RULES ON THE COMPLAINTS PROCEDURE
1. Preliminary provisions
The Rules on the complaint procedure (hereinafter: the Rules) refer to the company Zavarovalnica Sava d.d. (hereinafter: the insurance company).
The Rules comply with the provisions of the Guidelines on Complaints-Handling by Insurance Undertakings and the Reports on Best Practices of Insurance Undertakings in Addressing Complaints, adopted by the European Insurance and Occupational Pensions Authority (EIOPA) and follows the legal obligations regarding the regulation of out-of-court consumer dispute resolution procedures.
The purpose of the complaint procedure is to improve the quality of insurance services, achieve a higher level of satisfaction of the users of insurance services, reduce the number of court proceedings (pursuing the principle of an amicable solution of disputes) and improve confidence in insurances in general.
2. General part
2.1 Content of the Rules
The Rules regulate the procedure for resolving complaints of policyholders, insured persons, potential insured persons, injured parties or other beneficiaries of insurance contracts (hereinafter: complainants) in connection with misunderstandings and disputes in the conclusion of insurance contracts and the payment of insurance of compensation.
The Rules also regulate the procedure in disputes related to non-compliance with the Insurance Code, good business practices and basic standards of insurance practice.
The provisions of the Rules relate to the composition and work area of the bodies competent to make decisions regarding complaints.
Upon conclusion of an insurance contract, the insurance company informs the policyholder of the possibility of an internal complaints procedure in the insurance terms.
General provisions of the procedure relating to the procedure for processing complaints or the conduct of employees in the event of receipt of complaints is applicable to all types of complaints, unless otherwise provided for in the special regulation of the procedure (Articles 3 and 4 of the Rules).
The Rules (in Article 5) particularly regulate the conduct of the competent insurance companies in the event of received initiative to initiate the procedure of an out-of-court settlement of disputes within the applicable provisions, the Out-of-Court Resolution of Consumer Disputes Act and the Rules on the Mediation Procedure in Domestic and Cross-border Consumer Disputes at the Mediation Centre of the Slovenian Insurance Association.
2.2 Concept and types of complaints
A complaint is a statement of dissatisfaction which the complainant addresses to the insurance company and relates to an insurance contract or a performed service of an insurance company or to a disagreement with the conduct of the employees of the insurance company or its agencies.
The appeal procedure and the jurisdiction to settle complaints are distinguished according to the nature of the complaint that arrives at the insurance company.
In view of the above, the Rules distinguish between two types of complaints, namely, substantive and general complaints.
Substantive complaints are those that relate to disagreements regarding the conclusion of insurances and the payment of insurance indemnity and compensation. Such complaints are in particular complaints concerning disputes regarding the basis of the obligations of an individual insurance contract or, regarding the merits of the claim for damages, disputes regarding the amount of liabilities of the insurance company and disputes concerning the complaint of irregularities in the conclusion of an insurance contract (if there are no irregularities relating to violation of the Insurance Code, good business practices, personal data protection, etc., for the settlement of which the authorized person referred to in the third paragraph of Article 2.5 of these Rules is competent).
General complaints are those relating to non-compliance with the Insurance Code and the basic standards of insurance practice. Such complaints are in particular those relating to complaints concerning infringement of consumer law, protection of personal data, good business practices, relating to the equality of clients, the inadmissible conduct of the insurance company or its contractual partners, the informing of clients and those relating to the acquaintance of the complainant with the contents of the insurance contract, premium, etc., as arising (Article on the relationship of the insurance company towards clients) also from the Insurance Code.
The complaint procedure does not consider simple requirements for the performance of a contract, for providing information or explanations and applications (for review). Similarly, in the complaints procedure, reclamations, urgencies for the implementation of individual activities, proposals for supplementing the procedure, etc. are not considered, which are normal and present in the daily work of the professional services of the insurance company.
Complaints with regard to activities outside the registered activities and the competence of the insurance company are not subject to consideration in the complaints procedure, however the insurance company may nevertheless respond to them, clarify its position and, where possible and appropriate, forward the data to the institution which is competent for such complaints.
The subject of complaint procedures of an insurance company are also not complaints which constitute an initiative for the initiation of proceedings for an out-of-court resolutions of a dispute initiated by the complainant (consumer) through the Mediation Centre SZZ (hereinafter: MC), as the registered contractor to settle consumer disputes under the provisions of the Out-of-Court Resolution of Consumer Disputes Act. Out-of-court of these complaints or initiative is the responsibility of MC.
2.3 Lodging and content of the complaint
The client may lodge the complaint in writing by sending it to the address of the insurance company or to the address of its individual organizational units, by e-mail, through the website of the insurance company (online form – complaints), through the contact centre of the insurance company or verbally in a protocol at the insurance company.
The complaint must be comprehensible and complete and must include:
- name and surname of the client,
- the client’s address,
- the reason for the complaint and
- the signature of the client lodging the complaint (except in the case of complaints lodged by e-mail).
In the event that the complaint is incomprehensible, the body to which the complaint or the accusations relate to, is obliged to inform the client in writing to supplement or correct the complaint within 8 days and that the complaint will otherwise be rejected. The request for supplementation is sent by registered mail. If the complaint is not supplement or corrected, the complaint is dismissed.
Anonymous complaints are not considered by the Complaint Bodies; they only inform the work department to which such a complaint relates.
2.4 Conduct of employees in case of receiving a complaint
Upon receipt of the complaint, the complaint must be sent immediately to the person of the insurance company to which the complaint relates (for example, to the claimant, to the person to which the complaint of inadmissible conduct refers, etc.).
2.5 Complaint Bodies and their composition
The Complaints Commission (hereinafter: the Commission) is responsible for resolving substantive complaints and for resolving general complaints, the Commissioner for Complaints Resolution: the Commissioner).
The competence of the Commission’s management is entrusted to its President, who is appointed by decision of the company’s Management Board. The competence of managing the tasks of the Commission is entrusted to a person appointed by the decision of the company’s Management Board.
The Commission consist of a minimum of 25 members appointed by the company’s experts, on a joint proposal by the President of the Commission and on a proposal of one of the executive directors of the personal of non-life insurance or of the claims sector. The members are appointed and dismissed by the Management Board. In case of more complicated complaints, the Commission may also involve other professional associates of the insurance company.
The Commissioner decides on complaints on their own, however they may engage various professional associates of the insurance company when deciding on individual complaints (especially in case of more complicated complaints).
In addition to the President of the Commission, the Commission and the Commissioner each have their own administrative workers, who are responsible for providing administrative and technical support to the Commission (keeping records, inviting the Boards to the Commission sessions, preparing minutes, preparing and forwarding written decisions to the complainants, etc.) for the smooth functioning of the work of the Commission and the Commissioner. The Administrative Assistant of the Commission is appointed by the company’s Management Board by a decision.
The President of the Commission shall also have a deputy appointed by the company’s Management Board by a decision.
For members of the Commission, which are on the list of presidents of boards, the participation according to the schedule in the Board of Complaints is a priority obligation and a duty. Exceptionally (justifiable reasons), the President of the Commission, on the proposal of an already appointed member, may replace the latter with another member.
2.6 Independence of the Complaint Bodies
The Commission and the Commissioner are autonomous and independent in resolving complaints, and they decide in accordance with legal regulations, insurance terms and prices, codes, good insurance practice and in accordance with the acts specified in the introductory provisions of the Rules.
2.7 Binding nature of decisions of Complaint Bodies
The decisions of the Commission and the Commissioner are sent to the complainants and to the professional service with the jurisdiction for the disputed case, whereby the decision of the said Complaint Bodies for the professional service is binding, it is obliged to execute it.
Professional services of the insurance company or its organizational units are obliged to provide assistance to the Commission and the Commissioner for the smooth conduct of its work.
2.8 Reply to the complainant and its contents
On the basis of the facts and evidence collected, the Complaints Body shall decide on the merits of the appeal and submit to the complainant a written reply (by registered mail) on the resolution of his complaint, within the deadlines arising from these Rules. The decision which is submitted to the complainant contains an introduction, a brief summary of the facts or claims of the parties, and in particular the explanation from which it must be made clear, for what reasons or on the basis of which facts the decision of the Complaints Body is based. The decision on the complaint must not contain (only) a summary of what the complainant or the professional service have already stated in the rejection. The reply to the complainant is signed by the President of the Board of Complaints.
2.9 Final decision and legal instruction
The decision of the Complaints Body is final or there is no appeal against it. Exceptionally, in the case of obtaining a new complaint, if it contains new facts and evidence, the case may be dealt with again (see paragraphs IV, V, VI of Article 4.2 and Article 4.3 of these Rules).
The reply to the complainant regarding his complaint must also include a legal instruction on the possibility of appealing against the decision of the Complaints Body to the Insurance Supervisor of Good Business Practices in the Insurance Company operating within the Slovene Insurance Association, Železna cesta 14, 1000 Ljubljana (general complaints). Disputes between the policyholder or the injured parties on the one hand and the insurance company on the other hand are solved by the court competent for the seat of the insurance company or in accordance with Article 5 of these Rules also by the Mediation Centre at the Slovenian Insurance Association (substantive complaints).
2.10 The flow of information and proposals from the Complaints Bodies
The Complaints Body is responsible for the flow of information between him and the expert services and may also convene consultative meetings for this purpose.
The Complaints Body may suggest individual expert services or organizational units the adoption of certain solutions to improve the way of work and professional conduct.
In the event of major irregularities noticed by the Commission when performing the work, in particular in the event of significant damage or suspected fraud (substantive complaints) or in case of serious breaches of the Code and good business practices or recurring such violations by the same complainant, inform the company’s Management Board thereof.
3. Substantive complaints
The process of handling substantive complaints
3.1 Handling by the complainant
The person to whom the complaint refers (hereinafter referred to as the “the party complained against”) shall respond in writing to the complaints within 5 days from the date on which the complaint was received. The complaint must be sent to the party complained against no later than the day following the day it arrived at the insurance company.
If the party complained against discovers that the complaint is substantiated (partially or completely) or that the complainant has not yet been provided with all necessary information on the individual case, he shall immediately inform the complainant thereof and try to regulate the resolve the disputed relationship with them. If there is no consensus solution of the case within 8 days in such situations, the party complained against must immediately handover the case to the the Commission and act in a meaningful manner in accordance with the provisions of the following paragraph.
If the the party complained against considers that the complaint is unsubstantiated, they give a brief summary of the statements in the complaint, a brief summary of the complaints and their own expert opinion on the groundlessness of the complaint.
Within the above-mentioned five-day period, the party complained against informs the complainant of the receipt of the complaint, of the further proceeding in connection with it or on the withdrawal of the complaint to be sent to the Commission for consideration.
If after the receipt of the complaint the party complained against discovers that the procedure must be supplemented, which could change the original decision of the party complained against and the above mentioned decision is not changed after supplementing the procedure, the party complained against is obliged to send the complaint to the Commission for resolution. In any case, the the party complained against is obliged to inform the complainant of the purpose to supplement the procedure.
In any case, the party complained against is obliged to ensure that the client receives a reasoned answer to their decision.
If the client makes a proposal to supplement the procedure, where the further consideration of the case requires the obtaining of additional documentation, additional implementation of evidence, etc., the procedure will proceed according to the regular procedure for resolving the client’s claim.
3.2 The beginning of the procedure and the final date of the decision
Upon receipt of the proposal by the Commission, the Administrative Assistant shall determine whether all the assumptions referred to in Paragraph 3 of Article 3.1. of these Rules have been fulfilled. Then the President of the Commission, in the light of the content of the insurance case, appoints the composition of the Board of Complaints.
When considering complaints, the insurance company must comply with the legal 30-day deadline in which it must communicate the decision on the complaint to the complainant. To this end, the Commission is obliged, after receiving the complaint for consideration, within seven days, call a session of the Board and send the decision on the complaint, which the Board is obliged to adopt on the day of the session, to the complainant no later than the next working day after the decision. The period between the day on which the Commission receives the complaint and the day of the session of the Board may not exceed 14 days. In the event of a possible exceeding of the deadline, the Commission must state and communicate the reasons for the delay to the complainant.
The Administrative Assistant continuously ensures that complaints are considered within the specified deadline.
If the Commission returns the case to the party complained against or expert service to supplement the procedure, and in doing so, discovers that due to the supplementation or other justifiable reason, a final decision will not be possible or difficult to adopt within 30 days, the President of the Board must enter the reason for exceeding the mentioned deadline in the decision of the Commission, by which the procedure is to be supplemented (or in the case of another justifiable reason) and which is received by the complainant.
The operation of the Commission is permanent, the President of the Commission (or his deputy), or, under their authorization, the Administrative Assistant, shall ensure the timely convening of the Commission Boards. The Commission Boards consider cases generally according to the order of arrival of complaints.
The person convening the Board sessions is obliged to inform the president and members of the Commission Board of the session at least 7 days before the session. The party complained against shall also be informed of the session.
3.3 Board session of the Commission of Complaints
The President of the Commission or, under their authorization, the Administrative Assistant shall be responsible for the convening of sessions and the composition of the Boards of Complaints, while ensuring that, a final decision is made on the complaint, at the latest within 30 days of receipt of the complaint at the insurance company.
Complaints related to the Complaints Body are received and recorded by the Administrative Assistant who also takes care of other administrative and technical support to the Commission, while the convening of sessions of Boards of Complaints fall within the competence of the President of the Commission, or, under their authorization, the competence of the Administrative Assistant.
The Board consists of three members, one of which is a university degree in laws, and the other two are appointed according to the type and nature of the disputed relationship.
The Board’s sessions may, in particular, to clarify the facts, at the invitation of the President of the Board, be attended by the party complained against, potential witnesses or, if necessary, another professional worker of the insurance company. In cases of more difficult or more demanding cases in which decisions on complaints are adopted, the President of the Board of Complaints may, due to the needs to acquire additional specific knowledge of a particular profession, involve expert workers from various fields (for example, a medical expert, traffic expert, etc.), as well as the complainant.
Boards of Complaints primarily hold meetings at correspondence sessions using modern electronic technology. Boards of Complaints may exceptionally hold a meeting on the proposal of the President of the Board at the company’s headquarters, if this is useful in order to clarify the facts of the individual case. Exceptionally, it is possible to hold meetings at business units, if this is reasonable due to the cost-effectiveness of the procedure (a large number of complaints cases) and to clarify the facts of the individual case.
The President of the Board is a Professional Associate, an university graduate of law by profession, while the members of the Boards are appointed according to the content of the complaint or depending on the field of expertise to which the complaint relates.
3.4 Decision making and operation of the Commission
The Board decides independently, usually with a consensus, if not, with a majority of two votes against one.
If a member of the Board does not agree with the decision adopted, they have the right to request that their opinion shall be entered as a separate opinion in the minutes.
After the voting is complete and the decision is adopted, the President of the Board of Complaints shall formulate a professionally reasoned decision at the session itself, which shall be entered in the minutes of the meeting.
The Board constitutes a quorum and may hold a session only, if all three members of the Board are present.
If the complainant attends the session, they have the right to give an oral explanation or to supplement the complaint and to propose a solution to the dispute.
In a complaint case, in respect of which a conflict of interest in the decision-making process on a particular complaint is given at a member of the Board of Complaints, such a member can not be a member of the Board hearing and adjudicating on this complaint.
The Administrative Assistant of the Commission is obliged to send to the complainant a reasoned decision of the Board of Complaints no later than 7 days from the adoption of the decision of the Board of Complaints. The reply to the complainant shall be sent in writing, by registered mail.
The decision or the final response to the complainant must also include a legal instruction on further options within the existing out-of-court dispute resolution mechanism provided for in the applicable legislation.
The legal counsel who manages the claim in the regular procedure shall also be acquainted with the aforementioned decision.
3.5 Minutes of the session of the Complaints Commission
Regarding complaints, the Administrative Assistant maintains a register of complaints, which usually contains at least: date of the complaint or the date of receipt of the complaint, date of the meeting, names of the members of the Board of Complaints, name of the rapporteur and the complainant, name of the disputed case, indication of the insurance type to which the complaint refers, reason for the complaint and the decision with a professional explanation decision on the complaint. The register should also contain a possible instruction to the professional service and possible notice from Paragraphs I, II, III, IV and V of Article 3.1 of these Rules.
The minutes of the session of the Board shall be kept in electronic format, which shall be kept by the Administrative Assistant.
3.6 Receipt of a second (new) complaint
In the event of a second complaint, the case is forwarded to the party complained against, who shall give an opinion on the second complaint. If new facts or new evidence change their original decision, they inform the complainant thereof or try to settle the disputed relationship with them.
If the party complained against decides that there are no new facts or evidence or if their opinion regarding the initial decision, confirmed by the Complaints Body, remains unchanged, despite the existence of new facts or new evidence, they shall act in the manner provided for in Article 3.1. of these Rules (forwarding the case to the Commission). In this case, the final position is adopted by the Complaints Body, which communicates the final decision (by registered mail) to the complainant.
There is no appeal against the decision on the second complaint.
The Complaints Body may already decide whether the facts and evidence are new already before forwarding the second complaint to the party complained against. If there are no new facts or evidence, the Complaints Body communicates the opinion regarding the final decision of the Commission to the complainant by registered mail.
Regarding the issue of a new complaint, the provisions of Article 3.1. of these Rules apply mutatis mutandis.
4. General complaints
The process of handling general complaints
4.1 Handling by the party complained against
The party complained against, who receives a general complaint, is obliged to forward the complaint immediately, no later than the next working day after receipt, to the Commissioner.
Complaints that are forwarded to the Commissioner for resolution are accepted and recorded by the Legal Department.
4.2 Handling and deciding of the Commissioner
Upon receipt of a complete complaint, the Commissioner shall, in writing, invite the party complained against or their superior to make a written statement regarding the complaint and shall also attach relevant documentation to the explanation confirming their statements.
The Commissioner may also request explanations from other employees in the insurance company; they may also request additional explanations from the complainant, if this is necessary for clarification of the actual situation.
In order to clarify certain issues related to the decision on the complaint, the Commissioner may also involve certain professional associates of the insurance company, who assist the Commissioner in relation to determining the actual situation or, in connection with the complaint, express their own opinion, while the final decision on the complaint is within the competence of the Commissioner.
On the basis of the facts and evidence collected, the Commissioner decides whether the complaint is substantiated and responds to the client’s complaint in writing (by registered mail). The reply to the complainant must be explained.
The Commissioner shall inform the party complained against, their immediate superior or the relevant competent services, which are obliged to take measures to eliminate the identified irregularities or other appropriate measures to prevent further misconduct of the decision on the complaint. The Commissioner may also propose appropriate disciplinary proceedings against the offender.
The decision of the Commissioner is final or there is no appeal against it. A new consideration of the case is only possible if new facts are acquired or new evidence to which the complainant refers.
The Commissioner must respond to the client’s complaint no later than 30 days from the date of receipt of the complete complaint.
4.3 Receipt of a second (new) complaint
In the event of a second complaint, the case is forwarded to the party complained against, who shall give an opinion on the second complaint and acquaints the Commissioner with the opinion.
On the basis of possible new facts or new evidence, the Commissioner shall re-decide on the case and forward the final decision to the Complainant by registered mail.
There is no appeal against the decision on the second complaint.
Regarding the issue of a new complaint, the provisions of Article 3.1. of these Rules apply mutatis mutandis.
4.4 Minutes on complaints
The Administrative Assistant keeps minutes on complaints or decisions regarding complaints. The minutes shall contain at least: date of the complaint or the date of receipt of the complaint, reference number of the file, reason for the complaints and the decision with a professional explanation and any notification arising from paragraph I, II, III, IV and V of Article 3.1 of these Rules.
The minutes shall be kept in electronic format, which shall be kept by the Administrative Assistant.
5. Out-of-court settlement of consumer disputes
5.1 Receiving an initiative to initiate a procedure and invitation to competent authorities
Upon receipt of the notice on the initiative to initiate the procedure for out-of-court settlement of a consumer dispute received by the insurance company from the MC, the person authorized to manage the area of general legal matters or, the person authorized by them shall immediately inform the person concerned of the receipt of the notification with the powers of the director of the insurance company in respect of which the initiative is submitted and invites him to provide a response. They also remind them to comply with the deadline in which the insurance company is obliged to provide the aforementioned response.
5.2 Response of responsible persons and records
The person with the powers of the director of the area referred to in the previous paragraph then obtains relevant information in relation to the initiative from the person to whom the complaint or the initiative refers and ensures that these opinions regarding the client’s statements are communicated directly to the MC.
Further correspondence between the MC/insurance company, in accordance with the provisions of the Rules on the Mediation Procedure in Domestic and Cross-border Consumer Disputes at the Mediation Center SZZ, is carried out by the organizational unit of the insurance company, which responded to the initiative to initiate the procedure for resolving a particular consumer dispute, which also takes care of the rest the obligations of the said Rules (payment of awards to the mediator, etc.).
Each organizational unit keeps its own record of matters that have been resolved with the help of a consumer dispute resolution provider.
6. Record of complaints
The Complaints Body shall keep a register of complaints, composed of a set of data referred to in Paragraphs 3.5, 4.4. and 7 of these Rules. The register of complaints of Complaints Bodies shall be kept separate.
7. Care for development
In addition to activities from paragraphs I, II, III, IV and V of Article 3.1 of these Rules and activities related to the smooth operation of Complaints Bodies, the latter also monitor the statistics relating to the filing of complaints and the decision on them, follow the standards of good insurance practice, monitor the development of the insurance practice or, on the basis of case analysis , either the company’s management, or for individual organizational units, propose measures to improve business in general. The Complaints Bodies provide the Management Board with a report on work, trends, etc., once a year (by the end of the first quarter of the year) for the past year.
8. Sava Insurance Company – subsidiary in Croatia
Complaints relating to the subsidiary of the insurance company in Croatia shall be settled in accordance with the internal acts of the subsidiary and in accordance with the national legislation of the Republic of Croatia. Notwithstanding the foregoing, the insurance company provides the subsidiary with any other professional support related to the resolution of these complaints, or, in relation to individual cases which are settled in the context of these.
9. Transitional and final provisions
These Rules shall enter into force when adopted by the Management Board of the company and shall become effective on November 2, 2016. On the same day, the Rules on the Complaints Procedure of Zavarovalnica Maribor, d.d. dated September 13, 2016, as well as (except for the part, referred to in the following paragraph of this Article), the Rules on the Internal Complaints Procedure of Zavarovalnica Tilia, d.d., dated July 16, 2016 and the Protocol on the Complaints Procedure of Zavarovalnica Tilia, d.d., dated August 30, 2011.
Procedures relating to the Protocol on the Complaints Procedure of Zavarovalnica Tilia, d.d., related to the insurance policies of Zavarovalnica Tilia, d.d., issued before November 2, 2015, shall be completed according to the procedure at Zavarovalnica Tilia d.d., effective on November 1, 2016. However, this exception does not apply to the part of the aforementioned Protocol, which refers to the composition of the Boards of the insurance company after November 2, 2016. In this case, therefore, regardless of the use of the procedures, provided for in the acts of Zavarovalnica Tilia d.d., the provision of these Rules shall apply on November 1, 2016.
The signed original is kept in the Compliance Service. The original electronic record kept as well.
The administrator of this act is the Claims Department.