen from the preamble
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description of “diagnosis of major illness” . The insurance company subsequently revised its decision and accorded the benefit of the doubt to Tan, and settled the claim on an exgratia basis.

CASE TWO: K. Nathan bought a life insurance policy with a supplementary accidental coverage. A few years later he was found dead by the roadside not far from his home. The nominee under the policy submitted a death claim to his insurance company. But the insurance company repudiated the claim on the ground that according to a toxicology report the alcohol content in the blood of the deceased was 332 milligram ethanol/100 millilitre and the deceased was thus considered to be intoxicated at the time of his death. The insurance company relied on a provision in the supplementary accidental contract which stipulates that the insurance company would not be liable for injury or death resulting directly or indirectly caused or accelerated by (iii) being under the influence of intoxicating liquor or any narcotic or drug. A post-mortem was carried out, and according to the report the cause of
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death of the deceased was asphyxia due to manual strangulation. Thus, the cause of death was not due to or accelerated by being under the influence of intoxicating liquor which is excluded under the policy. The Insurance Mediator ruled in favour of the late Nathan’s nominee, and the insurance company paid the claim.

CASE THREE: Mohd Razlan bought a personal accident policy. One day he submitted a claim under the policy alleging that he accidentally knocked himself against his car’s side mirror, injurying his eye and bleeding from the nose. He was admitted to the hospital. According to the medical report, Razlan was found to have thrombocytopenia on admission and the doctor reported that the nose bleeding was probably the result of thrombocyltopenia as no mass lesion or other abnormality was noted in the nose and the nasopharynx. The insurance company repudiated the claim on the ground that Razlan’s condition did not satisfy the requirement of the policy, which is bodily injury affected directly or independently of all other causes by violent accidental external and visible means.
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The Insurance Mediator ruled in favour of the insurance company based on the medical report that the thrombocytopenia condition of Razlan would constitute “other causes”. The above are three of the many examples of disputes involving holders of life insurance policies and their respective insurance companies that have come before the Insurance Mediation Bureau (IMB) last year. Set up by the insurance industry in 1992, the IMB is an alternative channel to resolve claims disputes between policyholders and their insurance companies. Bank Negara already has a Customer Service Bureau (CSB) within its Insurance Regulation Department that handles complaints and enquiries on insurance matters from the public. The CSB works closely with insurance companies and insurance associations to resolve grievances against insurance companies. It also analyses trends

emerging from complaints received in order to identify and address persistent problems in insurance practices. The CSB ’s functions are further enhanced by a computerised database system on public complaints against financial institutions, which enables expeditious handling of public complaints. However, the CSB is a department under the administration of Bank Negara. The IMB, which is not a department under Bank Negara, is an additional avenue for policyholders to settle their disputes with their respective insurance companies. IMB is headed by an Insurance Mediator, who oversees the operations and reports to a Council. Above the Council is a Board of Directors. The IMB has 53 life and general insurance companies as members.

• New Sunday Times, 11 November 2001.

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ARTICLE 2

SCOPE OF IMB CONFINED TO CLAIMS UP TO RM100,000 AGAINST FIRMS
As mentioned previously, the Insurance Mediation Bureau (IMB) was set up by the insurance industry in 1992 as an alternative channel to resolve claims disputes between policyholders and their insurance companies. According to Bank Negara, the scope of the IMB is confined to claims by policyholders against their own insurance companies (excluding third party claims) for claims of amounts up to RM100,000 per claim. The Insurance Mediator’s functions are listed as: 1) To act as a counsellor or conciliator in order to facilitate the satisfaction, settlement or withdrawal of the complaint; 2) To act as an investigator and adjudicator in order to determine the complaint by upholding or rejecting it wholly or in part; 3) Where the complaint is upheld, wholly or partially, to make a monetary award against the
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insurance company (which is a member) binding up to RM100,000 and being a recommendation only as to any excess; and 4) To make such recommendations or such representations as he thinks fit to the complainant, to the insurance company or to the Council. However, neither the complainant nor the Council shall be informed of any recommendation or representation as to any payment (ex gratia or otherwise) being made by the insurance company unless that company agrees to divulge the information. The IMB has come out with a standard procedure how policyholders can make a complaint against their respective insurance companies. Any policyholder who is not satisfied with the decision of the senior management of an insurance company which is a member of the IMB may write to the Insurance Mediator giving
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details of the dispute, the name of the insurance company and the policy number. Copies of correspondence between the policyholder and the insurance company may be sent to facilitate tracing the case file kept by the company. However, before the complaint is referred to the Insurance Mediator, it must be considered first by a senior officer of the insurance company. When the offer or observations of the senior officer are not accepted by the policyholder, the matter can then be referred to the Insurance Mediator; but within six months after the senior officer has made his offer or observations. The policyholder does not have to pay a single sen to refer his case to the Insurance Mediator After the case is heard, and when the Insurance Mediator makes an award against an insurance company, the policyholder is required to inform him whether he accepts the award within 14 days, so that the company can be informed of his decision.

There is no appeal procedure within the IMB. If the policyholder does not wish to accept the award, he may reject the decision of the Insurance Mediator, and he is free to institute civil court proceedings against the insurance company or refer it to arbitration. On the other hand, once the Insurance Mediator directs that a claim must be paid, the insurance company is bound by that decision. The IMB is not responsible for handling payment following the decision of the Insurance Mediator. The insurance company when informed of the acceptance of the award is required to remit the amount direct to the claimant within 30 days. At present, the IMB does not charge any fees for services provided to resolve the dispute.

• New Sunday Times, 18 November 2001.

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ARTICLE 3

REDUCING IMB’S WORKLOAD THROUGH EDUCATION
In buying a life insurance policy, a consumer must know what he is getting into. He must take the initiative to study the terms and conditions of his policy, and to take precaution to comply with them. Consumers are advised to ask the servicing agents to explain details of the policy coverage, its benefits and the exclusion/limitations in the policy. This is important to enable the consumers to fully understand what is covered and not covered under the policies. So when a policyholder complains against his life insurance company, there is always a likelihood that the policyholder may not have fully understood the terms and conditions of his policy that he has signed. Despite the fact that some times the policyholder may be in the wrong, life insurance companies do have a heart in ensuring that they provide the best of services to their respective policyholders. After all the policyholders are their customers, and by giving them good customer services, word of mouth will help spread the good image of that life insurance company. Due largely to the fact that life insurance companies are handling amicably the complaints of their respective policyholders, the increase in the number of complaints against life insurance companies has slowed considerably. For instance in year 2000, the number of complaints against life insurers recorded at 290 cases out of a total of 1,783 complaints received throughout the insurance industry. However, if we compare the number of complaints received to policies in force, this figure is a negligible 0.004 per cent. Most of the complaints last year were with regards to agency matters, delay in settling claims and repudiation of liability with reference to conditions of policy contract.

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But not all the complaints against life insurance companies reached the Insurance Mediation Bureau (IMB), though, the number of cases handled by IMB has risen four-fold from 110 in 1996 to 463 in 1999. Last year the IMB handled 515 complaints, an increase of only 11.2 per cent. The Insurance Mediator in his report for 2000 said that the reduction in the percentage of the number of reference handled by the IMB might provide an indication that the policyholders were satisfied with the decisions of their insurance companies. It also indicated that the internal complaint procedures of the insurance companies and the Guidelines on Claims Settlement Practices had been complied with. At the same time, the IMB also held meetings with claims managers on how to resolve complaints with an understanding of what would happen if the disputes were to be referred to the IMB. Discussions were also held on how to deal more effectively with cases before they become formal complaints.

Of the 515 cases the IMB handled, only 170 were complaints against life insurance companies. They comprised mainly death claims (47 cases), hospital surgical benefit claim (38 cases), total and permanent disability benefit claim (27 cases), dread diseases (16 cases), comprehensive accident benefit/accident indemnity claim (14 cases), enhanced payor waiver of premium benefit claim (eight cases) and comprehensive/personal accident and hospitalisation benefit claim (seven cases). And of the 170 complaints, the IMB completed and resolved 146 cases last year. The bulk of the cases were mainly death claims and hospital surgical benefit claims. Policyholders must also fully understand their rights as consumers when buying life insurance products from insurance companies, like they would when buying perishable products.

• New Sunday Times, 25 November 2001.

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ARTICLE 4

DEALING WITH CLIENTS WHO ARE MORE AWARE OF RIGHTS
It has always been said that The Consumer is the King. And when a consumer complains, the provider of a service or seller of a product listens. However, buyers of a service or product do complain most of the time for one reason or another. And sometimes such complaints are genuine, sometimes not. Malaysian consumers today are more educated, knowledgeable and aware of their rights, and have become less hesitant to pursue their rights. There seems to be an awakening among local consumers, specifically life insurance policyholders of what they want of their policies that. This is a good sign, not just for the policyholders in general but also for the life insurance industry at large, as insurance companies are now able to deal more intelligently with policyholders. Policyholders, as consumers, essentially have eight basic rights: Satisfaction, information, choice, basic goods and services, need to be heard, seek redress, consumer education and safe
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and clean environment. Apart from Malaysian consumers being knowledgeable about their rights, the insurance industry, which itself underwent a change in the last 10 to 20 years, also saw the problems of insolvent insurers, unfair trade practices and inefficient operations as the main catalyst in boosting growing pressures and criticisms from policyholders against the life insurance companies. In 1987, nine insurance companies were found to be have failed to meet the minimum solvency requirements. The problem has since been resolved. Complaints against the life insurance industry can be categorized as: 1) Unreasonable delays in settling claims 2) Unfair claims settlement 3) Operating at high marketing costs 4) Collusion and price fixing 5) Poor service to policyholders 6) Providing incomplete and false information 7) Resorting to pressure selling 8) Lack of professionalism
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From the statistics provided by Bank Negara it is clear that there is growing dissatisfaction of policyholders not only with life insurance companies but also general insurance companies. Last year Bank Negara received a total of 1,783 complaints from the public against insurance companies, of which 290 were against life insurance companies. In 1997, the total number of written complaints amounted to 1,259, which was the lowest received by Bank Negara.

To resolve this growing consumer pressure, Bank Negara on July 1, 1998 set up a dedicated Customer Services Bureau (CSB) within its Insurance Regulation Department, which acts as a central point of reference for all complaints from the public.

• New Sunday Times, 9 December 2001.

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ARTICLE 5

SELF-REGULATORY MEASURES IN INSURANCE INDUSTRY
In addition to Bank Negara’s Customer Services Bureau, the insurance industry has set up the Insurance Mediation Bureau (IMB) as an alternative channel for the public to refer their disputes with their respective life (and general) insurance companies for settlement. Despite this move, the life insurance industry is not sitting idle. It has been responding on its own to the growing consumer pressures by having selfregulatory measures, which have been introduced with the objectives of: 1) Instilling discipline and promoting healthy competition among companies in the industry; and 2) Providing an element of protection to policyholders. Many have argued the pros and cons for self-regulation, but self-regulatory measures are essentially to instil greater self-discipline among the life insurance companies, thus avoiding the need for stricter legislations. While laws can be passed by Parliament to ensure that the rules and regulations
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are followed, a sort of a top-down legal command, self-regulatory measures which are really bottom-up way of managing can therefore respond to changing circumstances faster than legislations. Self-regulatory measures are not cast in stone somewhat unlike legislations, where the process of amending a small aspect of the law is very tedious. True, self-regulatory measures do not have the power of the law, as they are merely voluntary. Thus in the event of life insurance companies breaching them, policyholders cannot resort to the courts to address such shortcomings. Laws are interpreted by the courts but statements of practices are interpreted by those who drafted them. One very significant self-regulatory measure is the setting up of the Life Insurance Association of Malaysia (LIAM), where the Insurance Act 1996 has made it mandatory for all life insurance companies to be members. (For general insurance, there is the General Insurance Association of

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Malaysia, or commonly known as PIAM). LIAM is vested with the powers to enforce the rules and regulations that have been formulated by the authorities, so as to ensure among others, the life insurance companies are conducting their businesses in a professional manner. LIAM has also initiated on its own measures such as various inter-company agreements and guidelines that help to regulate the proper conduct of businesses by its members, and to ensure ethical conduct and professionalism between insurers and agents. In 1991, as a further step towards greater self-regulatory, LIAM formulated

a Code of Ethics and Conduct for its members that deals with life insurance selling and practices. The IMB is really a self-regulatory measure that was set up in response to an increasing number of disputes between policyholders and their respective insurance companies. The role of the IMB dovetails very neatly with the CSB and the self-regulatory measures of LIAM (and PIAM), and its significance cannot be underestimated.

• New Sunday Times, 16 December 2001.

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ARTICLE 6

MAKING ACCIDENT AND HOSPITALISATION CLAIMS THE SIMPLE AND EASY WAY
When a policyholder buys a life insurance policy he is buying an intangible product, meaning something that is hard to define or measure and not physical. The policyholder is really buying a “promise” by the life insurance company to pay him/her upon a certain event occurring, namely death, injuries sustained in an accident or hospitalised due to illness. To receive a certain agreed value, the policyholder pays an annual premium, and thus depends on the integrity and reputation of the life insurance company to fulfill its obligations. The Government therefore maintains a strict control over the life (and general) insurance companies simply because of this purchase of an intangible product by the policyholder who has to depend on the integrity and reputation of the insurance company to fulfill its obligations. Insurance is by no means an easy subject for the ordinary man to understand, as
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the contract for the purchase of a life insurance policy is usually in legal language and jargon. Precisely due to this fact that the Government has strict regulations governing trade practices of life insurance companies. The insurance industry is also strictly regulated because life (and general) insurance affects the interests of the public. Life insurance is a form of financial protection for an individual, his family and/or his business. If life insurance companies fail to honour their “promise” to pay after the regular premiums have been paid and when the policies mature, then this failure would adversely affect many policyholders. Premiums for life insurance are usually seen as a form of long-term savings. And for the life insurance company not to honour its obligations would be disastrous to the individual’s future livelihood. Thus the Insurance Act 1996 governs life (and general) insurance companies,
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the way they operate, how they manage their businesses, and provides adequate protection to policyholders and penalties for the insurance companies in cases of breaches of the obligations. The Act also provides procedures for claims to be made against life (and general) insurance companies in case of the policyholder meeting with an accident and needs hospitalisation, or death due to illness or accident, and maturity of the policy. Claimants are advised to contact their insurance companies or servicing agents for assistance to lodge the different types of claims.

3) Documents that are to be submitted to support the Claim are: • Medical certificates. • Medical reports. • X-ray film or radiologist report if there is a fracture. • Outpatient follow-up card. • Discharge notes. • Police reports for motor vehicle accidents. • Newspaper cuttings of the accident, if any. • For dismemberment cases, coloured photographs of the site of injury, if any.

Procedures for accident claims: Procedures for hospitalisation claims: 1) A written notice of the injury sustained to be given to the life insurance company within 20 days after the date of the accident. Failure to do so within the stipulated time would require an explanation letter. 2) The policyholder must complete the Claim form truthfully and in complete details. The Claim form comes in two sections - Section 1 to be completed by the policyholder, and section 2 by the attending doctor. The policyholder will pay for the medical report fees.
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1) A written or verbal notice of Claim must be given to the life insurance company within a reasonable period (as according to the insurance company’s contractual provisions in the contract that the policyholder signed) of the commencement of the confinement in the hospital. 2) Proof of hospitalisation to be furnished to the insurance company at the expense of the policyholder within a specified period mentioned in the policy contract.
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3) The policyholder must complete and signed the Claim form. 4) The Hospitalisation Report must be completed by the attending doctor, and the policyholder pays for the report fee. 5) The policyholder must submit the original bills and receipts to claim for reimbursements. In the event of a hospital and surgical benefit

claim, certified true copies of the bills and receipts would suffice.

NEXT WEEK: Procedures for Death Claims and Maturity Claims

• New Sunday Times, 23 December 2001

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ARTICLE 7

LOOKING AT WAYS OF FILING DEATH AND MATURITY CLAIMS
Continuing from the week before last, today’s article will look at how to file death claims and maturity claims. Procedures for Death Claims: For life policies the death claims can either be contestable or incontestable. Contestable claims are for death occurring within two years from the date of issue of the policies or date of latest reinstatement of the policies whichever is later. There are two types of contestable death claims: • For natural deaths, the documents to be furnished by the deceased’s claimant are: physician’s statement, death certificate, claimant ’s statement, five copies of Clinical Abstract Application forms (duly signed and witnessed), proof of relationship, the policy the deceased signed with the life insurance company. And proof of age (if there is any discrepancy). If there is additional accidental death coverage, in addition to the above, post mortem report, toxicology
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report and coroner’s inquest would also be required. • For accident deaths, the documents to be furnished by the deceased’s claimant are: All the documents as in cases of natural deaths, plus postmortem report, police report and newspaper cuttings (if any). For incontestable death claims for death occurring within two years from the date of issue of the policies or date of latest reinstatement of the policies whichever is later, there are again two types: • For natural deaths, the documents to be furnished are: Death certificate, claimant ’s statement, proof of relationship and proof of age (if there is a discrepancy). • For accident deaths, the documents needed are: All the documents as in cases of natural deaths, plus postmortem report, police report and newspaper cuttings (if any). For personal accident policies, the beneficiary of the insured (or the
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deceased) can make a death claim by submitting the following documents: • Death certificate, original or certified true copy. • Claimant’s statement duly signed and witnessed by a person who has no interest in the claims. • The policy contract the deceased signed with his/her insurance company. • A police report. • Post-mortem report or physician statement duly completed by the physician who last attended the insured, if a post-mortem report is not available. • Proof of relationship such as a marriage certificate or birth certificate. Procedures for Maturity Claims: For endowment life insurance policies, the insurance company pays the amount insured upon maturity of the policy in the event the policyholder survives to the end of the maturity period. The insurance company would usually inform the policyholder of the impending maturity of his/her endowment policy, and would request the policyholder to follow the following procedures: • The insurance company will forward an identity form, a survival form and a discharge form to the policyholder for completion and returned with the policy contract.
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• If the policyholder is the life insured, then he/she must provide proof of age, proof of survival, complete a discharge voucher and submit together with the policy document. • If the policyholder is not the life insured, then he/she must give a deed of assignment or any other title document, and a simple statement stating that the person insured is alive but unable to sign the survival certificate. Endowment life insurance policies usually provide a few settlement options, which the policyholder can exercise upon maturity of the policies. There are four common options: • Full amount of the cash proceeds. • Convert the proceeds into an annuity, either as an annuity certain or a life annuity. • Leave the proceeds as a deposit with the insurance company on agreed terms. • Draw the proceeds by installments over a number of years. Interest will be credited to the outstanding balances.

• New Sunday Times, 13 January 2002.
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BAHAGIAN 1

ISU TENTANG KES-KES ADUAN
KES PERTAMA: Rabiah Talib menandatangani borang polisi insurans hayat pada 14 Oktober 1994. Beliau mengesahkan bahawa beliau tidak menghidapi sebarang penyakit. Syarikat insurans hayat meluluskan permohonannya pada 27 Oktober 1994 dengan syarat: Perlindungan akan bermula apabila kami menerima bayaran premium yang pertama dengan sepenuhnya iaitu RM5,244.50. Dan sewaktu pembayaran premium keadaan kesihatan anda hendaklah sama seperti pada masa anda memohon polisi insurans ini. Syarikat insurans menerima premium daripada Rabiah pada 30 September 1996. Pada 5 November 1996, Rabiah telah meninggal dunia akibat daripada kanser gastrik yang teruk. Pewarisnya telah membuat tuntutan kematian dengan syarikat insuransnya. Laporan perubatan mendapati arwah Rabiah telah didiagnosis menghidap kanser gastrik yang teruk semenjak September 1996. Syarikat insurans menolak liabiliti tuntutan kematian tersebut atas alasan bahawa keadaan kesihatan arwah Rabiah sewaktu premium dibayar tidak sama dengan borang permohonan yang diserahkan kepada syarikat insurans. Berdasarkan ini, surat kelulusan yang dikeluarkan pada 27 Oktober 1994 adalah tidak sah. Pengantara Insurans telah membuat keputusan berpihak kepada syarikat insurans berdasarkan penerimaan bersyarat permohonan arwah Rabiah dan maklumat yang diperolehi daripada laporan perubatan.

KES KEDUA: K. Nathan telah membeli sebuah polisi insurans hayat. Beberapa tahun kemudian, Nathan dijumpai mati di tepi jalan tidak jauh daripada rumahnya. Pewaris polisinya pun membuat tuntutan kematian daripada syarikat insurans berkenaan. Syarikat insurans telah menolak tuntutan tersebut atas alasan bahawa

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laporan toksikologi menunjukkan kandungan alkohol di dalam darah mendiang Nathan adalah 332 miligram ethanol/100 mililiter. Mendiang Nathan dikatakan mabuk semasa dia meninggal dunia.

membuat tuntutan insurans terhadap polisinya. Beliau mendakwa bahawa beliau telah terlanggar cermin tepi keretanya dan mengakibatkan matanya tercedera dan hidungnya berdarah. Beliau terpaksa dimasukkan ke wad di hospital besar untuk mendapatkan rawatan. Mengikut laporan perubatan, Razlan didapati mempunyai “thrombocytopenia” sewaktu beliau dimasukkan ke hospital. Doktor melaporkan bahawa hidungnya berdarah berkemungkinan besar disebabkan oleh “thrombocytopenia” kerana tidak terdapat kecederaan yang teruk atau keadaan yang tidak normal pada bahagian hidung atau nasofarinks. Syarikat insurans telah menolak tuntutan tersebut atas dasar bahawa kecederaan Razlan tidak memenuhi syarat polisi iaitu kecederaan anggota akibat daripada sebab-sebab lain melalui cara luaran yang nyata dan ganas secara tidak sengaja. Pengantara insurans telah membuat keputusan memihak kepada syarikat insurans berdasarkan laporan perubatan yang menyatakan keadaan “thrombocytopenia” Razlan adalah akibat “sebab-sebab lain”. Ketiga-tiga kes di atas adalah merupakan contoh kes-kes pertikaian di antara pemegang polisi dengan syarikat
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Berpegang Syarikat insurans berpegang pada peruntukan di dalam polisi yang mengatakan bahawa syarikat adalah tidak bertanggungjawab di atas sebarang kecederaan yang diakibatkan secara langsung atau tidak langsung atau dipengaruhi oleh keadaan seseorang yang mabuk atau khayal akibat daripada pengaruh alkohol, narkotik atau dadah. Suatu post-mortem dijalankan dan laporan mengatakan punca kematian adalah asfiksia akibat dicekik. Oleh itu, punca kematian bukanlah disebabkan atau dipengaruhi oleh keadaan mabuk yang tidak termasuk dalam polisi insurans. Pengantara Insurans telah membuat keputusan berpihak pada pewaris Nathan dan tuntutan tersebut diluluskan oleh syarikat insurans.

KES KETIGA: Mohd Raslan yang membeli polisi insurans kemalangan diri telah
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insurans yang telah dikendalikan oleh Biro Pengantaraan Insurans pada tahun lepas. Biro telah ditubuhkan oleh industri insurans pada tahun 1992. Ia merupakan saluran alternatif untuk menyelesaikan pertikaian di antara pemegang polisi dan pihak syarikat insurans. Bank Negara juga ada menubuhkan Biro Perkhidmatan Pelanggan di bawah Jabatan Pengawalan Insurans. Biro Perkhidmatan Pelanggan ini mengendalikan kes-kes aduan dan pertanyaan daripada orang awam mengenai hal-hal insurans. Biro Perkhidmatan bekerjasama rapat dengan syarikat insurans serta Persatuan insurans untuk menyelesaikan rungutan dan aduan terhadap pihak syarikat insurans. Ia juga menganalisis aduanaduan yang diterima untuk mengenal pasti dan mencari jalan penyelesaian bagi masalah yang sering dihadapi berkaitan dengan amalan industri ini. Fungsi Biro Perkhidmatan telah dipertingkatkan dengan adanya sistem pangkalan data berkomputer yang mengandungi maklumat-maklumat tentang aduan-aduan orang ramai terhadap institusi kewangan. Ini

membolehkan Biro mengendalikan aduan tersebut dengan lebih pantas. Biro ini adalah satu jabatan di bawah pentadbiran Bank Negara. Tetapi Biro Pengantaraan Insurans bukan di bawah pentadbiran Bank Negara. Ia merupakan saluran tambahan untuk pemegang polisi menyelesaikan pertikaian mereka dengan syarikat insurans yang terlibat. Biro Pengantaraan Insurans diketuai oleh Pengantara Insurans yang bertanggungjawab ke atas operasi Biro dan beliau melapor kepada pihak Majlis yang dikawal oleh Lembaga Pengarah. Biro Pengantaraan Insurans mempunyai tataurusan persatuannya sendiri. Buat masa kini, Biro mempunyai seramai 53 ahli yang terdiri daripada syarikat insurans hayat dan am. Bank Negara menetapkan, skop Biro Pengantaraan Insurans terhad pada tuntutan pemegang polisi terhadap syarikat insuransnya (tidak termasuk tuntutan pihak ketiga) dan jumlah maksimum setiap tuntutan adalah RM100,000.

• Utusan Malaysia, 13 Ogos 2001.

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BAHAGIAN 2

PEMEGANG POLISI MESTI FAHAM HAK TUNTUTAN
Semasa membeli polisi insurans hayat, setiap pengguna haruslah mengambil tahu lebih mendalam tentang polisi yang akan dibeli. Dia hendaklah mengambil inisiatif mengkaji syarat dan terma polisi dengan teliti dan mengambil langkah-langkah untuk memenuhi syarat-syarat tersebut. Seperti yang selalu dikatakan, anda hendaklah sentiasa membaca huruf-huruf bercetak halus. Apabila sesorang pemegang polisi membuat aduan terhadap syarikat insurans, ada kemungkinan dia tidak begitu memahami syarat-syarat polisi dengan sepenuhnya. Meskipun ada kemungkinan bahawa pemegang polisi itu tersilap, namun syarikat insurans hayat tetap memastikan bahawa perkhidmatan yang terbaik diberikan kepada pemegang polisi mereka. Ini adalah kerana pemegang polisi adalah pelanggan mereka. Dengan memberikan perkhidmatan yang terbaik, ia akan membantu meningkatkan imej dan nama baik
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syarikat insurans hayat tersebut. Memandangkan syarikat insurans hayat mampu menangani aduan-aduan daripada pemegang polisi mereka dengan baik, jumlah kes aduan terhadap syarikat insurans hayat telah banyak menurun. Mengikut statistik daripada Bank Negara Malaysia (BNM) jumlah aduan terhadap syarikat insurans hayat meningkat sebanyak 19.8 peratus pada tahun 1998. Tetapi kadar ini turun ke 6.2 peratus pada tahun lepas. Pada tahun 2000, hanya terdapat 290 kes atau 16.26 peratus daripada jumlah keseluruhan 1,783 kes aduan yang dilaporkan terhadap syarikat insurans hayat dan am. Sebahagian besar daripada aduan pada tahun lepas adalah berkaitan hal-hal agensi, kelewatan menyelesaikan tuntutan dan penolakan liabiliti atas syarat-syarat kontrak polisi. Namun begitu, bukan semua kes aduan terhadap syarikat insurans hayat
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diterima oleh Biro Pengantaraan Insurans. Jumlah kes aduan yang dikendalikan oleh Biro telah meningkat sebanyak 4 kali ganda daripada 110 pada tahun 1996 kepada 463 pada tahun 1999. Walau bagaimanapun kes yang diuruskan oleh Biro pada tahun lepas hanya berjumlah 515, iaitu peningkatan sebanyak 11.2 peratus sahaja. Dalam laporan tahunan 2000, Pengantara Insurans berkata pengurangan dalam kes aduan yang dikendalikan oleh Biro mungkin menunjukkan pemegang polisi telah berpuas hati dengan keputusan syarikat insurans mereka. Ia juga menunjukkan bahawa syarikatsyarikat insurans telah mematuhi prosedur aduan dalaman syarikat masing-masing dan juga Garis Panduan Mengenai Amalan Penyelesaian Tuntutan. Pada masa yang sama, Biro juga mengadakan mesyuarat dengan pengurus-pengurus tuntutan membincangkan cara bagaimana aduan diselesaikan jika pertikaian tersebut dirujuk kepada pihak Biro. Biro juga sentiasa mengadakan perbincangan tentang bagaimana menguruskan kes aduan dengan lebih efektif sebelum pemegang polisi
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memutuskan untuk memfailkan aduan mereka secara rasmi.

Insurans Daripada jumlah 515 kes yang dikendalikan oleh Biro, hanya 170 kes yang membabitkan syarikat insurans hayat. Kes-kes aduan ini terdiri daripada tuntutan kematian (47 kes), tuntutan faedah hospital dan bedah (38 kes), tuntutan faedah hilang upaya menyeluruh dan kekal (27 kes), penyakit kritikal (16 kes), tuntutan faedah kemalangan komprehensif/ indemniti kemalangan (14 kes), tuntutan faedah penepian premium (8 kes) dan tuntutan faedah komprehensif/ kemalangan diri dan hospital (7 kes). Daripada 170 aduan tersebut, Biro telah menyelesaikan 146 kes iaitu 85.49 peratus daripada jumlah kes yang diselesaikan pada tahun lepas. Kebanyakan kes tersebut adalah tuntutan kematian dan tuntutan faedah hospital dan bedah. Dalam laporan tahunan pada tahun lepas, Pengantara Insurans berkata mendidik pengguna merupakan komponen yang penting dalam meningkatkan perkhidmatan pelanggan. Pemegang-pemegang polisi hendaklah faham sepenuhnya tentang polisi
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insurans dan apakah tuntutan yang akan dipenuhi oleh polisi tersebut. Yang lebih penting pemegang-pemegang polisi mestilah faham sepenuhnya akan hak-hak mereka sebagai pengguna ketika membeli produk insurans hayat daripada syarikat insurans, sama juga

seperti mereka membeli barang yang mudah rosak daripada syarikat-syarikat produk pengguna.

• Utusan Malaysia, 20 Ogos 2001.

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BAHAGIAN 3

KEPENTINGAN PEMEGANG POLISI DIUTAMAKAN
“Pengguna adalah Raja”. Itulah yang sering diperkatakan. Apabila pengguna membuat aduan, si pembekal perkhidmatan atau penjual produk hendaklah memberi perhatian terhadap aduan tersebut. Sudah menjadi kebiasaan para pengguna merungut tentang suatu perkhidmatan ataupun produk atas berbagai-bagai sebab. Di antara sungutan-sungutan tersebut ada yang berasas dan benar dan ada juga yang tidak. Pada masa kini, para pengguna di Malaysia adalah lebih berpendidikan, berpengetahuan dan sedar akan hakhak mereka. Mereka tidak akan teragakagak untuk mempertahankan hak mereka jika keadaan memerlukan. Nampaknya, para pengguna pada masa kini terutamanya di kalangan pemegang polisi hayat adalah lebih yakin tentang apa yang mereka inginkan daripada polisi insurans yang telah mereka beli. Ini adalah petunjuk yang baik, bukan sahaja untuk pemegang polisi pada umumnya tetapi juga bagi industri insurans hayat. Ini adalah kerana syarikat insurans boleh berurusan dengan lebih cekap dan bijak dengan para pemegang polisi yang sedar dan sedia tahu apa yang mereka inginkan. Pemegang polisi seperti para pengguna pada umumnya mempunyai lapan jenis hak asasi iaitu kepuasan, infomasi, pilihan, barangan dan perkhidmatan asas, kebebasan bersuara, kebebasan menuntut tebus rugi, pendidikan konsumer serta suasana yang bersih dan selamat. Selain daripada para pengguna yang lebih berpengetahuan akan hak-hak mereka, industri insurans, yang telah mengalami keadaan ‘pembetulan’ sepanjang 10 hingga 20 tahun yang lalu, juga mendapati bahawa masalahmasalah penginsurans yang tidak solven, amalan perniagaan yang tidak adil dan operasi yang tidak cekap adalah faktor mangkin utama yang menyumbang kepada peningkatan tekanan dan kritikan daripada pemegang polisi terhadap syarikat insurans hayat. Pada tahun 1987, sembilan buah syarikat insurans didapati gagal memenuhi keperluan minimum

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kesolvenan. Masalah tersebut bagaimanapun telah dapat diselesaikan. Aduan-aduan terhadap industri insurans hayat boleh dikategorikan seperti berikut: 1) kelewatan yang tidak munasabah dalam menyelesaikan suatu tuntutan. 2) penyelesaian tuntutan yang tidak adil. 3) menjalankan operasi dengan kos pemasaran yang tinggi. 4) pakatan sulit dan penetapan harga. 5) perkhidmatan yang tidak memuaskan kepada pemegang polisi. 6) memberi maklumat yang palsu dan tidak lengkap. 7) mengguna taktik jualan yang mendesakkan. 8) kurang profesionalisme. Statistik daripada Bank Negara jelas menunjukkan bahawa perasaan tidak puas hati di kalangan pemegang polisi kian bertambah bukan sahaja terhadap syarikat insurans hayat tetapi juga terhadap syarikat insurans am. Pada tahun lepas, Bank Negara telah menerima sebanyak 1,783 jumlah kes aduan daripada orang ramai terhadap syarikat insurans. Daripada jumlah ini, 290 aduan adalah terhadap syarikat insurans hayat dan 1,493 terhadap syarikat insurans am. Pada tahun 1997,
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jumlah aduan bertulis yang diterima adalah sebanyak 1,259 kes, suatu jumlah yang terendah yang pernah diterima oleh Bank Negara. Untuk menangani tekanan daripada pengguna yang kian meningkat, Bank Negara telah menubuhkan Biro Perkhidmatan Pelanggan di dalam Jabatan Pengawalan Insurans pada 1 Julai 1998. Biro ini bertindak sebagai pusat rujukan bagi semua aduan yang diterima daripada orang ramai. Pada awal tahun 1992, industri insurans telah menubuhkan Biro Pengantaraan Insurans sebagai saluran alternatif bagi orang ramai untuk menyelesaikan pertikaian mereka dengan syarikat insurans hayat ataupun am. Walaupun dengan langkah-langkah yang telah diambil ini, pihak industri insurans hayat tidak berpeluk tubuh sahaja. Industri insurans telah mengambil langkah-langkah kawalan sendiri bagi menangani tekanan daripada para pengguna yang kian bertambah. Langkah-langkah ini diperkenalkan dengan tujuan untuk: 1) memupuk disiplin dan mengalakkan persaingan sihat di kalangan syarikat-syarikat dalam industri insurans. 2) memberi elemen perlindungan kepada para pemegang polisi.
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Ramai telah mempertikaikan tentang kebaikan dan keburukan kawalan sendiri. Langkah-langkah kawalan sendiri pada asasnya adalah untuk memupuk tahap disiplin diri yang lebih tinggi di kalangan syarikat insurans hayat demi mengelakkan kawalan perundangan yang lebih ketat. Undang-undang diluluskan oleh Parlimen untuk memastikan orang ramai mematuhi undang-undang dan peraturan. Ini merupakan perintah undang-undang dari peringkat atas ke bawah. Manakala langkah-langkah kawalan sendiri adalah cara pengurusan dari peringkat bawah ke atas dan berupaya bertindak balas terhadap keadaan yang berubah-ubah dengan lebih pantas berbanding dengan sistem perundangan. Langkah-langkah kawalan sendiri adalah lebih senang dirangka berbanding dengan pengubalan undang-undang di mana proses mengubal sebahagian kecil daripada aspek undang-undang adalah rumit dan memakan masa yang panjang. Memang benar, langkah-langkah kawalan sendiri tidak mempunyai kuasa undang-undang kerana ia adalah tindakan secara sukarela. Oleh itu, jika syarikat-syarikat insurans melanggar peraturan tersebut, para pemegang polisi
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tidak boleh mengambil tindakan mahkamah untuk menangani kelemahan itu. Undang-undang ditafsirkan oleh pihak mahkamah tetapi kenyataan amalan ditafsirkan oleh mereka yang mengubalnya. Salah satu langkah kawalan sendiri yang paling penting adalah dengan penubuhan Persatuan Insurans Hayat Malaysia (LIAM) di mana Akta Insurans 1996 telah mewajibkan semua syarikat insurans hayat untuk menjadi ahli persatuan ini. (Bagi insurans am, terdapat Persatuan Insuran AM Malaysia, atau lebih dikenali sebagai PIAM). LIAM telah diberi mandat untuk menguatkuasakan peraturan-peraturan yang telah dirangka oleh pihak berkuasa. Di antara tujuannya adalah untuk memastikan bahawa syarikat insurans hayat menjalankan perniagaan mereka secara profesional. LIAM juga telah mengambil inisiatif memperkenalkan memorandum perjanjian di antara syarikat-syarikat dan merangka garispanduan bagi membantu mengawal pengurusan perniagaan yang lebih teratur. Ia juga bertujuan untuk memastikan tingkah laku yang beretika dan profesional di kalangan penginsurans dan para ejen. Pada tahun 1991, sebagai langkah ke arah kawalan sendiri yang lebih
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berkesan, LIAM telah merangka Kod Etika dan Tingkah Laku yang merangkumi amalan dan jualan insurans hayat untuk ahli-ahlinya. Biro Pengantaraan Insurans juga merupakan langkah kawalan sendiri yang telah ditubuhkan untuk menangani pertikaian di antara pemegang polisi dan syarikat insurans yang kian bertambah. Peranan Biro

Pengantaraan Insurans bertepatan sekali dengan Biro Perkhidmatan Pelanggan Bank Negara dan langkah-langkah kawalan sendiri oleh LIAM (dan PIAM), di mana kepentingannya tidak boleh dipertikaikan lagi.

• Utusan Malaysia, 27 Ogos 2001.

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BAHAGIAN 4

MEMAHAMI CARA MEMBUAT TUNTUTAN
Apabila seorang pemegang polisi membeli polisi insurans hayat, dia membeli suatu produk yang tidak ketara iaitu suatu yang sukar didefinisikan ataupun disukat dan tidak mempunyai bentuk fizikal. Pemegang polisi sebenarnya membeli ‘janji’ syarikat insurans hayat yang menjanjikan bayaran jikalau berlakunya kematian, kecederaan akibat daripada kemalangan atau dimasukkan ke hospital kerana penyakit. Untuk menerima sejumlah bayaran yang telah ditentukan nilainya, pemegang polisi akan membayar premium tahunan dan bergantung pada kejujuran dan reputasi syarikat insurans hayat untuk memenuhi kewajiban dan tanggungjawab mereka. Oleh sebab itu kerajaan terpaksa mengenakan kawalan yang ketat ke atas syarikat insurans hayat (dan am) kerana pembelian produk yang tidak ketara ini di mana pemegang polisi terpaksa bergantung pada kejujuran dan reputasi syarikat insurans hayat untuk memenuhi tanggungjawab mereka. Insurans bukanlah subjek yang mudah difahami oleh orang biasa kerana kontrak pembelian insurans hayat lazimnya ditulis dalam bahasa dan istilah undang-undang. Disebabkan ini jugalah kerajaan mengenakan kawalan yang ketat ke atas amalan perniagaan syarikat insurans hayat. Industri insurans juga dikawal selia dengan ketat kerana insurans hayat (dan am) mempengaruhi kepentingan orang ramai. Insurans hayat adalah salah satu bentuk perlindungan kewangan bagi individu, keluarganya dan/atau perniagaannya. Jikalau syarikat insurans hayat gagal menunaikan ‘ janji ’ mereka untuk menunaikan bayaran setelah menerima premium-premium tahunan dan apabila polisi matang, kegagalan ini akan menjejaskan ramai pemegang polisi. Premium insurans hayat dianggap sebagai suatu simpanan jangka panjang. Jikalau syarikat insurans hayat gagal memenuhi kewajiban mereka, ia akan membawa akibat buruk terhadap pendapatan masa depan seseorang.

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Akta Insurans 1996 mengawal selia syarikat insurans hayat (dan am) tentang cara mereka beroperasi, cara bagaimana mereka menguruskan perniagaan dan memastikan perlindungan yang diberikan mencukupi demi menjaga kepentingan pemegang polisi dan mengenakan penalti terhadap syarikat insurans yang gagal memenuhi kewajiban mereka. Akta juga menyediakan prosedur tuntutan terhadap syarikat insurans hayat (dan am) untuk keadaan di mana pemegang polisi telah terlibat dalam kemalangan dan dimasukkan ke hospital, atau meninggal dunia kerana sakit atau kemalangan, dan apabila polisi matang.

dilengkapkan oleh pemegang polisi dan Bahagian 2 oleh doktor. Bayaran laporan perubatan ditanggung oleh pemegang polisi. 3) Dokumen-dokumen berikut perlu disertakan untuk menyokong tuntutan: • Sijil perubatan dan sijil tugas ringan. • Filem x-ray atau laporan pakar radiologi jikalau terdapat tulang yang patah. • Kad rawatan susulan pesakit luar. • Nota dibenarkan keluar daripada hospital. • Laporan polis bagi kes-kes kemalangan kenderaan. • Keratan akhbar tentang kemalangan tersebut, jika ada. • Gambar foto menunjukkan kecederaan yang dialami, jika ada.

Prosedur Tuntutan Kemalangan 1) Suatu notis bertulis tentang kecederaan yang dialami hendaklah diserahkan kepada syarikat insurans hayat dalam tempoh 20 hari selepas kemalangan berlaku. Jika gagal berbuat demikian dalam tempoh yang ditetapkan, surat penjelasan adalah diperlukan. 2) Pemegang polisi hendaklah mengisikan borang tuntutan secara jujur dan memberikan segala maklumat secara terperinci. Borang tuntutan dibahagikan kepada dua bahagian. Bahagian 1 untuk
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Prosedur Tuntutan Hospital 1) Suatu notis secara bertulis atau lisan tentang tuntutan hendaklah diberikan kepada syarikat insurans hayat dalam jangka masa yang munasabah (mengikut peruntukan kontraktual syarikat insurans dalam kontrak yang ditandatangani oleh pemegang polisi) tentang tarikh bermulanya dimasukkan ke hospital.
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Pemegang polisi 2) Bukti-bukti pemegang polisi telah dimasukkan ke hospital hendaklah diserahkan kepada syarikat insurans dengan perbelanjaan sendiri pemegang polisi dalam tempoh 30 hari selepas pemegang polisi dibenarkan keluar daripada hospital. 3) Pemegang polisi hendaklah melengkapkan borang tuntutan. 4) Laporan hospital hendaklah dilengkapkan oleh doktor dan kosnya dibiayai oleh pemegang polisi. 5) Pemegang polisi hendaklah menyerahkan resit dan bil asal untuk menuntut pembayaran balik.

a) Bagi kematian secara normal, dokumen-dokumen yang mesti diserahkan oleh pihak menuntut adalah: kenyataan doktor perubatan, sijil kematian, kenyataan pihak menuntut, lima salinan borang Aplikasi Abstrak Klinikal (yang ditandatangani dan disaksikan), bukti tali persaudaraan, polisi yang ditandatangani oleh pemegang polisi yang telah meninggal dunia dengan syarikat insurans hayat. Dan bukti umur (jika ada percanggahan). b) Bagi kematian akibat kemalangan, dokumendokumen yang diperlukan adalah: sama seperti dokumen yang diperlukan untuk kematian secara normal dengan laporan bedah siasat, laporan polis dan keratan akhbar (jika ada). 2) Kematian tidak boleh ditanding juga mempunyai dua jenis: a) Bagi kematian secara normal, dokumen yang perlu diserahkan adalah: sijil kematian, kenyataan pihak menuntut, bukti tali persaudaraan dan bukti umur (jika ada percanggahan). b) Bagi kematian akibat kemalangan, dokumen yang diperlukan adalah: semua
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Prosedur Tuntutan Kematian Bagi polisi insurans hayat, tuntutan kematian boleh ditanding ataupun tidak boleh ditanding. 1) Tuntutan boleh ditanding adalah untuk kes kematian yang berlaku dalam tempoh dua tahun daripada tarikh polisi dikeluarkan atau tarikh polisi dikuatkuasakan semula, mana-mana yang terkemudian. Terdapat dua jenis tuntutan kematian boleh tanding:
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dokumen yang diperlukan untuk kematian secara normal, termasuklah laporan bedah siasat, laporan polis dan keratan akhbar (jika ada). Bagi polisi kemalangan diri, pewaris bagi orang yang diinsuranskan (atau yang telah meninggal dunia) boleh membuat tuntutan dengan menyerahkan dokumen-dokumen yang berikut: 1) Sijil kematian, asal atau salinan yang disahkan. 2) Kenyataan si penuntut yang ditandatangani dan disaksikan oleh seorang yang tidak mempunyai kepentingan terhadap tuntutan tersebut. 3) Kontrak polisi yang ditandatangani oleh orang yang telah meninggal dunia dengan syarikat insuransnya. 4) Laporan polis. 5) Laporan bedah siasat atau kenyataan doktor perubatan yang dilengkapkan oleh doktor yang terakhir merawat orang yang diinsuranskan itu, jika laporan bedah siasat tidak dapat diperoleh. 6) Bukti tali persaudaraan seperti sijil perkahwinan atau sijil surat beranak.
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Prosedur Tuntutan Kematangan Bagi polisi insurans hayat endowmen, syarikat insurans akan membayar jumlah yang diinsuranskan apabila polisi matang jika pemegang polisi masih hidup pada penghujung tempoh kontrak. Syarikat insurans lazimnya akan menghubungi pemegang polisi tentang polisi endowmennya yang akan matang, dan meminta pemegang polisi mengikut prosedur berikut: 1) Syarikat insurans akan menghantar borang pengenalan, borang mandiri (survival) dan borang pelepasan kepada pemegang polisi untuk dilengkapkan. Borangborang ini hendaklah dikembalikan kepada syarikat insurans bersama dengan kontrak polisi. 2) Jika pemegang polisi adalah orang yang diinsuranskan, beliau hendaklah memberikan bukti umur, bukti masih hidup, baucar pelepasan yang lengkap dan menyerahkan semua ini bersama dengan dokumen polisi. 3) Jikalau pemegang polisi bukan orang yang diinsuranskan, beliau hendaklah menyerahkan surat serah hak atau dokumen hak milik yang lain dan kenyataan ringkas yang menyatakan bahawa orang yang
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diinsuranskan masih hidup tetapi tidak dapat menandatangani sijil mandiri (survival). Polisi insurans hayat endowmen lazimnya memberikan beberapa pilihan penyelesaian yang boleh dilaksanakan oleh pemegang polisi apabila polisi mereka matang. Biasanya terdapat empat pilihan: a)
b) Perolehan kematangan tunai. Menukarkan perolehan kematangan kepada anuiti, sama ada anuiti pasti atau anuiti hayat.

c)

Membiarkan perolehan kematangan sebagai deposit dengan syarikat insurans mengikut terma-terma yang dipersetujui. Mengeluarkan perolehan kematangan secara beransuran bagi tempoh beberapa tahun. Faedah akan dikreditkan ke atas baki dalam akaun.

d)

• Utusan Malaysia, 3 September 2001.

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Ahli-Ahli Persatuan Insurans Hayat Malaysia Member Companies of the Life Insurance Association of Malaysia

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.

Aetna Universal Insurance Berhad AMAL Assurance Bhd American International Assurance Company Limited Arab-Malaysian Assurance Berhad Asia Life (M) Berhad EON CMG Life Assurance Berhad Great Eastern Life Assurance (Malaysia) Berhad Hannover Life Re, Malaysian Branch Hong Leong Assurance Berhad John Hancock Life Insurance (Malaysia) Berhad Malaysia National Insurance Berhad Malaysian Assurance Alliance Berhad Malaysian Life Reinsurance Group Berhad Mayban Life Assurance Berhad MBA Life Assurance Berhad MCIS Insurance Berhad Prudential Assurance Malaysia Berhad Talasco Insurance Berhad

February 2002
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