Pukwana ya Kganya Terms & Conditions

53 13. Claims 13.1 Liability for Claims 13.1.1 The Beneficiary shall follow the claims procedure as set out in this Pukwana ya Kganya Contract in the event of a Claim in relation to an Assured Life. 13.1.2 The Insurer shall not be liable for a Claim - 13.1.2.1 where such Claim is not submitted in accordance with the provisions of this Pukwana ya Kganya Contract, or outside the time periods prescribed; 13.1.2.2 where the Insured Event occurred - 13.1.2.2.1 prior to the Inception Date; or 13.1.2.2.2 after cancellation of this Pukwana ya Kganya Contract; or 13.1.2.2.3 after cover in respect of an Assured Life in accordance with the terms and conditions of the Policies, has ceased; 13.1.2.3 in instances where a Premium in respect of a Policyholder is not paid, thereby constituting a Missed Premium, subject to - 13.1.2.3.1 the provisions of clause 8.2 of this Part I; and 13.1.2.3.2 the Forgiveness Rules, 13.1.2.4 if an Assured Life is subject to a Waiting Period as provided for in terms of the Policies, where applicable, and the Waiting Period has not yet expired. 13.1.3 Notwithstanding the provisions of this Pukwana ya Kganya Contract relating to Claims, the Insurer reserves the right to cancel this Pukwana ya Kganya Contract, repudiate a Claim and declare all Premiums paid by the Kganya Benefits Fund Trust in respect of the Policies forfeited, should there be evidence of, or an attempted submission of a fictional claim, fraud or misrepresentation, which fictional claim, fraud or misrepresentation materially affects the Insurer’s ability to assess the risk under this Pukwana ya Kganya Contract. 13.2 Submission of Claims 13.2.1 Claims must be submitted by the Beneficiary to the Insurer (or its duly appointed administrator, Kganya Insurance Administrators) i) within a period of 12 (twelve) Months after the happening of the Insured Event; and ii) must include the submission of all the Claim Documents as required in terms of the Policies. 13.2.2 A Claim for Benefits may be repudiated by the Insurer if a Claim is made after the 12 (twelve) Month period indicated in clause 13.2.1 of this Part I; or in the event that a Claim is not supported with all the relevant Claim Documents. 13.2.3 Claims for Benefits must be submitted to the Insurer (or its duly appointed administrator, Kganya Insurance Administrators) as follows: 13.2.3.1 at one of the Kganya Insurance Administrator’s Service Centres, the details of which can be found on the website of Kganya Insurance Administrators at https://mykganya.com ; or 13.2.3.2 any designated office of the Insurer. 13.3 Consideration of Claims 13.3.1 If the Insurer disputes or rejects a Claim, the Insurer will provide the Beneficiary with a notice setting out the reasons for the decision. 13.3.2 In such event, the Beneficiary may, within 90 (ninety) days from the date of receipt of the notice, make representations to the Insurer regarding the decision. 13.3.3 If the Beneficiary fails to make such representations, the Insurer shall not be liable to pay a Claim, and the Insurer’s liability to pay a Claim will be extinguished. 13.3.4 If the Beneficiary makes representations to the Insurer, the Insurer shall, within 45 (forty-five) days of receiving such representations, inform the Beneficiary of its decision. 13.3.5 After receipt of the decision of the Insurer, if the Beneficiary does not, within 12 (twelve) months from the date of the happening of the Insured Event, begin legal proceedings in a competent court and prosecute such proceedings to final judgment, any liability of the Insurer shall be extinguished and no Benefits will be payable for such Claim and/or the Insured Event. 13.3.6 The 12 (twelve) month period will be suspended during the 90 (ninety) day period mentioned in clause 13.3.2, and provided further that the Beneficiary will at all times have at least 6 (six) months after the expiry of the 90 (ninety) day period to institute legal action in a court of law or to lodge a complaint with the Long-term Insurance Ombudsman. 13.4 Payment of Claims 13.4.1 Claims shall be settled by the Insurer by electronic funds transfer ( “EFT” ) into the bank account nominated by the Beneficiary upon submission of the Claim. 13.4.2 The nominated bank account must be a bank account held with a South African bank, and payment will be made in South African Rands into such bank account. 14. Amendments 14.1 Amendments to this Pukwana ya Kganya Contract 14.1.1 The Insurer shall at all times be entitled to amend any provision of this Pukwana ya Kganya Contract (and, for the avoidance of doubt, the Policies forming part thereof) by 31 (thirty-one) days prior written notice to the Policyholder. 14.1.2 Unless specifically provided otherwise in this Pukwana ya Kganya Contract or indicated by the Insurer to the contrary, any amendments to the terms and conditions of this Pukwana ya Kganya Contract which result in changes to the Benefits payable, will not affect a Claim in respect of an Insured Event occurring prior to such changes coming into effect. The Insurer will at all times consider a Claim based on the policy wording and Benefits applicable at the date of the occurrence of the Insured Event. 14.1.3 Subject to and without limitation of the Insurer’s right to cancel this Pukwana ya Kganya Contract as set out in clause 16 of this Part I, upon the occurrence of a change in the Applicable Laws which impacts this Pukwana ya Kganya Contract, the Insurer shall be entitled to make such amendments to this Pukwana ya Kganya Contract as it deems necessary to ensure compliance with the change in the Applicable Laws. 14.1.4 The Insurer shall inform the Policyholder of any such change, and the effective date thereof. 14.1.5 If a provision of this Pukwana ya Kganya Contract conflicts with any provision of the applicable insurance laws as a result of a change in the Applicable Laws, the Insurer will at all times act in accordance with the provisions of the Applicable Laws notwithstanding any express provision of this Pukwana ya Kganya Contract to the contrary. 14.2 Changes to information included in the MPP Form and Payment Receipt Booklet 14.2.1 The Policyholder may amend any information included in the MPP Form and/or the Payment Receipt Booklet by – 14.2.1.1 completing the AMPP Form and submitting it to the Insurer’s duly appointed administrator, Kganya Insurance Administrators, or through the Church Branches; and/or 14.2.1.2 calling the call centre of the Insurer’s duly appointed administrator, Kganya Insurance Administrators.