Mempermudahkan Tuntutan Insurans Hayat Life Insurance

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
(i)
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
(ii)
(iii)
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
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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.
•
•
•
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.
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 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.
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.
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.
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 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.
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.
A post-mortem was carried out, and
according to the report the cause of
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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
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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
insurance company (which is a
member) binding up to
RM100,000 and being a
recommendation only as to any
excess; and
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.
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.
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;
The IMB has come out with a standard
procedure how policyholders can make
a complaint against their respective
insurance companies.
2) To act as an investigator and
adjudicator in order to determine
the complaint by upholding or
rejecting it wholly or in part;
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
3) Where the complaint is upheld,
wholly or partially, to make a
monetary award against the
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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.
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.
The policyholder does not have to pay
a single sen to refer his case to the
Insurance Mediator
At present, the IMB does not charge
any fees for services provided to resolve
the dispute.
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.
• New Sunday Times, 18 November
2001.
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ARTICLE 3
REDUCING IMB’S WORKLOAD
THROUGH EDUCATION
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.
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.
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.
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.
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.
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.
However, if we compare the number
of complaints received to policies in
force, this figure is a negligible 0.004
per cent.
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.
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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.
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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.
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.
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.
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:
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.
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
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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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.
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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
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.
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:
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.
1) Instilling discipline and promoting
healthy competition among
companies in the industry; and
2) Providing an element of protection
to policyholders.
Laws are interpreted by the courts but
statements of practices are interpreted
by those who drafted them.
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.
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
While laws can be passed by Parliament
to ensure that the rules and regulations
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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
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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
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.
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.
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.
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.
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.
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.
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,
Insurance is by no means an easy subject
for the ordinary man to understand, as
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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.
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.
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.
• 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.
claim, certified true copies of the
bills and receipts would suffice.
4) The Hospitalisation Report must
be completed by the attending
doctor, and the policyholder pays
for the report fee.
NEXT WEEK: Procedures for Death
Claims and Maturity Claims
5) The policyholder must submit the
original bills and receipts to claim
for reimbursements. In the event
of a hospital and surgical benefit
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• 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
30
Y
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
O U R
F
R I E N D
F
O R
L
I F E
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.
• 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.
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.
Y
O U R
F
R I E N D
F
O R
• New Sunday Times, 13 January
2002.
L
I F E
31
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.
T
E M A N
A
N D A
S
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
E P A N J A N G
H
A Y A T
1
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.
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.
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.
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.
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 berpihak pada pewaris
Nathan dan tuntutan tersebut
diluluskan oleh syarikat insurans.
Pengantara insurans telah membuat
keputusan memihak kepada syarikat
insurans berdasarkan laporan perubatan
yang
menyatakan
keadaan
“thrombocytopenia” Razlan adalah
akibat “sebab-sebab lain”.
KES KETIGA:
Mohd Raslan yang membeli polisi
insurans kemalangan diri telah
2
T
E M A N
A
N D A
Ketiga-tiga kes di atas adalah merupakan
contoh kes-kes pertikaian di antara
pemegang polisi dengan syarikat
S
E P A N J A N G
H
A Y A T
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
T
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N D A
S
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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3
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
4
T
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A
N D A
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
S
E P A N J A N G
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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
T
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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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5
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
6
T
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N D A
seperti mereka membeli barang yang
mudah rosak daripada syarikat-syarikat
produk pengguna.
• Utusan Malaysia, 20 Ogos 2001.
S
E P A N J A N G
H
A Y A T
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.
dengan lebih cekap dan bijak dengan
para pemegang polisi yang sedar dan
sedia tahu apa yang mereka inginkan.
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.
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.
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
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S
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.
Pada tahun 1987, sembilan buah
syarikat insurans didapati gagal
memenuhi keperluan minimum
E P A N J A N G
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7
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.
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.
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.
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:
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,
1) memupuk
disiplin
dan
mengalakkan persaingan sihat di
kalangan syarikat-syarikat dalam
industri insurans.
2) memberi elemen perlindungan
kepada para pemegang polisi.
8
T
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N D A
S
E P A N J A N G
H
A Y A T
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
T
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S
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
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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.
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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.
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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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 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.
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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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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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)
Perolehan kematangan tunai.
b)
Menukarkan perolehan kematangan
kepada anuiti, sama ada anuiti pasti
atau anuiti hayat.
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c)
Membiarkan perolehan kematangan
sebagai deposit dengan syarikat
insurans mengikut terma-terma
yang dipersetujui.
d)
Mengeluarkan
perolehan
kematangan secara beransuran bagi
tempoh beberapa tahun. Faedah
akan dikreditkan ke atas baki dalam
akaun.
• 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.
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
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