We will provide a decision / answer on the claim:

• For funeral cover claims – within 2 working days from receipt of all required documentation
• For group life claims - within 3 working days from receipt of all required documentation
• The benefit payment will reflect in the beneficiaries account within 2 working days from the date of the letter. Beneficiaries should wait to be contacted by the employer to inform them when the decision letter was received by Group Assurance.

This is the date that the employee was no longer able to perform all of the duties of their own occupation due to being ill or becoming injured. In most cases, this is the last day that the employee was physically in the workplace before becoming ill, or having an accident. It is not the date that the doctor or employer said that the member is unable to work, and it is not the date that the claim was sent to the insurer.

Sometimes employees return to work after becoming ill but then struggle to perform their duties or have frequent absences due to special medical investigations, treatment or relapses. A sick leave record and sick certificates would assist Old Mutual in determining the date of absence in these claims.

The waiting period starts immediately after the date of absence. The waiting period is the minimum period of absence from the employer’s service because of a medical condition, before a claim can be considered for assessment. Duration of waiting periods vary and is applicable to all members of the Scheme. There is no benefit payment made within the waiting period.

Inform Group Assurance immediately when you intend to return to work so that your benefit can be stopped.

If we require any further medical information we will send this request to you and provide a period of 8 weeks to submit this information. If you are not able to submit within this time, please let us know.

If we find that a claim is not valid, we will make every effort to contact you or your employer to discuss and explain our decision before we decline this claim.

Old Mutual is willing to discuss and review the outcome of your claim should you be unhappy with our decision. This process is summarised below:

1. Contact us directly:

The quickest and easiest way to query a decision is to contact us directly. Please write to Old Mutual Group Assurance within 90 days of receipt of our decision by using one of the following addresses:

• Disability claims: GAPDisabilityAssessments@oldmutual.com
• Death claims: GAPDeathClaims@oldmutual.com

You can also phone us on (021) 509 6855, or write to us at:
Old Mutual Group Assurance
PO Box 1659
Cape Town
8000

2. Contact Old Mutual’s internal complaints teams:

If, after the review of our decision as indicated above, you are still not satisfied, Old Mutual provides a complaint resolution process which aims to duly address any dissatisfaction you may have with Old Mutual’s decision. You can contact the OMSTA Complaints Management Department at the following details:
Email: complaintadmin@oldmutual.com
Fax: (021) 504 7700
Post: OMSTA Complaints Management Department
PO Box 201

The benefit is paid out as a lump sum on the death of the insured person’s spouse. The benefit may be expressed as a multiple of the insured person’s salary or flat cover.

Most schemes provide a fairly modest amount of cover, e.g. one year of annual salary as earned by the insured person at the time of their spouse’s death.

The premium rate for this benefit will generally be significantly less than the corresponding amount of cover for the insured persons’ lives. It is normally expressed in the same form, e.g. As a rate per E1 000 cover on the insured persons’ lives.

Permanent disablement will only be recognised if the spouse has become:

• Permanently bedridden, or
• Has suffered the permanent loss of sight in both eyes, or
• The use of both hands or both feet or one of each, provided that the disablement is not attributable to:
  • Self-inflicted injury or a pre-existing condition
  • Atomic, biological and chemical war events
  • Injury, disease or condition from which the spouse suffered and which was medically diagnosed prior to the date on which his/her disability benefit commenced under this plan or in respect of which the spouse underwent a surgical operation prior to such date.

The spouse’s age may not exceed 65, or the insured person’s normal retirement age. Disablement must have lasted continuously for at least six months and must be judged to be total and permanent before a benefit will be allowed. A benefit will be allowed sooner if the spouse has sustained a severance of both hands or both feet or one of each.

Because of the low level of benefit and the severe definition of disability, no taper off of benefit to age 65 is applied.